Infection Control Manual

INFECTION PREVENTION AND CONTROL MANUAL
February 7, 2013
VIHA Infection Prevention and Control Manual, February 7, 2013
TABLE OF CONTENTS
(Click here to see recent changes/additions) PART 1: INTRODUCTION .................................................................................. 8
1. Purpose ........................................................................................................................ 8 2. Scope of the Document ................................................................................................ 8 3. Guiding Principles ......................................................................................................... 8
PART 2: UNDERSTANDING HOW INFECTIONS ARE SPREAD ...................... 9

1. The Chain of Infection................................................................................................... 9
Figure 1: Chain of Infection ................................................................................... 9
A. B.
Causative Agents ............................................................................................... 10 Reservoirs .......................................................................................................... 11

Table 1: Human Reservoirs and Transmission of Infectious Agents .............. 12
C. D.
Portal of Exit ....................................................................................................... 12 Transmission ...................................................................................................... 13

1. Contact Transmission ............................................................................................. 13 2. Droplet Transmission .............................................................................................. 13 3. Airborne Transmission ............................................................................................ 13 4. Common Vehicle Transmission ............................................................................... 14 5. Vector Borne Transmission ..................................................................................... 14
E. F.
Portal of Entry ..................................................................................................... 14 Susceptible Host................................................................................................. 15
PART 3: INFECTION PREVENTION AND CONTROL PRACTICES AND PRECAUTIONS................................................................................................. 18

1. ROUTINE PRACTICES .............................................................................................. 18 A. Risk Assessment ................................................................................................ 18
Figure 2: Risk Assessment Decision Tree - Acute Care ................................... 20 Table 2: Risk Assessment .................................................................................... 21
Note: In this document the term patient is inclusive of patient, resident or client.
Page 2
B.
Risk Reduction ................................................................................................... 22

1. Hand Hygiene ......................................................................................................... 22 Indications for Hand Hygiene .................................................................................. 22
Figure 3: The Four Moments for Hand Hygiene .................................................. 23
Nail and Skin Care .................................................................................................. 24 Type of Cleansing Agent ......................................................................................... 24 Alcohol Based Hand Rub ........................................................................................ 24 Soap and Water ...................................................................................................... 25 Handwashing Technique......................................................................................... 25
Table 3: Levels of Hand Disinfection .................................................................. 26
Hand Hygiene Procedure ........................................................................................ 26 Alcohol based hand rub technique .......................................................................... 26 Soap and Water hand washing technique ............................................................... 26 Surgical asepsis (scrub) technique with an alcohol based hand rub ........................ 27 Surgical asepsis technique with a medicated soap ................................................. 27 2. Respiratory Hygiene/Cough Etiquette ..................................................................... 28 3. Patient Placement ................................................................................................... 29 4. Personal Protective Equipment ............................................................................... 29 Gloves .................................................................................................................... 29
Table 4: Examples of Tasks that Require the Wearing of Gloves .................... 30 Table 5: Glove Use in Patient Care...................................................................... 31 Figure 4: Choosing the Correct Glove ................................................................ 32
Gowns/Aprons ........................................................................................................ 33 Masks, Visors and Protective Eyewear ................................................................... 34 5. Hair/Jewelry/Uniforms ............................................................................................. 35 Hair ......................................................................................................................... 35 Jewelry ................................................................................................................... 35 Footwear ................................................................................................................. 35 Dress Code for Staff Who Do Not Wear a Uniform, Including Medical Staff ............ 35 Dress Code for Staff Wearing a Uniform ................................................................. 35
Page 3
6. Safe Handling of Sharps ......................................................................................... 36 7. Decontamination ..................................................................................................... 37

Table 6: Reprocessing Decision Chart ............................................................... 37 Table 7: Classes of Organisms in Order of Susceptibility to Disinfectants ... 40 Table 8: Disinfection Requirements for Equipment .......................................... 41 Table 9: Advantages and Disadvantages of Major Chemical Disinfectants ... 41
8. Housekeeping ......................................................................................................... 45 9. Laundry ................................................................................................................... 45 10. Waste ..................................................................................................................... 48 11. Managing Dishes, Glasses, Cups and Eating Utensils ............................................ 50 12. Recreational Reading Material and Games ............................................................. 52 13. Play Equipment and Toys ....................................................................................... 52 14. Healthy Workplace .................................................................................................. 53
C.
Education............................................................................................................ 54
2. ADDITIONAL PRECAUTIONS ................................................................................... 55 A. B. C. Contact Precautions ........................................................................................... 55 Droplet Precautions ............................................................................................ 58 Airborne Precautions .......................................................................................... 59
Table 10: Air Exchanges ...................................................................................... 63
D.
SUMMARY OF PRECAUTIONS ........................................................................ 64

Table 11: Precautions Table ................................................................................ 64
E. F.
Protective (Reverse) Precautions ....................................................................... 65 Management of Cases on Additional Precautions in Diagnostic Areas .............. 65
Figure 5: Management of Infected Patients/Residents on Precautions in Diagnostic Areas .................................................................................................... 67
G.
Discontinuing Additional Precautions ................................................................. 68

Table 12: Procedure for Discontinuing Additional Precautions ...................... 68
PART 4: HOUSEKEEPING............................................................................... 69
1. Clean Environment ..................................................................................................... 69
Page 4
A.
CLEANING ......................................................................................................... 69
1. Nursing/Housekeeping Responsibilities .................................................................. 69 2. Nursing Responsibilities: ......................................................................................... 70 3. Housekeeping Responsibilities: .............................................................................. 71
Table 13: Cleaning Solutions Used in Various Types of Cleaning ............... 71 Table 14: Some Equipment/Environmental Surfaces to be Cleaned Daily .. 73
B.
EVALUATING PRODUCTS ................................................................................ 77
2. Bed Bug Infestation .................................................................................................... 77 A. Pests and Infestations in Home and Community Care ....................................... 77
PART 5: ANTIBIOTIC RESISTANT ORGANISMS............................................ 78

1. Introduction ................................................................................................................. 78 2. Definitions ................................................................................................................... 78 3. Acute Care Screening Protocol .................................................................................. 78
Table 15: List of Organisms with Corresponding Precautions and Other Considerations ....................................................................................................... 79
4. ARO Screening and Collecting Swabs ....................................................................... 80

Table 16: Screening and Specimen Collection .................................................. 80
5. Overview of Antibiotic Resistant Organisms ............................................................... 81 A. B. C. Methicillin-Resistant Staphylococcus aureus (MRSA) ........................................ 81 Vancomycin-Resistant Enterococci (VRE) ......................................................... 82 Extended Spectrum Beta-Lactamase (ESBL) Organisms .................................. 82
6. ARO Room Placement ............................................................................................... 83

Figure 7: ARO Room Placement .......................................................................... 83
7. Key Management Issues ............................................................................................ 85

Table 17: Key Management Issues for MRSA and ESBL ................................... 85
PART 6: OUTBREAK MANAGEMENT ............................................................. 91

1. Introduction ................................................................................................................. 91 2. General Guidelines for Outbreak Management .......................................................... 92
Page 5
A.
Reporting a Suspected Outbreak ....................................................................... 92

Table 18: Contact List ............................................................................................ 92 Figure 8: Suspected Respiratory Infection or Gastroenteritis Outbreak Algorithm ................................................................................................................ 94
B.
Influenza-Like Illness (ILI) Outbreaks ................................................................. 95

Table 19: Common Differences between Influenza and Common Cold Symptoms ............................................................................................................... 96 Table 20: Respiratory Infections .......................................................................... 97 Table 21: Case Definition for ILI and an ILI Outbreak ....................................... 99
C.
Gastrointestinal Illness (GI) Outbreaks ............................................................. 106

Table 22: Common Bacterial and Viral Causes of Gastroenteritis ................ 107 Table 23: Gastrointestinal Illness Case Definition .......................................... 108 Figure 9: Requisition Form for GI Testing ........................................................ 114
D.
Outbreaks Caused by Other Organisms ........................................................... 115

1. Clostridium Difficile Outbreak ................................................................................ 115 2. Work Restrictions .................................................................................................. 116 3. Scabies ................................................................................................................. 116
PART 7: DEPARTMENTAL GUIDELINES ...................................................... 120

1. Inpatient Mother and Baby........................................................................................ 120
Table 24: Common Conditions and Precautions Needed ............................... 120 Figure 10: Precautions Required When Caring for Mother with Non-Genital Herpes ................................................................................................................... 121 Figure 11: Precautions Required When Caring for Mother with Genital Herpes ................................................................................................................... 121
2. Neonatal Intensive Care and Special Care Baby Units ............................................ 123
Table 25: Common Conditions and Precautions Needed ............................... 125
3. Pediatrics .................................................................................................................. 126 4. Infection Prevention and Control Practices for Surgical Service Areas .................... 130
Figure 12: Surgical Booking Procedure ........................................................... 132 Table 26: Assessment for Increased Risk of Communicable Disease Transmission ........................................................................................................ 132 Figure 13: Surgical Housekeeping Algorithm .................................................. 137
Page 6
5. Burn Unit Recommendations .................................................................................... 145 6. Renal Dialysis Department ....................................................................................... 147
Table 27: Disinfection Procedures Recommended for Commonly Used Items or Surfaces in Hemodialysis Units .......................................................... 155
7. Respiratory Department Guidelines .......................................................................... 159
PART 8: Specific Procedural Recommendations ............................................ 162

1. Asepsis ..................................................................................................................... 162
Table 28: Approved Antiseptic Agents and Procedures ................................. 164
2. Environment and Furniture ....................................................................................... 166 A. B. C. Storage of Decorative Items ............................................................................. 166 Furniture ........................................................................................................... 166 Fixtures and Fittings ......................................................................................... 167
APPENDICES ................................................................................................. 170

APPENDIX A: Type and Duration of Additional Precautions Where Recommended for Selected Infections and Conditions ............................................................................... 170 APPENDIX B: Glossary of Terms .................................................................................. 194 APPENDIX C: Specific Cleaning Instructions ................................................................ 202 A. B. C. D. E. Procedure for Cleaning Agitator Tubs/Hydrotherapy Tanks ............................. 202 Procedure for Cleaning Fans ............................................................................ 202 Procedure for Cleaning Commodes ................................................................. 203 Procedure for Cleaning Suction Regulators...................................................... 203 Procedure for Cleaning and Use of Hot/Cold Pack and Ice Bags ..................... 204
Table 28 - Products currently acquired through VIHA purchasing department: .......................................................................................................... 205
F.
Recommendations for Bath Mats Prior to Purchase ......................................... 205
Page 7
PART 1: INTRODUCTION
1. Purpose
This manual has been prepared to assist the healthcare worker by providing a succinct and current guide to infection prevention and control strategies in various healthcare settings. The principles and guidelines set out in the Manual are based on national and international published best practices, which have been modified to reflect the specific needs of VIHA. As new information becomes available, this document will be reviewed and updated, the most current edition will be accessible on the VIHA website.
2.
Scope of the Document
This document covers VIHA Acute, Residential care, Home & Community Care and other community settings as the implementation of routine practices applies to all programs and departments.
3.
Guiding Principles
Infection prevention and control strategies are designed to protect patients/residents, healthcare providers and the community from the risk of transmissible disease. A systematic approach to infection prevention and control requires each health care provider to play a vital role in protecting everyone who utilizes the healthcare system, in all of its many forms: pre-hospital settings, hospital, clinics, residential and home and community care. To protect patients/residents/clients, staff and visitors from transmitting and/or acquiring hospital associated infections through ensuring adherence to best infection prevention and control practices. Healthcare providers must adhere to infection prevention and control guidelines and policies at all times, and use critical thinking, risk assessment and problem solving in managing clinical situations.
Reference: Ontario Ministry of Health and Residential care Infection Prevention and Control Core Competencies Program, Reviewed and revised January, 2011
Page 8
PART 2: UNDERSTANDING HOW INFECTIONS ARE SPREAD

