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What You Need to Know 1 Bacteria and viruses are most commonly transmitted on the hands of health care workers 2 The single most important way to prevent the spread of these organisms is good hand hygiene 3 Good hand washing Using alcohol hand gels Hand care (lotions, cover cuts) Taking care of dermatitis Reporting of skins lesions or rashes to your Manager and Employee Health 4 When hands are visibly dirty or contaminated Before and after patient care Before eating After using the restroom Before donning sterile gloves After removing gloves If moving from a contaminated body site to a clean body site during patient care After contact with inanimate objects (including medical equipment) 5 When hands are visibly soiled Before eating After using the restroom When caring for patients with C. Difficile 6 7 8 9 Coagulase positive staph/Staph aureus resistant to Oxacillin/Methicillin (MRSA) Coagulase negative or positive staph resistant to vancomycin Strep GrD enterococcus resistant to vancomycin (VRE) Strep pneumoniae highly resistant to penicillin (MIC>2) 10 Resistant/Intermediate to: All aminoglycosides (amikacin, gentamicin, and tobramycin. All cephalosporins (cefazolin, cefepime, ceftazidime, etc. All penicillins (ampicillin, pipercillin, pip/tazo, ampicillin/sulbactam, etc.) Imipenem or meropenem All isolates of Stenotrophomonas ESBL producing bacteria 11 12 Source: Urine Collected: 09/05/07 01:45 Site: Received : 09/05/07 01:45 Culture Urine FINAL 09/08/07 11:31 Organism 01 Escherichia coli >100,000 cfu/ml . . . . . . . . . . . . . This organism is an Extended Spectrum b-Lactamase (ESBL) producer. Consultation with ID specialist is suggested. Organism 02 Mixed Flora 10,000-20,000 cfu/ml _____________________________________________________________________________ Organism E.coli ANTIBIOTIC MIC INTRP _____________________________________________________________________________ Amikacin 16 S Ampicillin >=32 R Cefazolin >=64 R Cefepime >=64 R Ceftriaxone >=64 R Cefuroxime-Sodium >=64 R Gentamicin >=16 R Imipenem <=1 S Levofloxacin >=8 R Piperacillin >=128 R Piperacillin/tazobactam 8 S Tobramycin >=16 R Trimethoprim/Sulfa <=20 S Nitrofurantoin <=16 S _____________________________________________________________________________ S=SUSCEPTIBLE I=INTERMEDIATE R=RESISTANT _____________________________________________________________________________ 13 Source: Blood Collected: 06/17/09 08:03 Site: Received : 06/17/09 09:41 Culture Blood FINAL 06/21/09 11:00 06/19/09 Gram Stain: Gram Positive Cocci in Clusters Organism 01 Staphylococcus (coagulase negative) . . . . . . . . . . . . . Macrolide resistant Staphylococcus aureus and Coagulase Negative Staphylococcus may have inducible resistance to clindamycin. If clindamycin is needed, contact Microbiology for further testing. Plates will be held 3 days after culture is completed. _____________________________________________________________________________ Organism ScoagANTIBIOTIC MIC INTRP _____________________________________________________________________________ Erythromycin >=8 R Gentamicin <=0.5 S Levofloxacin >=8 R Oxacillin MIC >=4 R Penicillin-G >=0.5 R Vancomycin 2 S _____________________________________________________________________________ S=SUSCEPTIBLE I=INTERMEDIATE R=RESISTANT _____________________________________________________________________________ 14 Source: Urine, Routine Collected: 05/02/09 01:48 Site: Received : 05/02/09 01:48 Culture Urine FINAL 05/27/09 10:00 Organism 01 Acinetobacter baumannii complex >100,000 cfu/ml There are no CLSI (NCCLS) interpretive standards for the organism/drug combination of Acinetobacter sp./tigecycline. Tigecycline is a restricted antibiotic. Infectious disease consult required. Testing of colistin, polymixin B, and tigecycline performed by: ARUP Laboratories 500 Chipeta Way Salt Lake City, UT 84108 1-800-522-2787 Organism 02 Enterococcus faecium - (Group D) >100,000 cfu/ml . . . . . . . . . . . This organism is a VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) _____________________________________________________________________________ Organism A.bau cpx E.faeci ANTIBIOTIC MIC INTRP MIC INTRP _____________________________________________________________________________ Amikacin >=64 R Ampicillin/sulbactam >=32 R Cefepime >=64 R Ceftazidime >=64 R Gentamicin >=16 R Levofloxacin >=8 R >=8 R Meropenem <=4 S Piperacillin >=128 R Tobramycin >=16 R Colistin 0.12 S Polymyxin B 0.25 S Penicillin-G >=64 R Linezolid 2 S Vancomycin >=32 R Nitrofurantoin 128 R _____________________________________________________________________________ S=SUSCEPTIBLE I=INTERMEDIATE R=RESISTANT 15 MRSA in dry conditions – Plastic charts – 11 days Laminated tabletop – 12 days Cloth curtains – 9 days VRE 50% survival at 7 days on upholstery, furniture and wall coverings Could be transferred easily by touching contaminated surfaces Huang et al., Infect Control Hosp Epidemiol 2006; 27:1267-69 Lankford et al., Am J Infect Control 2006; 34: 258-63 16 A patient with a resistant organism is placed on Contact Precautions by nursing staff When lab calls When Infection Control calls By physician order Per isolation guidelines Patient can be placed on Contact Precautions without a physician order 17 Consists of: Private room Stop sign and Contact Precautions sign outside the door Gloves to enter the room Gown for contact with patient or environment Dedicated equipment 18 19 Infection Control places a Precautions Worksheet and a yellow Contact Precautions sticker on the chart Patient is maintained on precautions until clearance criteria are met Notify Infection Control before discontinuing Contact Precautions 20 No Special Precautions Required Rationale: ____________________________ ED I.C. CONTACT PRECAUTIONS – Private Room/Gowns/Gloves MRSA RULE-OUT MRSA Hx of MRSA VRE C.diff RULE-OUT C.diff RESISTANT GRAM NEGATIVE RODS SCABIES/LICE SHINGLES LOCALIZED IN IMMUNOCOMPETENT PATIENT OTHER_________________ RESPIRATORY “DROPLET” PRECAUTIONS – Surgical Mask/NO Neg Air Flow MENINGITIS RULE-OUT MENINGITIS INFLUENZA RULE-OUT INFLUENZA OTHER _________________ RESPIRATORY “AIRBORNE” PRECAUTIONS – N-95 TB Mask/Neg Air Flow TB RULE-OUT TB CHICKENPOX SHINGLES DISSEMINATED OR IN IMMUNOCOMPROMISED PATIENT OTHER_________________ Pl PLEASE DO NOT THIN Notify Infection Control Specialist before discontinuing Precautions MAINTAIN THIS WORKSHEET IN FRONT OF CHART SEND WITH CHART IF PATIENT TRANSFERRED WITHIN THE HOSPITAL NOT PART OF THE PERMANENT MEDICAL RECORD DISCARD THIS FORM AFTER PATIENT DISCHARGE <PLACE PATIENT LABEL HERE> COMMUNITY MEDICAL CENTER PRECAUTIONS WORKSHEET 5/11//09 JB 21 Criteria for Discontinuing Contact Isolation Reason for Isolation + MRSA during current Hospitalization Or Hx MRSA Rule Out MRSA + VRE during current Hospitalization or Hx of VRE + C.diff during current Hospitalization Rule Out C.diff Discontinuing Criteria After completion of antibiotic therapy: 2 negative cultures of the original source(s) of positive culture(s) 48 hours apart, OR If culturing of original infection source not possible/feasible, ie wound closed, no sputum production, blood was the original source, etc.: o 1 negative MRSA Nasal Screen (NICU pts = 1 negative MRSA Nasal and Rectal Screen) Negative culture of suspected MRSA site, ie wound, sputum, urine, etc. Clearing for VRE cannot be initiated until completion of antibiotic therapy and: 2 negative cultures of the original source(s) of positive culture(s) 48 hours apart, OR Culturing of original infection source not possible/feasible, ie wound closed, no sputum production, blood was the original source, etc. AND 2 negative stool VRE Surveillance screens 48 hours apart After completion of antibiotic therapy: If patient no longer has s/s of C.diff (ie diarrhea) If patient still has diarrhea, 1 negative C.diff. 1 negative C.diff prior to or during 1st 48 hours of antibiotic therapy, unless endoscopy shows colitis. C.diff ordered but patient not having bowel movements to obtain specimens. Comments Patients with rectal tubes are considered to be still having diarrhea. If patient not having stools, notify RN to contact MD to discontinue orders for C.diff. 22 23 24 25 26 27 28 29 30 Required for diseases that are spread by: Small particles of evaporated droplets that remain suspended in the air for long periods of time Dust particles contaminated with an infectious agent 31 Private room with Negative Air Flow Place blue Respiratory “Airborne” Precautions and Stop Sign on the door Wear N-95 mask Put on mask prior to entering the room. Take off mask after exiting the room. Must be fit-tested to wear N-95 Mask. Keep the room door closed 32 COMMUNITY MEDICAL CENTERS RESPIRATORY Airborne Precautions Private Room / Negative Air Flow Room / N-95 TB Mask Notify Infection Control before Airborne Precautions are discontinued. Put on N95 mask before entering the patient room. Wash hands or use alcohol hand gel before leaving room. Remove mask after leaving room. Keep the room door closed. 