1. The Chain of Infection
The spread of infection is best described as a chain with six links: 1. a pathogen or causative (infectious) agent 2. a reservoir 3. a portal of exit from the reservoir 4. a mode of transmission 5. a portal of entry into the host 6. a susceptible host
Figure 1: Chain of Infection
Infectious Agents Susceptible Host
Reservoirs
Portal of Entry
Mode of Transmission
Portal of Exit
An infection can be prevented by breaking any link in the chain of infection. Infection prevention and control measures are designed to break the links and thereby prevent new infection. The chain of infection is the foundation of infection prevention and control.
Page 9
A.
Causative Agents
Bacteria, viruses, fungi and protozoa (microorganisms) are very common in the environment. Most of these microorganisms cause people no harm, and can in fact be beneficial. Creating an environment with no organisms is not a realistic goal.
Bacteria are single celled organisms, some of which can cause disease. We all live with numerous bacteria, referred to as our normal flora or resident bacteria, which usually do not cause disease unless their balance is disturbed.
Most bacteria require an infectious dose to cause disease; that is, it usually takes thousands to cause disease, not just one or two. Bacteria vary in infectivity (how easy they are to catch) and virulence (the level of danger from the infection they cause).
Viruses are intracellular pathogens, either DNA or RNA, meaning they can only reproduce inside a living cell. Viruses such as HIV and Hepatitis B and C have the ability to enter and survive in the body for years before symptoms of disease occur. Other viruses, such as the influenza viruses, quickly announce their presence through characteristic symptoms.
Fungi are prevalent throughout the world, but only a few cause diseases in humans, most of which predominately affect the skin, nails and subcutaneous tissue. A common yeast, Candida albicans, is normal human flora that can cause chronic or severe infections. Fungal infections can be life threatening in critically ill patients/residents. Fungi such as Pneumocystis carinii can be life threatening in persons with HIV/AIDS.
Prions are a form of infectious protein believed to be the cause of Creutzfeldt Jakob disease (CJD).
Protozoa are single or multi-celled microorganisms that are larger than bacteria. Examples of disease causing protozoa include Amoebas and Giardia, which cause diarrhea, and Plasmodium species, the cause of malaria. They may be transmitted via direct or indirect contact or the bite from an arthropod vector.
Parasites are larger organisms that can infect or infest people. Infestation with arthropods, such as lice and scabies, occurs by direct contact with the arthropod or its eggs. Heminths include roundworms, tapeworms and flukes. They infect humans principally through ingestion of fertilized eggs or when the larvae penetrate the skin or mucous membranes.
Causative organisms can be eliminated by several methods, including:

Page 10
Sterilizing surgical instruments and anything that comes into contact with sterile spaces of the body Using good food safety methods Providing safe drinking water Vaccinating people so they do not become reservoirs of illness Treating people who are ill Following good hand hygiene practices
B.
Reservoirs
Microorganisms require water to grow and reproduce, so reservoirs are often moist areas. Sometimes a reservoir includes our own normal flora as a contaminant, such as at a sink faucet.
In some cases the environment can serve as the reservoir. For example, water supplies may become contaminated by Legionella species. Inadequate air exchange can allow pathogens such as Mycobacterium tuberculosis and Aspergillus to contaminate air supplies. Environmental contamination by pathogens such as Staphylococcus aureus and Enterococcus species also commonly occur in bathrooms and/or on equipment. Appropriate infection prevention and control measures and engineering controls can prevent these reservoirs.
Common reservoirs in healthcare facilities include: Ill people Well people. Our normal flora includes bacteria that can be pathogenic if in the wrong part of the body Food; raw meat may harbor pathogens Water from fish tanks or flower vases may contain pathogens, which can cause harm especially for compromised patients/residents
Actions we take to eliminate reservoirs include: Treating people who are ill Vaccination Safe handling and disposal of body fluids appropriately Handling food safely Monitoring for water contamination, and restricting flowers in sensitive areas of the hospital
Page 11
Table 1: Human Reservoirs and Transmission of Infectious Agents
Reservoir
Blood
Transmission vehicle
Blood, needle stick, other contaminated equipment, splashes
Infectious agent
Hepatitis B and C HIV Staphylococcus aureus Staphylococcus epidermidis Staphylococcus aureus Coliforms Pseudomonas Neisseria gonorrhoeae Treponema pallidum Herpes simplex virus Hepatitis B Influenza viruses Group A streptococcus Staphylococcus aureus Tuberculosis Hepatitis A Shigella Salmonella Norovirus Rotavirus Escherichia coli Enterococci Pseudomonas
Skin and Soft Tissue
Drainage from a wound or incision
Reproductive tract and genitalia
Urine, semen, vaginal secretions
Respiratory tract
Droplets from sneezing or coughing
Gastrointestinal tract
Vomitus, feces, bile, saliva
Urinary tract
Urine
Note: This list is not exhaustive. Reference: Public Health Agency of Canada. (1999) Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care. (currently under revision)
C.
Portal of Exit
The portal of exit is the way in which the causative agent gets out of the reservoir, and it is the link of the chain that we can do the least about. Any break in the skin, including natural anatomical openings and draining lesions, may be the portal of exit from a person; any bodily fluid may carry microorganisms out of the body. Some potent germs live on the patient/residents skin, and thus can easily exit their reservoir. Actions we take to reduce risk from portals of exit include: Covering coughs and sneezes with appropriate measures (e.g. coughing into the elbow) Handling body wearing appropriate personal protective equipment (gloves and gowns) then performing correct hand hygiene
Page 12
Cover draining wounds covered with an appropriate dressing Health care workers refraining from work when exudative (wet) lesions or weeping dermatitis are present
D.
Transmission
This is the weakest link in the chain of infection. Most efforts to prevent the spread of infection are aimed at eliminating the mode of transmission. Microorganisms are transmitted in healthcare settings by several routes, and the same microorganisms may be transmitted by more than one route. There are five main routes of transmission; contact, droplet, airborne, common vehicle and vector borne. For the purpose of this manual, common vehicle and vector borne will be discussed only briefly, as neither play a significant role in HCAI.
1. Contact Transmission
Direct contact transmission is the most important and frequent mode of transmission of HCAI, and is divided into direct and indirect contact transmission. Indirect contact transmission usually involves contact between a susceptible host and a contaminated inanimate object, such as equipment, instruments or environmental surfaces. This is often the result of contaminated hands touching an object or environment. For example, activity staff who use a ball to pass from resident to resident.
2. Droplet Transmission
Theoretically, droplet transmission is a form of contact transmission. However, the mechanism of transfer of the pathogen to the host is quite distinct from either direct or indirect contact transmission. Droplets are generated from the source person primarily during coughing, sneezing and talking, and during the performance of certain procedures such as suctioning and administering nebulized medications. Transmission occurs when large droplets containing microorganisms generated from the infected person are propelled a short distance through the air (usually less than one metre) and deposited on the hosts conjunctivae, nasal mucosa or mouth. Because droplets do not remain suspended in the air, special air handling and ventilation are not required to prevent droplet transmission; that is, droplet transmission must not be confused with airborne transmission. Droplets can also contaminate the surrounding environment and lead to indirect contact transmission.
3. Airborne Transmission
Airborne transmission occurs by dissemination of either airborne droplet nuclei; small particle residue (five microns or smaller in size) of evaporated droplets containing microorganisms or dust particles containing the infectious agent (e.g. dust created by rotary powered foot care tools). Microorganisms carried in this manner remain suspended in the air for long periods of time and can be dispersed widely by air currents. These may be inhaled by a susceptible
Page 13
host within the same room, or over a longer distance from the source patient/resident, depending on environmental factors. Environmental controls are important special air handling and ventilation help reduce airborne transmission.
4. Common Vehicle Transmission

Common vehicle transmission applies to microorganisms transmitted by contaminated items such as food, water and medications, to multiple hosts, and can cause explosive outbreaks. Control is through using appropriate standards for handling food and water, preparing medications and appropriate hand washing.
5. Vector Borne Transmission

Vector borne transmission occurs when vectors such as mosquitoes, flies, rats and other vermin transmit microorganisms. This route of transmission is of less significance in healthcare facilities in Canada than in other settings.
E.
Portal of Entry
The portal of entry can be thought of as the hole in the skin that allows the germ to get into the body and cause disease. Pathogens cannot cause disease if they cannot get into the body. Examples of portals of entry include: Mouth, nose and eyes Other anatomical openings Skin breaks (cuts, rashes) Surgical wounds Intravenous sites Anatomical openings with tubes in place (these are more susceptible than those without) Needle puncture injuries Actions to protect portals of entry include: Dressings on surgical wounds IV site dressings and care Elimination of tubes as soon as possible Masks, goggles and face shields Keeping unwashed hands and objects away from the mouth (dont lick fingers to turn pages) Actions and devices to prevent needle stick injuries Food and water safety
Page 14
F.
Susceptible Host
Susceptibility can be reduced in several ways. For some diseases there are effective vaccines. Some diseases produce lasting immunity after illness. People have better resistance to disease when they are well rested, well fed and relatively stress free. People who have a healthy immune system are often able to resist infection, even when bacteria are present.
Host factors that influence the outcome of an exposure include the presence or absence of natural barriers, the functional state of the immune system and the presence or absence of an invasive devise.
Natural barriers to infection include: Intact skin and mucous membranes Cilia (small, hairlike projections that line the respiratory system) that filter inhaled air and trap microorganisms Lung macrophages large white blood cells that ingest microorganisms, other cells and foreign particles, in a process called phygocytosis Antibodies (humeral immunity) resulting from immunization or previous disease Acidic environment of the stomach, urine and vaginal secretions Normal flora provides competition to pathogens. An upset to the balance of normal flora can allow pathogens to cause infection, such as when a yeast infection follows a course of antibiotics The immune system is a complex network of cells, tissues and organs that interact to defend the body against infections. Defense mechanisms can be non-specific or specific and include humeral immunity (antibodies that circulate in the blood), cell mediated immunity (white blood cells) and the inflammatory response, which brings an increase in these infection fighting defenses to the site of infection
A person with normal immune system function is described as immunocompetent. Someone whose immune system is impaired by illness or age is said to be immunocompromised. The very young and the very old are at risk with a compromised immune system. Infections are a major cause of death among newborns. Although babies receive certain temporary immunities from their mother through the placenta and in breast milk, their immune systems are still developing, making them vulnerable to infection. Examples of susceptible hosts include: People with chronic diseases People with invasive devices or tubes in place (e.g. catheters) Malnourished people The very old and the very young
Page 15
People who are tired or under high stress People with skin breaks such as surgical wounds, IV sites or chronic rash People undergoing steroid therapy or treatment for cancer People with HIV Infection People who are well and healthy. No one is immune to all disease
Actions required to minimize risk to susceptible hosts include: Vaccinating people against illnesses to which they may be exposed Preventing new exposure to infection in people who are already ill, are receiving immunocompromising treatment or are infected with HIV Maintaining good nutrition Maintaining good skin condition Covering skin breaks Encouraging rest and balance
The nature of healthcare settings makes patients/residents vulnerable to the spread of infections, because it brings together many ill people who are both reservoirs and susceptible hosts. Staff are also both reservoirs and susceptible hosts, so we cannot eliminate those two major links of the chain of infection. This is why we must make such efforts to eliminate the mode of transmission; hand hygiene is still the single most effective way to prevent the spread of infection. The reservoir and the susceptible host may reside in the same person, if the individuals normal flora gets into the wrong part of the body it may cause infection. Examples of this situation include: Fecal flora in the urinary tract, causing a urinary tract infection (UTI) Oral flora in the lungs, causing aspiration pneumonia Skin flora in an IV site, causing a site infection or a blood stream infection To avoid providing the mode of transmission between different body sites of the same patient/resident, one must change gloves and wash hands when moving from one site to another, from a contaminated area to a cleaner one following the Four Moments for Hand Hygiene Preventing the spread of infectious organisms includes: Early identification of the infectious organism Prompt appropriate precautions put in place for patients/residents Initiation of appropriate treatment
Page 16
Precautions have disadvantages to the facility, patients/residents, personnel and visitors, including the cost of specialized equipment and environmental controls, which inconvenience healthcare workers and force solitude for patients/residents. However, these disadvantages must be weighed against the facilities mission to prevent the spread of infection.
Source: Evans, N and McDonald, M. Infection Control Guidelines for Healthcare Professionals.
Routine Practices are to be applied at ALL times by ALL staff.
Page 17
PART 3: INFECTION PREVENTION AND CONTROL PRACTICES AND PRECAUTIONS

1. ROUTINE PRACTICES
Infection prevention and control measures are designed to break the links in the Chain of Infection and thereby prevent new infection. In healthcare settings, because agent and host factors are more difficult to control, interruption in transfer of microorganisms is directed primarily at transmission. Routine practices play a key role in preventing the transmission of infectious disease. The Public Health Agency of Canada (PHAC) has used the term Routine Practices since 1999, for the process of risk assessment and risk reduction strategies. Routine practice, previously known as Standard Precautions, is to be used with all patients/residents at all times. Routine practices supersede, and are more encompassing than, previous Blood Borne Pathogen Precautions or Universal Precautions. Based on the assumption that all blood and certain body fluids (urine, feces, wound drainage, sputum) contain infectious organisms (bacteria, viruses or fungi), routine practices reduce exposure (both volume and frequency) of blood and body fluids to healthcare providers. Furthermore, routine practices reduce the risk of cross infection through the reduction in contamination and transmission of microorganisms. The key to implementing routine practices is to assess the risk of transmission of microorganisms before any interaction with patients/residents. The elements of routine practices are summarized here into three parts: a. Risk Assessment b. Risk Reduction c. Education
Modified from: The Canadian Committee on Antibiotic Resistance (2007) Infection Prevention and Control Best Practices for Residential care, Home and Community Care including Health Care Offices and Ambulatory Clinics.
A.
Risk Assessment
Risk assessment is performed principally to rule out the presence of infectious disease, but it is also necessary to ensure that appropriate precautions are initiated for the various procedures.
Page 18
1. Admission
Assessment should be standardized during the admission process to include: Recent exposures to infectious diseases such as Chickenpox, Measles or Tuberculosis Recent travel history, particularly travel abroad New or worsening cough, and are unable to follow respiratory/cough etiquette Fever New undiagnosed rash Sudden onset of diarrhea Drainage or leakage not contained in a dressing and/or medical appliance Any risk of colonization and/or infection with an Antibiotic Resistant Organism (ARO). See the ARO Screening Questionnaire (catalogue number 28125) on the Forms Navigation Bar.
2. Ongoing
A risk assessment should be completed on an ongoing basis, assessing the following: Is the patient continent? How susceptible is the patient to infection? Is their immune system intact? Does the patient have any invasive devices or open areas? What is the risk of exposure to blood, body fluids, microorganisms, mucous membranes or non-intact skin in the task about to be performed? Does the patient have a new or worsening cough, and are unable to follow respiratory/cough etiquette? Does the patient have a fever? Does the patient have a new undiagnosed rash? Does the patient have sudden onset of diarrhea? Does the patient have any drainage or leakage not contained in a dressing and/or medical appliance? How competent is the healthcare provider in performing the task? How cooperative will the patient be while the task is performed?
Page 19
Figure 2: Risk Assessment Decision Tree - Acute Care
Page 20
Table 2: Risk Assessment

Hand Hygiene (4 moments) for all patients Dealing with blood and/or body fluids Non-infectious diagnosed vomiting and/or diarrhea Non-draining wounds Based on the assumption that all blood and certain body fluids (urine, feces, wounds, and sputum) contain infectious organisms (bacteria, viruses or fungi). Routine practices reduce exposure and potential cross infection.
Routine Practice
Additional Precautions
Primary Reason
Known ARO positive/
Secondary Reason
ARO disease alert on patient chart Including known or recent history of Clostridium difficile Weeping Cellulitis/Shingles Known MRSA in sputum with productive cough With one or more of the following: fever, headache, sore throat, general aches and pains, lethargy, chest discomfort With Diarrhea NYD With one or more of the following: cough/ headache/rash (i.e. petechiae non blanching With any of the following: cough, head pain and malaise With new or worsening cough
Justification
Patient will remain on additional precautions if ARO disease alert is present despite any negative sets of results until reviewed by an ICP. Based on the assumption that feces contain infectious organisms (bacteria, viruses or fungi) Based on the assumption that infectious organisms are present Potential for infectious organism transmission via droplet route
Contact Precautions
Diarrhea NYD Draining infected wounds
Respiratory Infection with symptoms and/or New or Worsening cough
Potential for pneumonia, influenza A or B, Coronavirus, Rhinovirus, RSV, Adenovirus, etc. Potential for infectious organism transmission via droplet route, including Norovirus, etc.
Droplet Precautions
Vomiting NYD
Fever of >38.55 C (<35.6 or >37.4 C in the elderly))
Potential for Rubella (German Measles), Neisserria meningitides
Airborne Precautions
Rash resembling vesicles/pustules/ macules Query Pulmonary TB or history of Pulmonary TB
Potential for Rubeola, Variola, Chicken Pox, Varicella Zoster (that are widespread and cannot be occluded by dressings)
Potential for active Pulmonary TB
Page 21
B.
Risk Reduction
Risk reduction consists of many elements, all aimed at assisting the healthcare provider to minimize his/her exposure to and contamination with microorganisms. The degree to which the elements of risk reduction (e.g. personal protective equipment (PPE), clean environment) are implemented are dependent upon the findings of the Risk Assessment. For example, the choice of PPE and cleaning solutions will be determined by whether a patient presents with undiagnosed diarrhea or not. 1. Hand hygiene 2. Respiratory/cough etiquette 3. Patient placement 4. Personal Protective Equipment 5. Uniform and work clothing 6. Safe handling of sharps 7. Decontamination 8. Housekeeping 9. Laundry 10. Waste 11. Managing dishes/tray delivery 12. Recreational Reading Material 13. Play Equipment and Toys 14. Healthy workplace
1. Hand Hygiene
Hand hygiene is the single most important procedure for preventing cross infection. Body secretions, excretions, environmental surfaces and hands of all healthcare workers can carry microorganisms (bacteria, viruses and fungi) that are potentially infectious to them and others. Hand washing is known to reduce patient morbidity and mortality from hospital acquired infection. It causes a significant decrease in the carriage of potential pathogens on the hands.
Indications for Hand Hygiene The decision to decontaminate hands should be based on an assessment of the risk that microorganisms have been acquired on the hands and transiently carried to another person or location.
Page 22
Figure 3: The Four Moments for Hand Hygiene
Reference: Government of Ontario (2006)
Hand hygiene must be carried out in the following situations: At the beginning of every shift Before contact with any patient In between contact with each and every patient After contact with a patient on Additional Precautions or one who is colonized with microorganisms of special clinical significance, e.g. resistant to a number of antibiotics Before performing mouth care Before and after contact with susceptible sites, e.g. wounds, burns, IV sites Before performing invasive procedures, e.g. where natural defenses against infection are breached After hands have been contaminated, e.g. contact with body fluids, soiled linen, equipment or garbage After gloves have been removed Before handling food or medicines Before handling clean linen After using the toilet or after toileting others Before and after eating Prior to entering and leaving a nursing station
Page 23
Prior to using computers and other electronic devices
Hand hygiene may also be desirable at other times. The Infection Prevention and Control Team may request additional requirements for hand hygiene, e.g. during an outbreak of infection.
Nail and Skin Care The nails are the area of greatest contamination. Short nails are easier to clean and are less likely to tear gloves. Please refer to VIHAs Policy 15.1 Hand Hygiene Policy. Nail varnish is prohibited, regardless of colour, for staff with direct patient contact, or who work in areas where direct patient contact takes place Nail extensions/nail art and acrylic nails are prohibited for staff with direct patient contact, or who work in areas where direct patient contact takes place Ensure the skin on your hands does not become dry or damaged. In these conditions the hands show a higher bacterial load, which is more difficult to remove than with healthy, intact skin. Hand lotion may be used to prevent skin damage from frequent hand washing. Note: skin lotions for patient and/or staff use have been reported sources of outbreaks, so pump dispensers are preferable over tubes or jars. If a pump dispenser is not available, individualized containers must be used1 Creams that have been taken into a patients room should be dedicated to that patient and either disposed of or sent home with the patient on discharge Compatibility between lotions and antiseptic products, and lotions potential effect on glove integrity should be checked (i.e. lotions should not be petroleum based). Please check with Infection Prevention and Control or Occupational Health and Safety to ensure lotion is approved for use
Type of Cleansing Agent Alcohol Based Hand Rub Indications: Use routinely when hands are not physically soiled
Skin lotion and cream containers for patients are classified as single patient use items Page 24
Alcohol based hand rubs2 (ABHR) can be used in place of soap and water, except where hands are visibly soiled (e.g. feces, blood, etc.). They are especially useful in situations where hand washing and drying facilities are inadequate or where there is a frequent need for hands to be decontaminated (such as in clients homes). Every effort should be made to install these products as close to point of care as possible. Alcohol based surgical scrubs are used in situations where a reduction in the resident microbial flora is considered desirable, such as in an operating theatre or similar department, and before performing an invasive procedure, especially the placement of an indwelling medical device.
Reference: WHO, World alliance for Patient Safety (2006) WHO guidelines on hand hygiene in healthcare (advanced draft). April 2006. Report No: WHO/WPI/QPS/05.2
Soap and Water Indications: When hands are physically soiled When hands look or feel dirty Following contact with blood or body fluids Following contact with any patient with diarrhea/vomiting, and their environment, including bathroom facilities In clinical areas, soap is supplied as liquid or foam, in sealed containers, where the dispensing nozzle is integral to the container, and changed when the unit is empty. Soap dispenser pumps are never to be reused, refilled or topped up and must be disposed of once empty. It is recommended that hands are washed with soap and water if in contact with spores (e.g. Clostridium difficile), because the physical action of washing, rinsing and drying hands has been proven to be more effective than alcohols, chlorhexidine, iodophors and other antiseptic agents.
Handwashing Technique A brief wash will remove the majority of transient microorganisms, but the technique should aim to cover all surfaces of the hands. Where soap or a surgical scrub has been used, hands should be rinsed under running water and thoroughly dried with a disposable towel. The soap and hand towels should be of a quality acceptable to users, so as not to deter hand washing. The skin should be maintained in good condition to discourage the accumulation of bacteria.
2
The optimal concentration of ABHR is 70-90% with added emollients; a minimum of 70% ethanol will protect against Norovirus. If the ABHR is a gel, a minimum of 80% ethanol is recommended. ABHR dispensers should read volume per volume, not weight per volume.
Page 25
Hand hygiene should include the cleaning of arms to the elbow, especially when wearing a sleeveless apron.
Table 3: Levels of Hand Disinfection
Method
Social
Solution
Alcohol based hand rub or Soap and Water hand wash (if visibly soiled and/or contact with spores likely) Soap and Water hand wash followed by an alcohol based hand rub A 2 minute antiseptic wash (i.e. chlorhexidine (CHG 4%)) and dry on sterile towels or Soap and water hand wash followed by surgical alcohol based hand rub
Task
For Routine Practices
Hygienic hand disinfection Aseptic (Surgical scrub)
Prior to invasive procedures performed at unit level Prior to surgical procedures
Hand Hygiene Procedure The areas of the hands that are often missed are the wrist creases, thumbs, fingertips, under the fingernails and under jewelry. For this reason, only a plain wedding band with no stones is acceptable (please refer to VIHAs Policy 15.1 Hand Hygiene Policy).
Alcohol based hand rub technique Soap and water hand wash must be performed if hands look or feel dirty Apply an application to fill cupped palm of one hand Rub into all surfaces of hands (finger tips and nails, wrists, palms, backs of hands and between fingers) There must be sufficient wetness on all skin surfaces that it takes 15 or more seconds to dry Rub hands together until rub has evaporated prior to gloving or touching the patient
Soap and Water hand washing technique Wet your hands up to the wrists ensuring all surfaces of the hands are covered by water Apply the cleanser/soap Smooth it evenly all over your hands, including the thumbs and in between fingers, lather well rubbing vigorously. Place fingertips and nails into the lathered palm and rub. Repeat with opposite hand Rinse off every trace of lather under running water, to prevent skin irritation Dry thoroughly, taking special care between the fingers. More than one paper towel may be necessary
Page 26
Surgical asepsis (scrub) technique with an alcohol based hand rub Use sufficient product to keep hands and forearms wet with the alcohol based surgical scrub (ABSS) throughout the procedure (usually at least a cupped hand filled with ABSS). Apply ABSS to clean, dry hands and nails: Cup hand and hold 12 inches from the nozzle PUMP 1 o Dispense first full pump into the cupped palm of one hand (fill cupped hand) o Dip fingertips of the opposite hand into the ABSS and work in under the nails Wipe the excess solution from the fingertips back onto the palm of the same hand o Spread the remaining amount from the palm from wrist to elbow of the opposite arm, covering all surfaces PUMP 2 o Place another full pump into the opposite, dry palm and repeat the above procedure with the other hand PUMP 3 o Dispense a final full pump into either palm and reapply to all aspects of both hands up to the wrist o Proceed to the operating room suite holding hands above elbows After applying ABSS allow hands and forearms to dry thoroughly before donning sterile gloves and gown.
Surgical asepsis technique with a medicated soap Wash hands and arms up to elbows with a non-medicated soap before entering the Operating Room area or if hands are visibly soiled Start timing o Scrub each side of each finger, between the fingers and the back and front of the hands for 2 minutes o Scrub the arms, keeping the hand higher than the arm at all times. This helps to avoid recontamination of the hands by water running from the elbows, and prevents bacteria laden soap and water from contaminating the hands o Wash each side of the arm from wrist to elbow for 1 minute o Repeat this process on the other hand and arm, keeping the hands above the elbows at all times. If the hand touches anything except the brush at any time, the scrub must be lengthened by 1 minute for the area that has been contaminated o Rinse hands and arms by passing them through the water in one direction only; from fingertips to elbow o Proceed to the operating room suite, holding hands above elbows
Page 27
At all times during the scrub procedure, care should be taken not to splash water onto surgical attire Once in the operating room suite, hands and arms should be dried using a sterile towel before putting on gown and gloves. Aseptic technique must be maintained at all times
2. Respiratory Hygiene/Cough Etiquette