33 Diseases that require Airborne precautions: Tuberculosis Chickenpox Disseminated Shingles SARS/Avian Flu 34 For patients placed on Airborne Precautions, Infection Control will – Place a Precautions Worksheet and a blue Respiratory “airborne” Precautions sticker on the chart Respiratory “airborne” Precautions can be initiated without a physician order 35 Prevalence in Fresno County = 100 new cases/year Screening of patients for TB: Signs/Symptoms •Cough>3weeks •Fever •Weight loss •Bloody sputum •Night sweats •Suspicious chest •X-ray Risk Factors •Immunocompromised •History of TB •Recent exposure •Recent immigration from or travel to an area with a high rate of TB •Homelessness •Spent time in a correctional facility 36 REVIEW OF PATIENT INFORMATION REVEALS POSITIVE* SYMPTOMS AND HIGH RISK FACTORS POSITIVE SYMPTOMS* BUT LOW RISK FACTORS NEGATIVE SYMPTOMS BUT HIGH RISK FACTORS** NEGATIVE SYMPTOMS AND/OR LOW RISK FACTORS INITIATE RESPIRATORY PRECAUTIONS~AND RULE OUT ACTIVE TB CHEST X-RAY EVALUATE CLINICALLY EVALUATE ONLY IF CHANGE CLEAR/NEGATIVE FOR TB: NO NEED FOR RESPIRATORY PRECAUTIONS UNLESS ADDITIONAL CONCERNS ARISE POSITIVE/SUSPIC IOUS FOT TB: INITIATE RESPIRATORY PRECAUTIONS – AND RULE OUT ACTIVE TB*** NO NEED FOR RESPIRATORY PRECAUTIONS UNLESS ADDITIONAL CONCERNS ARISE 37 For patients with a suspicion of TB – Infection Control will review the medical record A Tuberculosis Suspect Case Report will be completed by Infection Control and faxed to the Public Health Department (PHD) 38 With submission of “Suspect” report form to the PHD, patient will be placed on a Public Health Department “HOLD” Patient MAY NOT be discharged without written consent of the County TB Controller or designee 39 Infection Control will notify the appropriate Case Manager/Discharge Planner when a patient is put on precautions and placed on a PHD “Hold” Discharge of the patient is arranged through the Discharge Planner in collaboration with the PHD 40 If patient wants to leave Against Medical Advice (AMA) – Try to persuade them to stay If they insist on leaving, try to get an address, if possible Notify Infection Control and the PHD or on nights and weekends, call the Sheriff 41 42 43 Required for diseases that are spread: Through the air by large particle droplets Droplets usually travel short distances, ie less than 3 feet. 44 Private room, NO negative air flow. Put on regular surgical mask before entering the room. Remove mask before leaving the room. 45 Diseases that require Respiratory “Droplet” Precautions Meningitis Pertussis (whooping cough) Influenza 46 47 Found in your binder Lists several diseases/conditions with required special precautions and modes of transmission Need to be familiar with it to comply with Infection Control policies 48 Disease Precautions Mode of Transmission Comments C.Diff Contact Fecal-Oral Caution with stool. Do Not Use Hand Gel Influenza Droplet-duration of illness Droplet Does not require negative airflow room; wear surgical mask Meningitis Hemophilus or Meningo coccal Droplet-for 24 hours @ start of effective ABX therapy Droplet Does not require negative airflow room; wear surgical mask; Notify IC and PHD; Contact EHS or ED if exposed to patient prior to initiation of isolation. 49 Over 70 reportable communicable diseases The duty of every health care provider knowing of, or in attendance on, a case or suspected case to report on a Confidential Morbidity Report (CMR) form and fax to PHD CMR generally completed and faxed by Infection Control 50 Anthrax, Botulism, Smallpox, Tularemia Salmonella, Shigella, Campylobacter, E.coli O157 Sexually Transmitted Diseases: gonococcal infections, syphilis, chlamydia TB Meningitis: bacterial, viral, fungal 51 MRSA Screening Program – CA State Central Line Insertion Process – CA State National Patient Safety Goals - JCAHO Hand Hygiene Implement Best Practice Guidelines to decrease central line infections, surgical site infections and hospital-acquired MRSA/VRE Reporting of hospital-acquired infections – CA State 52 Use soap and water for hand hygiene; DO NOT use an alcohol gel Use Contact Precautions for patients with confirmed or suspected C.difficile (i.e., put on gloves upon entering the room; put on gloves and a gown for any contact with the patient or the patient’s environment.) Monitor compliance with Contact Precautions (compliance monitoring for all patient care providers, including physicians, began 2/1/10.) Immediately notify clinical personnel if you suspect a patient has a C.difficile infection. Use bleach (Chlorox wipes or bleach solution) to clean the patient’s room. Prescribe antibiotics only when necessary. Educate the patient and patient’s family about C. difficile infection and prevention strategies. (Education materials soon to be placed on the Patient/Family Education website on the Community Forum.) Utilize the Central Line Insertion Process Bundle: Perform Hand Hygiene prior to line insertion. Use Maximal Barrier Precautions: Inserter to wear sterile gown, sterile gloves, mask/eye shield, and cap. Patient to be covered with a full body sterile drape. Use a chlorhexidine/alcohol antiseptic (ChloraPrep) for patient skin prep. Place a chlorhexidine impregnated disc (BioPatch) around the line so it touches the skin. Avoid using the femoral vein for central line access, unless absolutely necessary. Have all the necessary supplies readily available in a central line kit or cart. Complete the Central Line Insertion Process (“CLIP”) form/checklist; this is a CDPH requirement. Daily, assess and document line necessity and remove if nonessential. Disinfect catheter hubs, needleless connectors and injection ports with alcohol before accessing. Use caps to cover hubs/connectors/ports when not in use. Change line dressings/caps per hospital policy. Educate healthcare personnel, patients and their families about central line related bloodstream infections and prevention strategies. (Education is available on the Patient/Family Education website on the Community Forum.) Maintain strict adherence to hand hygiene: “Gel In & Gel Out” Use Contact Precautions for patients who are colonized or infected with MDROs. Immediately notify Clinical Personnel if you suspect a patient has an MDRO. Review the Infection/Isolation tab on the EPIC census to identify readmitted MDRO patients. Implement an MRSA screening program for early detection and isolation of colonized patients. (Program began at CMC in July 2009.) Prescribe antibiotics only when necessary. Follow CMC’s Reserved Antimicrobials guideline. Maintain clean patient care equipment and a clean environment. Educate healthcare personnel, patients and their families about MDROs and prevention strategies. (MRSA education is available on the Patient/Family Education website on the Community Forum.) Deliver IV antimicrobial prophylaxis within 1 hour before incision (2 hours for vancomycin and fluoroquinolones.) Use an antimicrobial prophylactic agent consistent with published guidelines. Discontinue the use of prophylactic antibiotic within 24 hours after surgery (48 hours after cardiothoracic procedures.) Proper hair removal (i.e., remove hair with clippers or do not remove the hair at all; razors are not to be used for hair removal.) Control glucose levels in cardiac surgery patients. Maintain perioperative normothermia in colorectal surgery patients. For Class 1 (“clean”) surgical procedures: Instruct patients to: Shower with 4% CHG the evening before and morning of the procedure. Dry a with fresh, clean, dry towel and don clean clothing after each shower. Screen for MRSA and decolonize if positive Educate the patient and patient’s family about surgical site infections and prevention strategies. (Education materials can be found on the Patient/Family Education website on the Community Forum.) Beverly Kuykendall, Manager, x52047; Cell 284-1427(CBHC, Dialysis, Cancer Center, CSTCC, Radiology, Lab, OP Clinics, Home Services, Endoscopy, Surgery and “Other” ancillary departments or off site facilities) Connie Young, RN, ICS, x56553; Cell 283-4628 (CRMC 2C, 2E, 6W, 7W, Step Down Unit, NICU) Juan Bulgara, RN, ICS, x34436; Cell 348-7441 (4N ICU, 4S ICU, CVU, 5N ICU, 5S ICU, Burn Center, ED ) Melissa Deen, RN, ICS, x57299; Cell 285-7718 (CRMC 1E, 4C, 4E, 8W, 9W, L&D, PNU) Shelli Ashbeck, RN, ICS, (Clovis) x44033; Cell 281-7786 (CCMC, Oakhurst Urgent Care, ) Karen Stevenson, RN, ICS, CRMC x56508; FHSH 433-8071; Cell—355-5826; (CRMC)—5E Ante-partum, 5C Peds, 5C M/S, 5W, (FHSH)—Inpatients, Outpatients and ancillary departments. 57