The transmission of SARS-CoV in emergency departments by patients and their family members during the widespread SARS outbreaks in 2003 highlighted the need for vigilance and prompt implementation of infection prevention and control measures at the first point of encounter within a healthcare setting. Respiratory hygiene/cough etiquette is targeted at patients/residents and accompanying family members and friends with undiagnosed transmissible respiratory infections, and applies to any person with signs of illness, including cough, congestion, rhinorrhea or increased production of respiratory secretions when entering a healthcare facility. The elements of respiratory hygiene/cough etiquette include: Education of healthcare facility staff, patients/residents and visitors Posted signs, in languages appropriate to the population being served, with instructions to patients/residents and visitors Source control measures (e.g. covering the mouth and nose with a tissue when coughing and prompt disposal of used tissues, using surgical masks on the coughing person when tolerated and appropriate) Hand hygiene after contact with respiratory secretions Spatial separation, ideally more than 6 feet between persons with respiratory infection in common areas, when possible
It should be noted that although fever will be present in many respiratory infections, patients/residents who are very old or very young and patients/residents with pertussis and mild upper respiratory tract infections are often afebrile. Therefore, the absence of fever does not always exclude respiratory infections.
Patients/residents who have asthma, allergic rhinitis or chronic obstructive lung disease also may be coughing and sneezing. While these patients/residents often are not infectious, cough etiquette measures are prudent.
Healthcare personnel are advised to observe droplet precautions and hand hygiene when examining and caring for patients/residents with signs and symptoms of respiratory infection. Healthcare personnel who have a respiratory infection are advised to avoid direct patient
Page 28
contact, especially with high risk patients/residents. If this is not possible, then a mask should be worn while providing patient care.
Modified from: Siegel, J.D., Rhinehart, E., Jackson, M. Chiarello, L. and the Healthcare Infection Control Practices Advisory Committee (2007) Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. June 2007
3. Patient Placement
A further aspect of routine practices is the decision making process for patient placement. Options include single patient rooms, two patient rooms and multi-bedded rooms/bays. Single room accommodation is always the preferred option. However, most facilities have limited resources in this area, and competing considerations when determining the appropriate placement of patients/residents. Single patient rooms are always preferred when there is a concern about the transmission of an infectious agent. In situations that require prioritization of such accommodation, it is prudent to prioritize these rooms for patients/residents who pose a high cross infection risk to other patients/residents, particularly for those who are at increased risk of an adverse outcome from the acquisition of an infection. Occasionally, due to the number of patients/residents who are colonized or infected with the same organism, cohorting the group of patients/residents in the same area may be an option (see ARO Room Placement).
4. Personal Protective Equipment

Personal protective equipment (PPE) is used for two reasons: To protect staff from blood or body fluid contamination To reduce the risk of cross infection through the reduction in contamination and transferring of microorganisms to other patients/residents, staff, visitors and the environment
Gloves The hands of clinical staff are the most likely means of transmission of healthcare associated infection. Through hand washing and the appropriate use of gloves the risk of cross infection is minimized. There are a number of materials used in the manufacture of gloves, including latex, nitrile and vinyl (PVC). The choice of material will depend on the type of task being performed, contact with chemicals and the risks associated with latex sensitization. The use of vinyl gloves is not
Page 29
recommended for prolonged tasks that require manual dexterity or when contact with blood or body fluids is anticipated. The purpose of wearing gloves is to either prevent the hands becoming contaminated with dirt or microorganisms, or to prevent the transfer of organisms already present on the skin or the hands. It is essential to ensure that hands are washed before putting on gloves and following the removal of gloves.
Table 4: Examples of Tasks that Require the Wearing of Gloves
Gloves must be worn:

When touching mucous membrane
Gloves should not be worn:

When there is no risk of exposure/ splash/ contact with blood, body fluids and non-intact skin When assisting or feeding a patient For social touch When pushing a wheelchair When delivering meals, mail, clean linen For providing care to clients with intact skin, e.g. taking temperature
When changing a dressing, or having contact with non-intact skin When changing diapers or adult briefs When performing personal hygiene for clients When performing mouth care When indicated for Additional Precautions
Staff must ensure that the appropriate type of glove is selected for particular procedures with the purpose to ensure safety and protection for staff and patients/residents. When considering the nature of the task, the need for sterile or non-sterile gloves should be assessed. Sterile gloves are worn to protect the patient during aseptic invasive procedures. Non-sterile gloves, latex or latex alternative (e.g. nitrile) are worn to protect the healthcare worker where direct exposure to blood or body fluids and other microorganisms is anticipated. Storage of disposable gloves: it is important to store latex and nitrile gloves separately at all times. This will include, and not be exclusive to, the clean utility room and within all clinical area where the gloves are available for use. Although latex gloves are low protein, there is still a risk of transfer of this protein to nitrile gloves. Nitrile gloves are recommended as an alternative product to latex in the presence of allergy.
Page 30
Table 5: Glove Use in Patient Care

Types Latex Specifications Material Level of protection Allergen content Strength and durability Puncture resistant Fit and comfort Chemical resistance Advantages Natural rubber Long standing barrier qualities Powder free are lower in allergens Very strong and durable Has re-seal qualities Provides excellent comfort and fit Good protection from most caustics and detergents Synthetic rubber Excellent physical properties and dexterity Contains no latex protein Very strong and durable Excellent puncture resistance Good fit due to high elasticity Excellent resistance Disadvantages Poor against oils, greases and organics Not recommended for individuals who have allergic reactions or sensitivity to latex Recommended use Most common glove type for a sterile glove and for significant exposures to blood and blood contaminated body fluids Recommended for weak acids, weak bases, alcohols, water solutions Storage DO NOT STORE near Nitrile gloves
Nitrile
Material Level of protection Allergen content Strength and durability Puncture resistant Fit and comfort Chemical resistance
Not recommended for aromatic solvents, many ketones, esters, many chlorinated solvents
Vinyl (PVC)
Material Level of protection Allergen content Strength and durability Puncture resistant Fit and comfort Chemical resistance
Polyvinyl chloride Good level of protection, but based on the quality of the manufacturer Punctures easily when stressed Rigid non elastic Medium chemical resistance
Not recommended for aliphatic, aromatic and chlorinated solvents, aldehydes, keytones Quality varies with manufacturers
Used as a general purpose glove when additional strength and dexterity are required Recommended for oils, greases, acids, caustics, aliphatic solvents Alternative to latex for those with a latex allergy for tasks where exposure to blood and body fluids is likely Most common type of general purpose glove for procedures of short duration and minimal exposure to blood and body fluids Recommended for strong acids, bases, salts, other water solutions, and alcohols
DO NOT STORE near Latex gloves
Adapted from: Sunnybrook Hospital (Toronto) June 2008

Page 31
Figure 4: Choosing the Correct Glove
Examination Glove
Latex / latex alternative (e.g. nitrile)
Vinyl (PVC)
Polyethylene/ Polythene
Sterile
Non-Sterile
Non-Sterile
Only used in catering
All aseptic procedures with potential exposure to blood or body fluids. Sterile pharmaceutical preparations.
Non-aseptic procedures with a high risk of exposure to blood or body fluids. Procedures involving sharps Handling cytotoxic material Handling chemicals and disinfectants
Tasks which are short and nonmanipulative Tasks which will not pull or twist the glove Tasks where contact with blood or body fluids is unlikely For cleaning tasks
Note: when handling chemicals and liquids, follow the manufacturers guidelines on glove selection.
Non-disposable household gloves are worn for tasks other than direct patient care (e.g. laundry, or for all work requiring chemicals, cleaners and disinfectants). Where the use of non-disposable household gloves is required, the: Employees department will provide them Department is responsible for maintaining written protocols on the use of gloves and ensuring that employees are aware of and comply with these protocols Gloves must meet WorkSafe BC standards for the task
Page 32
o Non-disposable gloves must be designated to the individual worker, and must be inspected by the worker daily to ensure that the gloves have no holes or tears in them. If gloves are damaged, they must be discarded and replaced o They must be dried and stored in a clean, dry area o Disposable gloves must not be used as a liner o If disposable gloves are used, then they must be changed regularly to ensure integrity and cleanliness o Regardless of type of glove, they must be washed between clean and dirty tasks and whenever the floor bucket disinfectant solution is changed.
Gowns/Aprons Disposable gowns and/or plastic aprons should be worn when there is a risk that clothing may become exposed to blood, body fluids and excretions, with the exception of sweat, or when close contact may lead to contamination by microbes from the patient, materials or equipment. Long sleeved impermeable gowns should be worn where there is a risk of contamination or splashing of blood, body fluids, secretions or excretions, onto the skin or clothing of the healthcare worker. Gowns and aprons are worn as single use items, and must be disposed of after one procedure or episode of patient care. Hand hygiene following apron use must include cleaning of exposed arms to the elbows. Scrubs or laboratory style coats/jackets worn over clothing are not considered to be PPE and must not be worn in place of a disposable gown. Their long sleeves also inhibit correct hand hygiene, and can be a source of contamination. Cloth gowns do not provide the required protection and should not be used. Gowns/aprons must be worn when the caregivers clothing is likely to become contaminated with blood, feces, urine or any other secretions They must be worn when the uniform is likely to become contaminated by microorganisms, e.g. during bed making They must be worn when giving direct patient care Gowns/aprons must only be worn for the duration of the task and disposed of as waste Personal Protective Equipment should be changed following procedures, between patients/residents, and if they become heavily contaminated or torn/split during a procedure Hand hygiene must be performed when the gown or apron is removed Hand hygiene must include cleaning of exposed arms to elbows if using an apron
Page 33
Masks, Visors and Protective Eyewear The mucous membranes of the mouth, nose and eyes are susceptible areas for infectious agents. Therefore, the use of masks, visors or protective eyewear and full-face shields are important parts of routine practices. Some masks are supplied with the additional protection of a visor. Masks with the additional protection of a visor are single use and must be disposed of when a period of care has finished. Some visors are also supplied as single use, and as such must not be decontaminated. However, reusable visors and goggles can be decontaminated using a Hydrogen peroxide solution, or ready to use Hydrogen Peroxide 0.5% wipe.
Masks are worn: By healthcare personnel when engaged in procedures requiring sterile technique to protect patients/residents from exposure to infectious agents carried in the healthcare workers mouth or nose By coughing/sneezing patients/residents to limit potential dissemination of infectious respiratory secretions from the patient to others By healthcare personnel when engaged in aerosol generating procedures with a patient with a droplet infection, e.g. open suctioning, nebulized medication, bronchoscopy
A fit tested3 N95 mask is to be worn: During the care of patients/residents who are diagnosed or suspected as having an airborne infection (e.g. Pulmonary Tuberculosis) N95 masks must be used during the entire period of infectiousness (consult with Infection Prevention and Control) A single-use N95 mask must only be worn once
Masks and eye protection or a visor are worn: By healthcare personnel to protect them from contact with infectious material from patients/residents, e.g. respiratory secretions and sprays of blood or body fluids, consistent with Routine Practices and Droplet Precautions.
Please refer to Donning & Doffing PPE posters
Fit tests are performed by Employee Occupational Health & Safety. Page 34
5. Hair/Jewelry/Uniforms
Hair Hair should be clean, neat and tidy Hair fastenings should be minimal Long hair should be tied up off the collar when working in the clinical setting
Jewelry Rings with stone settings must not be worn in clinical situations, as they compromise hand hygiene Wrist watches, bracelets, bangles or other wrist adornments must be removed when caring for patients/residents (exception: Medical Alert Bracelets) as they inhibit correct hand hygiene. Please refer to VIHAs Policy 15.1 - Hand Hygiene Policy for more information
Footwear Suede or fabric shoes are not acceptable as these cannot be shoe polished or machine washed
Dress Code for Staff Who Do Not Wear a Uniform, Including Medical Staff Long sleeves (i.e. scrubs, tee shirts or white coats with long sleeves) should not be worn in the clinical setting and when assessing patients/residents due to the increased potential of the cuffs coming into contact with patients/residents and becoming contaminated4 Ties and lanyards (e.g. hanging nametags) should be tucked in prior to taking part in clinical procedures
Dress Code for Staff Wearing a Uniform Sleeves should end above the elbow. Long sleeves (white coats with long sleeves) should not be worn in the clinical setting and when assessing patients/residents due to the increased potential of the cuffs coming into contact with patients/residents and becoming contaminated 5
If these requirements cannot be met for religious reasons, alternative options will be determined through discussion with Infection Prevention and Control and area Manager. 5 If these requirements cannot be met for religious reasons, alternative options will be determined through discussion with Infection Prevention and Control and area Manager.
Page 35
Material should be such that it may be laundered on a HOT WASH (above 65 degrees C) to ensure adequate decontamination. A clean uniform must be worn every shift/ working day Sweaters or jackets should not be worn over the uniform, as they are likely to become contaminated with microorganisms Uniform should be changed as soon as possible after finishing work Uniforms should not be worn when visiting public areas such as stores
References: Department of Health 2007 UNIFORMS AND WORKWEAR An evidence base for developing local policy Halls, F. et al 1984 A question of uniform. NURSING TIMES Vol 87: No50, pp 53 -54
6. Safe Handling of Sharps

The term sharps includes items such as needles, scalpels, scissors, broken glass a nd other items that may cause laceration or puncture to the skin. Sharps are responsible for a significant number of injuries to staff each year. Safe management of sharps can help to reduce the risk of injury, and therefore the acquisition of infections such as blood borne viruses by both staff and patients/residents. A high proportion of sharps injuries occur during disposal and waste collection. Many sharps hazards have been removed through the introduction of safety engineered sharps. Nonetheless, the prevention of sharps injuries is an essential part of routine practices, including handling and disposing of sharps in a manner that will prevent injury to the user and others. IV tubing should not be cut for disposal, as this will create a sharp end and risk aerosolising the contents. It is the responsibility of the user to ensure the safe disposal of a sharp.
Sharps disposal containers must be readily available in all areas Sharps must be discarded immediately after use, directly into a disposal container at the point of use Sharps must not be recapped after use, prior to disposal directly into a disposal container Never bend or break needles after use Do not disassemble needles from syringes or other devices; always dispose of as a single unit IV tubing should be placed directly into a sharps disposal container without cutting it Scalpel blades must be removed using forceps Never fill a sharps disposal container more that full Never leave a sharp protruding from the sharps disposal container
Page 36
7. Decontamination
Transmission of infectious agents can occur during casual contact from inanimate object to clean surfaces. Micro-organisms can survive on surfaces for long periods. All items of reusable equipment and furnishing in healthcare settings must be cleaned and disinfected/sterilized according to the manufacturers instructions between patient use (e.g. stretchers, BP cuffs, etc). Items that cannot be appropriately decontaminated must not be purchased. Discuss possible new equipment with IPC Practitioner prior to purchasing it in order to assess its suitability for the clinical area with regard to decontamination.
Cleaning Definition: cleaning is the physical removal of dirt and organic matter. Cleaning removes up to 80% of microorganisms and is an essential part of infection prevention and control. Organic matter can inactivate certain disinfectants, and therefore must precede disinfection and sterilization. It is important to ensure that multi-use equipment is cleaned properly between patients/residents. Equipment that is classified as critical or semi-critical must be disinfected at the appropriate level following each use (See Disinfection Requirements for Equipment). Non-porous non-critical and other items, for example scales or stethoscopes, can be easily cleaned with an intermediate or low-level disinfectant (see Reprocessing Decision Chart Table below and Classes of Organisms in Order of Susceptibility). Non-critical and other items made of fabric material should be cleaned when visibly soiled and following exposure to blood or body fluids. These items should also have an established routine cleaning with an intermediate or low-level disinfectant. Items such as blood pressure cuffs, which come into contact with the patient, should be wiped between patients/residents using a disinfectant wipe. Patients/residents on additional precautions require dedicated equipment wherever possible. If this is not possible, all equipment must be thoroughly decontaminated following each use, regardless of its classification. If equipment/device cannot be immediately disinfected, all soil must be immediately removed from the device.
Table 6: Reprocessing Decision Chart
Process Cleaning Some items may require low level Item All reusable equipment Examples All equipment requires cleaning after use and before further disinfection processes are initiated Products and methods Physical removal of soil, dust, or foreign material. Chemical, thermal, or mechanical aids may be used. Soap and water Page 37
Process disinfection
Item
Examples Specific environmental surfaces that are touched by personnel during procedures involving parenteral or mucous membrane contact (e.g. dental lamps) Bedpans, urinals, commodes Stethoscopes Blood pressure cuffs Ear specula Hemodialysis surfaces in contact with dialysate
Products and methods Enzymatic agents Quaternary ammonium compounds Some iodophors (e.g. 3% hydrogen peroxide)
Cleaning followed by intermediate level disinfection
After large environmental blood spills Alcohols or spills of microbial cultures in the Hypochlorite solutions laboratory Iodophors Glass or electronic thermometers Hydrotherapy tanks for patients/residents whose skin is not intact Cleaning Semi-critical Items intended for sterilization in the Flexible endoscopes, followed by items plasma or EO sterilizers must be laryngoscopes, respiratory high level meticulously cleaned prior to therapy equipment disinfection sterilizing. Nebulizer cups Anaesthesia equipment Pasteurization Nasal specula 2% gluteraldehyde Tonometer food plate 6% hydrogen peroxide Ear syringe nozzles Peracetic acid Vaginal specula Chlorine or chlorine compounds Vaginal probes used in sonographic scanning Pessary and diaphragm fitting rings Cervical caps Breast pump accessories Cleaning Critical items All items coming into contact with Glass or electronic thermometers followed by Steam under pressure sterile tissue sterilization Dry heat Surgical instruments All instruments used for foot care Ethylene oxide gas 2% glutaraldehyde All implantable devices 6-25% hydrogen peroxide Cardiac and urinary catheters peracetic acid All intravascular devices chlorine dioxide Biopsy forceps or biopsy 6-8% formaldehyde equipment associated with endoscopy equipment Bronchoscopes, arthroscopes, laparoscopes Cystoscopes Transfer forceps High speed dental hand pieces Adapted from: Health Canada, CCDR Hand Washing, Cleaning, Disinfection and Sterilization in Health Care, December 1998, Volume 24S8
Some Semi-critical items
Page 38
Disinfection Definition: Removal and destruction of most pathogens (or disease-causing organisms) by the use of friction (cleaning) and a use of a disinfectant. Usually disinfectants are cidal in that they kill the susceptible potential pathogenic agents. Generally, disinfectants used throughout VIHA both clean and disinfect. The selection of a disinfectant should be based on the function the disinfectant is expected to perform, not necessarily on a sales pitch or on what has always been used. Ideally, a disinfectant should be broad spectrum (eliminates bacteria, viruses, protozoa, fungi and spores). The Table on Classes of Organisms in Order of Susceptibility to Disinfectant outlines the classes of organisms and what is required in the way of disinfectants to eliminate them. Disinfectants are necessary in healthcare settings to kill potentially infectious microorganisms, but may be harmful to staff/patients/residents/public if used inappropriately. All disinfectants used in VIHA facilities are to be approved for use in healthcare facilities and possess a drug identification number from the Health Protection Branch of Health Canada Disinfectants should be compatible with the equipment/device to be disinfected The use of the device should be considered when deciding the type of disinfectant to use Personal and environmental safety should also be considered when selecting a disinfectant The manufacturers instructions for use and storage must be followed Disinfectants should also be: Non-irritating Non-toxic Non-corrosive Inexpensive Selection decisions should include effectiveness against the potential pathogenic agent, safety to people, impact on equipment, the environment, and expense.
Page 39
Table 7: Classes of Organisms in Order of Susceptibility to Disinfectants
Organism Type
Level of Disinfectant
Hardiest Organisms
Bacteria with Spores (B. subtitles, C. tetani, C. difficile, C. botulinum, B. anthracis) Protozoa with Cysts Giardia lablia, Cryptosporidium parvum) Mycobacteria (M. tuberculosis, M. avium-intracellulare, M. abscessus) Non-Enveloped Viruses (Coxsackievirus, poliovirus, rhinovirus, Norwalk-like Virus, hepatitis A virus) Fungi Candida species, Cryptococcus species, Aspergillus species, Dermatophytes) Vegetative Bacteria (Staphylococcus aureus, Salmonella typhi, Pseudomonas aeruginosa, coliforms)
Chemical Sterilant
High Level
Intermediate Level
Most Susceptible Organisms
Enveloped Viruses (Herpes simplex, varicella-zoster virus, cytomegalovirus, measles virus, mumps virus, rubella virus, influenza A and B virus, respiratory syncytial virus, hepatitis B & C viruses, hantavirus and human immunodeficiency virus)
Low Level
The effectiveness of a disinfectant depends on many factors. These include: Type of contaminating microorganism. Each disinfectant has unique antimicrobial attributes Degree of contamination. This determines the quality, efficacy and time of exposure of the disinfectant required Amount of protein based material present. High protein based materials absorb and neutralize some chemical disinfectants Presence of organic matter and other compounds such as soaps may neutralize disinfectants Chemical nature of disinfectant. It is important to understand the mode of action in order to select the appropriate disinfectant Concentration and quantity of disinfectant. It is important to choose the proper concentration and quantity of disinfectant that is best suited to each situation Contact time and temperature. Sufficient time and appropriate temperature must be allowed for action of the disinfectant and may depend on the degree of contamination and organic matter load
Page 40
Residual activity and effects on fabric and metal should be considered for specific situations Application temperature, pH and interactions with other compounds must be considered
Source: BCCDC Laboratory Services, A Guide to Selection and Use of Disinfectants, 2003
Table 8: Disinfection Requirements for Equipment
Category Critical Items that come in contact with the blood stream or sterile body tissues Semi Critical Items that come in contact with mucous membranes or non-intact skin Non-Critical Items that come in contact with intact skin Items that do not come in contact with the patients skin
Level of Disinfection Sterilization
Examples Surgical instruments Acupuncture needles Foot care instruments Internal scopes Contact lenses Reusable Peek Flow Meters Mouthpieces Thermometers Ear syringe nozzles Examination tables Stethoscope Blood pressure cuff Skin probes Furnishings Dishes Scales
High Level Disinfection High Level Disinfection Intermediate Level Disinfection Intermediate Level Disinfection
Low Level Disinfection
The advantages and disadvantages of the various chemical disinfectants are highlighted below.
Table 9: Advantages and Disadvantages of Major Chemical Disinfectants
Level of Uses Advantages Disadvantages Disinfection Manufacturers Recommendations for Concentration and Exposure Time must always be followed Alcohols IntermeExternal surfaces Fast acting Flammable keep away from (70% Isopropyl diate of patient No residue sources of ignition undiluted) assessment Non staining Dilution with water will diminish equipment, e.g. concentration and efficacy O2 saturation Inactivated by organic material monitors, finger May harden rubber or cause clips, deterioration of glues thermometers, Use in the OR near cautery is stethoscopes discouraged; can be on and glucometers. anesthetic carts or wall mounts Disinfectant
Page 41
Level of Uses Advantages Disadvantages Disinfection Manufacturers Recommendations for Concentration and Exposure Time must always be followed 6 Chlorines IntermeDisinfect Low cost Corrosive to metals Household bleach diate hydrotherapy Fast acting Inactivated by organic material, (5% Sodium tanks, dialysis Readily e.g. blood, feces Hypochlorite) equipment, available in non Irritant to skin and mucous mixed at a ratio of cardiopulmonary hospital settings membranes 1 part bleach to 9 training manikins Have sporicidal Use in well-ventilated areas parts water, for a and properties Unstable when diluted and total of 10 parts) environmental exposed to light (must be kept in surfaces. an opaque container) For effective use, the following Effective must be considered: disinfectant Appropriate dilution; following blood Stability/shelf life prior to spills. dilution; Stability/shelf life of product after dilution Follow manufacturers instructions for duration of shelf life, both before and after reconstitution Tablets and mixed solutions remain stable < 24 hours after reconstitution Bottles of bleach normally remain stable < 30 days after opening if in an opaque container. Household bleach (5% Sodium Hypochlorite) mixed at a ratio of 1 part bleach to 499 parts water, for a total of 500 parts) (1 cup per laundry tub) (100 ppm) For cleaning of personal laundry
Disinfectant
Also available in tablet and granule form. Follow manufacturers instructions for proper dilution. Page 42
Level of Uses Advantages Disadvantages Disinfection Manufacturers Recommendations for Concentration and Exposure Time must always be followed Hydrogen Low Equipment used Available to use Can be corrosive to aluminum, peroxide for home in ready-to-use copper, brass or zinc 3% concentrate healthcare, wipes Cannot be used on anesthetic diluted at a ratio patient Strong oxidant hosing of 1 part assessment and with good Limited sporicidal activity Hydrogen care at the cleaning Wet contact time must be more Peroxide to 16 bedside and properties than 5 minutes parts water for other treatment Fast acting patient care settings. Bactericidal in surfaces. less than 1 minute Viricidal in less than 5 minutes Environmentally friendly Hydrogen peroxide 3% concentrate diluted at a ratio of 1 part Hydrogen Peroxide to 64 parts water for floors Quaternary ammonium compounds (Usually diluted at 1 part quaternary ammonia to 256 parts water) Low Cleans floors, walls and furnishings.
Disinfectant
Routinely used in facilities for environmental cleaning in patient care areas (e.g. floors, walls and furnishings).
Inexpensive Generally nonirritating to hands in diluted form Contain cleaning properties Mildly corrosive
Limited use as disinfectant because narrow microbiocidal spectrum Non-sporicidal
Modified from: Health Canada. Canadian Communicable Disease Report, Dec 1998, Vol. 24S.
Sterilization The highest level of asepsis is defined by the removal of all microorganisms. It is achieved by autoclaving or by another sterilization process. Items must be thoroughly cleaned before sterilization can occur. For information on sterilization techniques used in your facility contact your local Central Sterilizing/Processing department. (Reprocessing Policy Manual)
Page 43
Storage Storage of Contaminated Equipment Storage of contaminated equipment is to be held in a designated area/container Gross soil must be removed before storage prior to cleaning The storage area must be physically separated (by walls where possible) from a clean area, and be cleaned daily Hand hygiene must be performed before leaving the dirty area Once items are cleaned, they should be labeled as such, and moved to a clean storage area Storage of Clean/Sterilized Equipment Areas designated for clean equipment should have a sign displayed identifying the area, and/or cleaned equipment should be labeled as clean Shelf life is event related, not always time related. Sterilized equipment/devices are no longer considered sterile if there is a disruption in the integrity of the packaging (e.g. packaging tear, the packaging becomes wet, or the item is dropped) Items purchased as sterile must be used before the expiration date. If the expiration date has passed, the item must be discarded The areas in which medical devices are stored or handled should be used for storage only, protected from vermin, moisture and the entry of dust from adjacent areas and ventilation systems. There must be sufficient storage space to prevent damage to the packages Sterile items should be stored in an area with limited traffic and a door Sterile medical devices should be stored at least: 25 cm from the floor 45 cm from the ceiling 5 cm from the wall Cardboard boxes must not be used for storage All storage should be above floor level to allow appropriate cleaning Storage must be away from a sink area, to prevent contamination from splashing
Event Related Sterility Devices that are received sterile must be maintained sterile until used or until the expiration date has passed, and they are discarded Shelf life of sterile items is event related. Event related factors that may cause contamination and decrease shelf life are: Method and frequency of handling (e.g. dropping a sterile item on the floor renders it contaminated)
Page 44
Method and conditions of storage, such as location (e.g. shelves located below knee level are considered at risk for contamination and are not appropriate for storage of sterile items) Space (e.g. sterile items stored beside a sink are at risk for splashing with water which compromises the integrity of packaging) Temperature, humidity and exposure to moisture, dirt, dust or vermin All sterile items must be checked for sterility before use. The date of expiration relates to product ingredients and stability. For packaged items, check to ensure the integrity of the package is intact and the sterile indicator is white with black stripes All cleaned and disinfected/sterilized devices must be covered and protected from moisture and dust during transport
8. Housekeeping
The environment acts as a suitable reservoir for many microorganisms, and therefore the provision of a clean environment for patient care is an integral part of infection prevention and control. (Housekeeping Section)
9. Laundry
All laundry is treated the same regardless whether a patient is on routine or additional precautions. Soiled linen shall be handled and transported in a manner in which contaminants are confined and contained. Clean linen that has been dropped on the floor is considered soiled. Soiled Linen Using the guidelines of routine practices, soiled or used linens generated from all sources are considered to be contaminated. Soiled linen from all patients/residents or areas will be handled in the same manner: Wear non-sterile gloves and disposable gown or apron Position hamper/tote/laundry bag in room (i.e. locate centrally in room and open lid) or as close to the room entrance as possible Ensure that linen is free of biomedical waste, sharps, instruments, and patients personal belongings Separately fold linen into itself. Avoid shaking or fluffing Dispose of into linen tote/hamper Remove PPE and perform appropriate hand hygiene Dirty linen is not to be placed on the bedside tables, floor or in the sink
Page 45
Soiled linen is to be handled as little as possible: Following removal from the patient bed space, linen must be immediately placed into a hamper/tote/laundry bag To prevent staff injuries, the soiled linen hamper/tote/laundry bags should not be overfilled. Close when full Linen that is heavily soiled, saturated or dripping should be placed in a leak proof clear plastic bag and then placed inside the regular hamper/ tote/ laundry bag The laundry hamper/tote/bags, particularly the large laundry bins should be stored in a predetermined dirty area that is at least one meter from any clean items and at least one meter from any fire equipment Mattresses and pillows that are covered with impervious plastic do not have to be sent to the Regional Laundry for cleaning and disinfecting as they can be effectively cleaned on-site using an appropriate disinfectant (see the Reprocessing Decision Chart). Mattresses and pillows must also be monitored for wear points, and replaced as necessary. Remove PPE after handling soiled linen and perform hand hygiene before handling clean linen
Laundering on the Units Laundering on units is not advocated in acute care setting. However, in some areas such as residential care settings it may be necessary. In these cases, the following is recommended: The outside of the machines (i.e. washer and dryer) should be cleaned with disinfectant prior to each use If hot-water laundry cycles are used, wash with detergent in water of at least 71o C (at least 160o F) for a cycle of 25 minutes or more Once washed, items should be dried quickly in a dryer (i.e. not air dried) The laundry area should be in a dedicated space and must not be located in the same area as a dishwasher or fridge (used for food)
Clean Linen Soiled linen must never come into contact with clean linen. Perform hand hygiene prior to removing clean linen from central supply area or from carts. Clean linen should be unpacked on return from the laundry and stored in a designated area within each department
Page 46
The linen room should have a door, which should be kept closed. If this is not possible then the linen cart covers should remain closed around the linen racks when not being accessed Clean linen must be stored at least one meter away from any dirty area/items or fire equipment Clean linen must be stored at least one meter from any dirty items Clean linen is to be handled as little as possible Linen which is removed from the clean supply area/cart is not to be returned to that cart The clean supply cart should only be stocked with one days supply, which should be used before restocking the cart Linen carts are to be dedicated for linen only. The clean linen carts are not to contain other supplies
Staff involved in the handling of linen shall ensure that there is no cross contamination of clean and soiled linens during transportation and storage.
Handling Soiled Linen contaminated with Hazardous Materials When hazardous materials are used, stored or disposed of, written safe work procedures must be developed and implemented for preparation, administration and waste handling. Departments intending to return soiled linens that are contaminated with hazardous materials must ensure that there is no potential risk to staff or patients/residents.
Hazardous materials include, but are not limited to: Chemicals that are a risk due to being toxic, poisonous, carcinogenic, noxious, flammable, combustible, corrosive or reactive with other chemicals. Radioactive substances that are present on soiled linen will be decontaminated at the site at which the patient resides. Linen contaminated by radioactive substances will not be sent to the Laundry until it is decontaminated by removing the radioactive nuclide contaminants or setting it aside for the appropriate time (i.e. ten half lives). Chemotherapy drugs (i.e. Antineoplastics).
Any contaminated linen identified by the user site as not able to be safely laundered will be disposed of by the original hospital. For replacement purposes, the originating hospital will inform the Regional Laundry of the disposal of its linen. If disposal of linen products contaminated by hazardous material is inevitable, the user hospital will consider the use of
Page 47
either disposable products or specific discard linen which are linens that are usable but near the end of their life cycle.
Note: Items of linen from patients/residents with unusual infections (e.g. Anthrax, Lassa Fever) should not be disposed of without consulting either the Medical Microbiologist in the first instance or the Infection Control Practitioner. Reference: Fraser Health Authority, Acute Care Infection Prevention and Control Manual, 2008
10. Waste
VIHA is committed to the safety of the general public, patients/residents and staff. This is of the utmost importance and, therefore, procedures will be adopted whereby any risks associated with waste disposal will be minimized. The object of this section is to provide guidelines and give procedures for the safe disposal of hospital waste. All garbage must be placed in leak proof bags and closed securely before removal from patients room. When garbage bags are full it should be secured and removed. All housekeeping staff will wear personal protective clothing when handling clinical waste. This clothing in normal circumstances will take the form of their general uniform, disposable apron and protective gloves. All staff who need to move bags of waste by hand should: Ensure the bags are effectively sealed and are intact Handle bags by the neck only Know the procedure in case of accidental spillage
Waste items such as used bandages, briefs and garbage are not to be placed on the bedside tables, floor or in the sink
Yellow Bag
Clinical / Biohazardous Waste
Containers of blood or other blood saturated body fluids. Disposable containers which are not emptied prior to disposal, should be securely taped shut and tubing clamped Secretions or exudates whose contents cannot be hygienically emptied into toilet (e.g. Hemovac, sputum vial) Transfusion lines or bags containing blood All body tissue including Exempt body tissue derived from the operating room Items saturated and dripping with blood and body fluids Microbiology cultures
Page 48
Black Bag
Domestic/ General Waste
Waste derived from the clinical and non clinical areas which is not mentioned above and is not heavily contaminated with blood or body fluids Urinary drainage bags and catheters Feces Office waste Kitchen waste
For chemotherapy disposal, see appropriate reference.
Biohazardous Waste Biohazardous waste bags should only be filled to full, as overfilling will prevent bags from being tied securely The containers for removal of biohazardous waste should be easily recognized, leak proof, and have a durable fitted lid. They must be sealed prior to transport and stored in areas unavailable to untrained staff, patients/residents or the public. Gloves and disposable apron should be worn when handling biohazardous waste. Hands should be decontaminated appropriately following removal of gloves Goggles or face shields should be worn when disposing of body fluids if there is a possibility of splash exposure to eyes or mucous membranes.
NOTE: Final disposal of Biohazardous waste will be either by incineration or by autoclaving followed by landfill disposal.
Spillage of Blood or Body Fluids (Body Fluids, Secretions and Excretions) Wear gloves and disposable apron Gross soil must be removed prior to cleaning and disinfecting Use paper towels for small spills, mop for large spills Clean the area Disinfect with approved hospital disinfectant or a fresh solution of household bleach (one part 5% bleach added to 9 parts water). Used paper towels, gloves and apron should be placed in Biohazardous Waste bag Mop heads should be placed in leak proof laundry bags Bucket contents should be poured down the hopper, and the bucket rinsed and wiped with the chlorine solution Hands must be washed at the end of the procedure
Page 49
Waste Containers Only impervious waste containers dedicated for the transporting of clinical waste should be used to minimize the potential for spillage and subsequent contamination of work place areas. Garbage bins used in all non-office environments should all have lids that ideally open with a foot-operated mechanism. Waste trolleys must be such that they can be easily cleaned and drained, do not offer harbourage to insects, and particles of waste do not become lodged in their fabric. The waste must be easily loaded, secured and unloaded. Clinical waste must not be transported in any other type of trolley. Biohazardous waste, sharps and general waste must never be mixed.
11. Managing Dishes, Glasses, Cups and Eating Utensils

Dishes/utensils are managed in the same manner, regardless whether a patient is on routine or additional precautions. Food Service workers must wash hands before leaving the kitchen and upon returning to the kitchen, after both delivery and pick-up of trolleys Food Service workers must decontaminate hands using an ABHR or wash hands upon entry and exit of each unit and as needed before handling the next tray in the event the patients personal effects were touched to allow placement of the tray on the over bed table. Gloves are not required in the delivery of trays For removal of trays, Food Service Workers must decontaminate hands upon entry to each unit and before putting on gloves. Trays are picked up from the over bed tables and returned to the trolley. Gloves are removed upon completion of tray pick-up, discarded appropriately, and hands decontaminated before leaving the unit. Carts must be covered prior to leaving the unit All trays and wares are washed, rinsed and sanitized in the kitchen area in accordance with standard dishwashing procedures Trolleys are washed, rinsed and sanitized by Food Services personnel between each meal period, and allowed to air dry before reuse Trolleys left on the unit for late trays are to be washed, rinsed and sanitized when taken to the food services area, and at a minimum on a weekly basis Note: Food Service Workers will not pick up any trays that contain bodily fluids or sharps. They will bring this to the attention of the nursing staff.
Routine Practices
Tray Delivery
Wash hands prior to tray delivery. Disposable gloves not required.
Tray Pick-up
Wear disposable gloves.
Page 50
Unit Staff Food Service Worker
Over bed table must be free of equipment and debris. Food Service worker does not clear over bed table. Place the tray on the over bed table following standard tray delivery procedures.
No preparations required.
With gloved hands, pick-up the tray and return it to the tray cart. Gloves are removed upon completion of tray pick-up, discarded, and hands washed or alcohol based hand rub applied before leaving the unit.
Managing Tray Delivery Procedures Specific to Additional Precautions The automated decontamination washing process effectively deals with all microorganisms. Disposable dishes and utensils will not be used. Food Services personnel wear aprons and gloves to strip all trays as all patient trays are considered contaminated Food trays must never be bagged. On the rare occasion that a patient vomits onto the tray, nursing staff (using droplet precautions) rinse off the vomit prior to returning the tray to the kitchen for disinfection Note: Food Service Workers will not pick up any trays that contain bodily fluids or sharps. They will bring this to the attention of the nursing staff. Contact Precautions (Yellow Sign) Unit Staff Food Service Worker Tray Delivery
Wash hands prior to tray delivery. Disposable gloves not required Over bed table must be free of equipment and debris. Food Service worker does not clear over bed table. Place the tray on the over bed table following standard tray delivery procedures.
Tray Pick-up
Wear disposable gloves No preparations required.
With gloved hands, pick-up the tray and return it to the tray cart. Remove gloves, wash hands or use ABHR and put on clean gloves prior to collecting any other trays.
Droplet Precautions (Green Sign)
Tray Delivery
Tray Pick-up
Unit Staff
Wash hands prior to tray delivery. Wear disposable gloves Disposable gloves not required Note: Food Service Personnel will not deliver/collect trays for anyone with gastro-intestinal symptoms Over bed table must be free of Nursing staff return the tray to the debris. Tray is taken directly from trolley for anyone on droplet the trolley and delivered by nursing precautions. Ensure the trolley is left staff to patients/residents on droplet uncovered. precautions. Trolley is brought to the unit. Trays for patients/residents on droplet Trays are not removed from patient rooms for anyone on droplet Page 51
Food Service Worker
precautions are left on the trolley and unit staff are notified. Trays are delivered to patients/residents on routine practices or contact precautions.
precautions. With gloved hands, collect trays from patients/residents on routine practices or contact precautions. Gloves are removed upon completion of tray pick-up, discarded, and hands washed or ABHR applied before leaving the unit.
Airborne Precautions (Blue Sign) Unit Staff
Tray Delivery
Wash hands prior to tray delivery. Disposable gloves not required Over bed table must be free of debris. Tray is taken directly from the trolley and delivered by nursing staff to patients/residents on airborne precautions. Do Not Enter the room. Trays for anyone on airborne precautions are left on the trolley and the unit staff notified. Trays are delivered to patients/residents on routine practices or contact precautions.
Tray Pick-up
Wear disposable gloves Nursing staff return the tray to the trolley for anyone on airborne precautions. Ensure the trolley is left uncovered.
Food Service Worker
Trays are not removed from patient rooms for anyone on airborne precautions. With gloved hands, collect trays from patients/residents on routine practices or contact precautions. Gloves are removed upon completion of tray pick-up, discarded, and hands washed or ABHR applied before leaving the unit.
12. Recreational Reading Material and Games

For normal operations outside of an outbreak situation: Magazines, book and puzzles in optimal condition may be placed in waiting areas and patient lounges for everyones enjoyment. If magazines/books/puzzles are torn, soiled or wet they must be removed and discarded. For operations during an outbreak situation: Magazines/books/puzzles/clutter will be removed from waiting rooms and patient lounges, in order to ensure required additional cleaning can be achieved. The Infection Prevention & Control Program will provide direction for the removal of magazines/books/puzzles/clutter from waiting rooms and patient lounges, during these times.
13. Play Equipment and Toys

Toys can be a reservoir for potentially pathogenic microorganisms that can be present in saliva, respiratory secretions, feces or other body substances. Toys referred to in this section include infant and toddler toys, dolls, games, books, puzzles, cards, craft supplies, electronic equipment and teaching toys/dolls.
Page 52
There will be written procedures (developed by each department) regarding the frequency and method for cleaning the toys Before and after playing with toys, children should be encouraged to or assisted in cleaning their hands with alcohol-based hand rub or soap and water Toys that are in a general play area must be easily cleanable or dedicated to a single child Toys will be nonporous and able to withstand rigorous mechanical cleaning Smooth/non-textured toy surfaces are essential to facilitate cleaning Water-retaining bath toys will not be used All toys will be cleaned and disinfected between users Playhouses/climbers will have their high touch surfaces cleaned on a daily basis. A thorough cleaning will be done on a regular schedule (developed by each department) Shared electronic games, video equipment and computers will be cleaned on the outer surface between users Playrooms or play areas that are used by more than one child will have an area for segregation of dirty toys (e.g., a bin into which children/parents/staff can place used toys), this area will have clear signage Clean toys will be stored in a manner that prevents contamination (e.g., dust and water splatter) and will be clearly marked as clean Toy storage boxes/cupboards will be emptied and cleaned weekly or earlier if visibly soiled
Please Note: For a child on Additional Precautions, the items are to be dedicated to that particular child and terminally cleaned upon discharge or when precautions are discontinued. Please Note: Toys should be removed from general waiting rooms if an adequate process cannot be established to ensure their daily inspection, cleaning and disinfection. Any toy that is found to be damaged, cracked or broken will be discarded.
Modified from: CHICA-Canada Practice Recommendations for Toys, November 20 2011
14. Healthy Workplace Worksafe BC refers to the term "workplace contaminants" as meaning chemical or biological substances arising from workplace processes, and may include airborne contaminants or contaminants on surfaces, such as tables, benches, eating utensils, clothing, or skin. The employer must ensure food is not stored or consumed in areas where the presence of these contaminants could result in a hazard to workers as a result of ingestion with food or beverages.
Page 53
Reference: Worksafe BC, OHS Regulation and Related Materials. General Conditions 4.84 Eating Areas, accessed December 5 2011
Please Note: Staff will refrain from keeping or consuming food in an area of a workplace where it could become unwholesome because of workplace contaminants
C.
Education
The final, and it could be argued the most important, element of routine practices is Education. The ongoing acquisition of knowledge related to what are the best infection prevention and control strategies and the communication of that knowledge to fellow professionals, patients/residents and visitors, followed by the demonstration of these skills in day to day practice, and are the keystones to ensuring the ongoing safety of VIHA patients/residents and staff. The following are ways in which education can be used to break the chain of transmission.
Understanding infection prevention and control practices. Understand and demonstrate work practices that reduce the risk of infection (e.g. hand hygiene, proper use of PPE, be immunized, and do not come to work with a communicable disease). Who provides infection prevention and control expertise to your setting? Who would you call for help? (See list of VIHA Infection Control Practitioners on the Contact Us navigation bar.)
Educate patients/residents/families about hygiene and infection prevention strategies such as hand hygiene. Know where to find in your facility (or who to ask for) standardized education materials on infection reduction strategies such as hand hygiene, respiratory etiquette, and influenza vaccination Be able to identify unusual clusters or illnesses (e.g. respiratory, gastrointestinal, skin); and be aware of person, time, place tracking; and report to the appropriate person
Infection prevention and control health promotion Attend in-services and read scientific literature on infection prevention and control Provide leadership and act as a role model to other healthcare providers, patients/residents and visitors with regard to infection prevention and control principles (e.g. communicate new/current material to other health professionals and patients/residents/families)
Page 54
Demonstrate work practices that reduce the risk of infection (e.g. use hand hygiene, use proper equipment, be immunized, and do not come to work with a communicable disease)
Modified from: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007
2.
ADDITIONAL PRECAUTIONS
Additional Precautions are required when routine practices are not sufficient to prevent transmission of certain microorganisms. 7 For example, additional precautions are warranted for: Diseases, either suspected or confirmed, during the infectious state Situations in which contamination of the patients environment is likely (e.g. a patient with diarrhea that cannot be contained) Patients/residents infected (and/or colonized in acute care) with certain organisms of interest that may be transmitted easily by direct or indirect contact with the patient (intact skin, wounds, or coughing) or with their environment
Reference: Public Health Agency Canada (1999) Infection Control Guidelines; routine practices and additional precautions for preventing transmission of infection in healthcare. Health Canada.
A.
Contact Precautions
1. Purpose
Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patients environment, e.g. scabies, antibiotic resistant bacteria (MRSA, ESBL). The application of contact precautions for patients/residents infected or colonized with Antibiotic Resistant Organisms. Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive
7
It is important to be sensitive to the effect that Additional Precautions have on patients and others. Patients can feel stigmatized by all the paraphernalia (e.g. gowns, masks, etc) and other patients/visitors may be concerned about their own personal safety. It is best to advise all concerned that the interventions are taken to protect everyone patients, staff and the public alike.
Page 55
environmental contamination and risk of transmission of microorganisms. The specific agents and circumstances for which contact precautions are indicated are found in Appendix A.
2. Requirements Signage and Placement

Contact precautions signage must be posted on the door and by patients bed in multi bed rooms. (See Contact Precautions poster, Catalogue # 0040506, on the Precaution Signs navigation bar on the Infection Prevention and Control website) A single-patient room is preferred for patients/residents who require contact precautions The door may be left open When a single-patient room is not available, consultation with the Infection Control Practitioner is recommended to assess the various risks associated with other patient placement options (e.g. cohorting, keeping the patient with an existing roommate) In multi-patient rooms, at least two meters (6 feet or more) spatial separation between bed and curtain is advised to reduce the opportunities for inadvertent sharing of items between the infected/colonized patient and other patients/residents
Page 56
3. Contact Precautions Staff, Patients/Residents, Visitors
Staff
Routine practices to be followed at all times
Patients/Residents
Patients/residents leaving room for tests/mobilization/ rehabilitation will do so with permission of healthcare provider Patients/residents will perform hand hygiene upon exiting and re-entering unit/room
Visitors
Hand hygiene will be performed upon entering/leaving the facility and the patients room
Healthcare personnel will wear appropriate PPE for all interactions that may involve contact with the patient/patient environment
Visitors/relatives will wear appropriate PPE when providing care or very close patient contact, as directed by responsible nurse
PPE will be changed following procedures, between patients/residents or when heavily contaminated/torn/split during a procedure Ensure single use and dedicated patient equipment for the duration of precautions -i.e. dedicated commode
Patients/residents will wear a clean nightgown/house coat or clothes
Visitors will not visit multiple patients/residents/rooms during a visit
Patients/residents wounds will be covered with a fresh dressing
Visitors must not visit public areas within the facility (unit kitchen, cafeteria, shops/kiosks in main entrance etc.) and SHALL NOT use the patient/resident bathroom
Shared equipment will be decontaminated appropriately prior to removal from precaution room and before further use All dedicated equipment will be decontaminated appropriately on discharge of patient / discontinuation of precautions and prior to removing from patient room Diagnostic procedures will not be postponed, inform receiving department of necessary precautions on the requisition or advising by telephone. Attempt should be made to book infectious cases at the end of the day Linen and garbage will be placed in regular bags and closed securely prior to removal from room
Page 57
B.
Droplet Precautions
1. Purpose
Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Droplet route means spread by large particle droplets when patients/residents cough, sneeze or talk (i.e. within a radius of two meters, or 6 feet). Because these pathogens do not remain suspended over long distances in a healthcare facility, special air handling and ventilation are not required to prevent droplet transmission. Infectious agents for which droplet precautions are indicated are listed in Appendix A and include B. pertussis, influenza virus, adenovirus, rhinovirus, N. meningitidis, and Group A streptococcus (prior to and for the first 24 hours of antimicrobial therapy).

Droplet Precautions sign must be posted on the door and next to patients bed in multi -bed rooms. (See Droplet Precautions poster, Catalogue #0040508, on the Precaution Signs navigation bar on the Infection Prevention and Control website.) During periods of high census, patients/residents on droplet precautions might be placed in a two or four-bed room. A green Droplet Precaution sign will be posted outside the room as well as on the curtain of the affected patient within that room. Single Room: the doors to single rooms can be kept open When a single-patient room is not available, consultation with infection prevention and control personnel is recommended to assess the various risks associated with other patient placement options (e.g. cohorting patients/residents with the same infection, keeping the patient with an existing roommate) Spatial separation of at least two meters (6 feet or more) from patient to curtain and drawing the curtain between patient beds is especially important for patients/residents in multi-bed rooms with infections transmitted by the droplet route
3. Droplet Precautions Staff, Patients/Residents, Visitors
Staff
Routine practices to be followed at all times. Gown, gloves and a surgical grade mask (120 mmHg) with visor will be worn within 2 metres (6 feet) of the patient. Particularly important when care promotes respiratory secretions, e.g. nebulisers, suctioning
Patients/Residents
Patients/residents leaving room for tests/mobilization/ rehabilitation will do so with permission of healthcare provider
Visitors
Page 58
Staff
PPE will be changed following procedures, between patients/residents or when heavily contaminated/torn/split during a procedure
Patients/Residents
Will wear a surgical grade mask (120 mmHg) without visor with ear loop design, fitted to the face
Visitors
Visitors/relatives who are providing care or very close patient contact within 2 metres (6 feet), will wear a surgical grade mask (120 mmHg) with ear loop design and attached visor. Additional appropriate PPE will be worn when directed by responsible nurse Visitors will not visit multiple patients/residents/rooms during a visit
Ensure single use and dedicated patient equipment for the duration of precautions i.e. dedicated commode Shared equipment will be decontaminated appropriately prior to removal from precaution room and before further use
Patients/residents will perform hand hygiene upon exiting and re-entering unit/room
Patients/residents will wear a clean nightgown/house coat or clothes
All dedicated equipment will be decontaminated appropriately on discharge of patient / discontinuation of precautions and prior to removing from patient room Diagnostic procedures will not be postponed, inform receiving department of necessary precautions on the requisition or advising by telephone. Attempt should be made to book infectious cases at the end of the day Linen and garbage will be placed in regular bags and closed securely prior to removal from room
Patients/residents wounds will be covered with a fresh dressing
C.
Airborne Precautions
1. Purpose
Airborne Precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (e.g. measles virus, varicella zoster virus [chickenpox], pulmonary tuberculosis, smallpox and possibly SARS-CoV). See Appendix A for detailed list.
Page 59

Airborne Precautions sign should be posted on the door indicating N95 mask and other appropriate precautions. (See Airborne Precautions poster, Catalogue #0040504, on the Precaution Signs navigation bar on the Infection Prevention and Control website.) The preferred placement for patients/residents who require Airborne Precautions is in a Negative Pressure Room. A Negative Pressure Room is a single-patient room that is equipped with special air handling and ventilation capacity. Negative Pressure Rooms have: Monitored negative pressure relative to the surrounding area 6 air exchanges per hour for existing facilities For all new construction and renovations, 12 air exchanges per hour are required Please access the Infection Prevention and Control internal web site for a list of Negative Pressure Rooms throughout VIHA
Reference: http://www.cdc.gov/hicpac/2007ip/2007ip_part3.html.
For patients within negative pressure room: Nursing staff will document that the room is compliant with negative pressure standards every shift FMO will ensure that the room is compliant with negative pressure standards daily In settings where airborne precautions cannot be implemented: Place the patient in a private room Keep the door to the room closed Have the patient wear a surgical grade mask (if possible) Staff must wear a high efficiency N95 mask for which they have been fit tested Visitors must wear a surgical grade (120 mmHg) fluid resistant mask (without visor) when in patient room (N95 respirators are only effective if they have been fitted properly) Arrange for transfer of patient to a facility with a Negative Pressure Room and contact Infection Prevention and Control. (See list of Infection Control Practitioners on the Contact Us navigation bar on the Infection Prevention and Control website) Please Note: Facilities Maintenance and Operations Department must be contacted when a Negative Pressure Room is required to verify that the room is monitored and airflow remains negative to surrounding areas.
Page 60
3. Airborne Precautions Staff, Patients/Residents, Visitors
Staff
Routine practices to be followed at all times. All staff entering patients room, escorting , treating or examining the patient must wear a high efficiency N95 mask the type and size for which they have been fit tested Wherever possible, non immune health care workers should not care for patients/residents with vaccine preventable airborne diseases
Patients/Residents
Patients/residents must remain in the room unless medical condition warrants urgent/emergent procedure /intervention.
Visitors
If the patient is required to leave the room for diagnostic procedures, patient will wear a surgical grade (120 mmHg) fluid resistant mask (without visor), fitted to the face if their respiratory status permits
Visitors/relatives will wear appropriate PPE when providing care or very close patient contact, as directed by responsible nurse. All visitors, whether or not providing care, must wear a surgical grade (120 mmHg) fluid resistant mask (without visor) Instructions on application of surgical grade (120 mmHg) fluid resistant mask (without visor) must be provided and use encouraged Visitors will not visit multiple patients/residents/rooms during a visit
The doors to the room must be kept closed
Patients/residents on airborne precautions are not permitted to go outside for a cigarette alternative nicotine source ordered by MRP Patients/residents will perform hand hygiene upon exiting and re-entering unit/room
Following a risk assessment, routine practices may dictate the use of gloves and gown during the episode of care PPE will be changed following procedures, between patients/residents or when heavily contaminated/torn/split during a procedure
Ensure single use and dedicated patient equipment for the duration of precautions i.e. dedicated commode. Individual sharps container must be in the room/ante room. Limit equipment and personal items. Used equipment is placed in Central Sterilizing/Processing bin. Items must be cleaned prior to placing in the bin Shared equipment will be decontaminated appropriately prior to removal from precaution room and before further use All dedicated equipment will be
Page 61
decontaminated appropriately on discharge of patient / discontinuation of precautions and prior to removing from patient room
Staff
Diagnostic procedures will not be postponed, inform receiving department of necessary precautions on the requisition or advising by telephone. Attempt should be made to book infectious cases at the end of the day Linen will be placed in regular bags and closed securely prior to removal from room Garbage will be placed in regular bags and closed securely prior to removal from room. Use of biomedical waste bags is not necessary Dietary staff do not deliver or remove food trays for rooms with patients/residents on airborne precautions. Regular dishes are to be used
Patients/Residents
Visitors
4. Actions when Negative Pressure Room Not Available or Malfunctions

If a negative pressure room is either not available or is non-functioning at your facility, the following steps should be taken: Consult with Infection Prevention and Control to determine risk Place patient in private room Ensure windows and door remain closed, even if the patient is not in the room Ensure bathroom fan is off and remains off Patient will wear surgical grade mask( if possible) when healthcare staff and/or visitors are in the room Staff must wear a high efficiency N95 mask for which they have been fit tested when in patient room
Page 62
Visitors must wear a surgical grade (120 mmHg) fluid resistant mask (without visor) when in patient room (N95 respirators are only effective if they have been fitted properly) Arrange for transfer to facility with Negative Pressure Room and contact Infection Prevention and Control The following steps should be followed when the Negative Pressure Room monitoring system indicates a failure with the system: Check that windows and doors are closed Contact Facilities Maintenance and Operations (FMO) immediately If FMO determines the problem cannot be fixed, follow the above policy for a facility with no Negative Pressure Room Please Note: FMO must post, or have available, a record of inspection and maintenance verifying the efficient operation of these negative air pressure room technologies. A regular schedule of inspections of such rooms must be established and maintained. There should be daily monitoring of negative pressure by nursing staff when room is in use.
5. Negative Pressure Room Following Patient Discharge or Transfer

All Health Care Workers entering a room occupied by or vacated by a suspect or confirmed infectious TB case shall wear appropriate respiratory protective device until 99% of the airborne contaminants have been filtered. Upon discharge or transfer, the door of a room occupied by a suspect or confirmed infectious TB case should remain closed and another patient should not be placed in the room until 99% of the airborne contaminants have been removed (see chart below).
Table 10: Air Exchanges Air changes per hour and time in minutes required for removal efficiency of 99% of airborne contaminants Minutes Required 99% Air Exchange Per Hour Removal Efficiency
1 2 3 4 5 6 7 8 276 138 92 69 55 46 39 35
Page 63
9 10-15
31 28
D.
SUMMARY OF PRECAUTIONS
Table 11: Precautions Table
Contact
Droplet
N. menigitidis, Mumps, Pertussis, Norovirus, vomiting, Influenza, invasive Group A streptococcus Toxic Shock, 2 or more of the following: Stiff neck Fever Headache Malaise Acute cough Preferred. If in multi-bed room draw curtains NO Gown + Gloves + Surgical grade (120 mmHg) fluid resistant mask with face shield Surgical grade (120 mmHg) fluid resistant mask with attached face shield (gown + gloves if providing 2 direct care ) Patient YES (if condition Staff
allows) YES (with attached face shield)
Airborne
Organism Based Precautions (not complete list)
MRSA, Clostridium difficile , lice, scabies
Pulmonary Tuberculosis, Measles, Chickenpox, disseminated Zoster
Syndromic Precautions
Draining wound, diarrhea NYD, infestation
Fever, weight loss+ cough, high TB risk, disseminated rash + fever
Private Room Negative Pressure Room Staff Personal Protective Equipment
Preferred
YES
NO
YES
Gown + Gloves
Gown + Gloves + 8 N95 mask
Visitor Personal Protective Equipment
Gown + Gloves 9 if providing direct care
Surgical grade (120 mmHg) fluid resistant mask (gown + gloves if providing 2 direct care ) Patient YES (if condition
allows)
Transporting patient (need for Surgical grade 120 mmHg fluid resistant mask)
Patient NO Staff - NO
Staff NO (must wear N951)
8 9
Fit tested Direct care = hands on care (i.e. bathing, dressing changes, toileting) Page 64
Cleaning
Precaution Clean
Precaution Clean
Precaution Clean
E.
Protective (Reverse) Precautions
Patients/residents with a suppressed or deficient immune system may be at increased risk of acquiring infection during hospitalization. Gowns, gloves and masks are not routinely required. Instrumentation (e.g. catheters and other devices) is to be used only when essential. The physician decides whether or not the patient requires Protective Precautions. Variables the physician may consider are: Severity of immune system depression Length of time patient has been neutropenic Absolute neutrophil count of 0.5 x 109/1 or less (Neutropenia) Procedure Routine practices are to be followed at all time including strict hand washing prior to all patient contact Place in a single room (preferably a Positive Pressure Room if available). Keep door closed. Place sign on door to notify other staff Limit raw vegetables and fruit. Fresh flowers are not allowed in the room Offer bottled/filtered water and commercially prepared single serving fruit juices Staff aware of incubating or having infection must not care for these patients/residents Visitors with any signs and symptoms of infection should be encouraged to avoid patient contact
F.
Management of Cases on Additional Precautions in Diagnostic Areas
Medical intervention and investigation should not be delayed because a patient requires additional precautions (however, if the test or treatment can be provided in the patient room this should be the first consideration). Use PPE and precautions as indicated on the Additional Precautions sign on the door of the patients room Porters must comply with precautions noted on signage, and must be instructed to remove attire and wash hands upon completion of transport. All equipment used must be appropriately cleaned following transport
Page 65
Charts should not be left on patients bed or given to patient to hold. If no other option is available, charts can be housed in a disposable bag or pillowcase for transport purposes For actively infected patients/residents (if unsure consult with Infection Prevention and Control), follow these procedures: The patient should be taken directly to the procedure room and not left in the corridor For non-urgent cases, book as the last case of the day; this facilitates cleaning of equipment Limit the number of moves and exposure to surfaces whenever possible Remove as much equipment as possible from the room Close all cupboard doors to protect equipment from exposure Use sheets to cover any equipment that cannot be encased or removed Should staff require equipment from a cupboard or from under a cover while performing diagnostic tests on infectious patients/residents, ensure that staff remove gloves and wash hands prior to obtaining this equipment. It is important that contamination of other packages does not occur, as many organisms can survive in the environment for long periods Upon completion of the procedure the patient should be returned to the unit as quickly as possible
Page 66
Figure 5: Management of Infected Patients/Residents on Precautions in Diagnostic Areas

Use Routine Practices for all care. Routine Cleaning
Is patient on Additional Precautions?
NO
YES
Can test/procedure be done in patient's room?
YES
Apply Precautions as identified on signage. Clean equipment post procedure.
NO
Is patient having an invasive interventional procedure? (i.e. Imaging)

NO
YES
Protocol B
What Personal Protective Equipment is required?
Gloves and Gown
Gloves, Gown and Mask
Can patient wear a mask?
NO
Protocol B
YES
PROTOCOL B:
Protocol A
Protocol A
PROTOCOL A: Minimize patient and staff contact with equipment. Clean patient and staff contact areas post-procedure.
Prepare environment:; Schedule as last case Close cupboard doors Move unnecessary equipment as far from patient as possible and cover with a sheet Prepare tray/equipment Use clean circulator only to access supplies TerminalClean post procedure all contact surfaces. (Closed cupboards which were not entered and covered/untouched equipment do not require cleaning.)
Page 67
G.
Discontinuing Additional Precautions
The table below outlines the criteria for discontinuing the use of additional infection control precautions without prior consultation with an Infection Control Practitioner. Please notify your Infection Control Practitioner when this occurs.
Table 12: Procedure for Discontinuing Additional Precautions
Routine Practices are used at all times. Additional precautions are in effect when symptoms of infection are present or when concerning infectious diseases are diagnosed. Additional Precautions may ONLY be discontinued when the following criteria are met: Notify your IPC Practitioner when this occurs PRECAUTIONS REASON ARO positive C.difficile positive CRITERIA
ONLY when authorized by Infection Prevention & Control 48 hours without diarrhea and formed/normalized stools are documented Stools formed/normalized x 48 hours and Negative C.difficile toxin Wound culture results are not MRSA and ARO culture results are negative and Antibiotics given for 24 hours or more and Clinical improvement observed Responding to antibiotics given for 24 hours or more OR 5 days since start of symptoms when a viral infection is suspected (labs, physical findings) AND Culture of sputum or blood is negative for MRSA AND Negative viral swab for influenza Negative ARO cultures OR Cough is resolved but must continue with Contact Precautions Cough is resolved but must continue with Contact Precautions Antibiotics given for 24 hours or more and Clinical improvement observed No diarrhea or vomiting x 48 hours Concentrated AFB smears negative x 3 ONLY when authorized by Infection Prevention & Control All skin lesions crusted Until lesions can be covered with dressings or are crusted over
Contact Precautions*
Diarrhea NYD (no vomiting) Skin/soft tissue infection or cellulitis
New or worsening cough
Droplet Precautions*
Suspected MRSA with cough Known MRSA with cough Fever with rash NYD, suspect Meningitis Diarrhea NYD with vomiting Suspected pulmonary TB Diagnosed pulmonary TB Chickenpox Widespread Varicella Zoster (Shingles)
Airborne Precautions*
* Immediately have the room discharge cleaned following VIHA Guidelines, Facility specific, even if the patient is not being discharged from the Unit/Facility
However, your Practitioner, in consultation with the Infection Prevention & Control Physician, may determine that precautions can be removed earlier for some situations (e.g. C.difficile).
Page 68
PART 4: HOUSEKEEPING
1. Clean Environment
[NOTE: This includes direction relating to current housekeeping service levels only.]
PRINCIPLES: As a guiding principle, all healthcare workers share the role of maintaining a clean environment.
GUIDELINES: Patient rooms, equipment used in the assessment and care of patients/residents/clients, diagnostic treatment and service delivery areas are to be cleaned according to the infection prevention and control standards described in this document. Housekeeping Services within VIHA are to establish and maintain a clean, sanitary, and aesthetically pleasing environment for patients/residents/clients, staff and visitors. QUALITY AUDITING: In addition to audits done by Housekeeping Services and Environmental Support Services, the IPC team may conduct independent audits of the environment, to determine adherence to quality standards.
A.
CLEANING
Please Note: Routine practices are used at all times when handling soiled items. This includes the wearing of PPE and hand hygiene which must be performed upon completion of the task
1. Nursing/Housekeeping Responsibilities
Cleaning of Isolation carts It is the responsibility of the nursing staff to empty the isolation cart following the patient/resident/client being removed from additional precautions. Unused gloves/masks/gowns, alcohol based hand rub and Percept wipe containers will remain on the isolation cart and be cleaned Partially used patient designated items such as wound care products shall be either sent home with the patient or discarded as garbage.
Page 69
It is the responsibility of the housekeeping staff to clean/decontaminate the isolation carts following the patient/resident/client being removed from additional precautions. This will be done the time of the patient/resident/clients room being terminally cleaned. At sites with Infection Prevention and Control Aides, the aides will compliment the cleaning/decontamination already in place.
2. Nursing Responsibilities:
When automated washer/disinfectors are installed in care areas bedpans, urinals and commode pots are emptied and decontaminated in these following each use, items placed in these are cleaned using cycle number 5. Once bed pans and urinals have been processed through the bed pan washer/disinfector at the appropriate cycle, they can be used by any patient on the unit (they do not need to be sent to central processing for further decontamination). Please refer to: DEKO or Meiko loading and usage instructions. The items removed from the machine can be used for any patient following processing through completed recommended cycle. Process Wash basins should be dedicated to the patient. Wash basins are wiped/decontaminated using an Accelerated Hydrogen Peroxide wipe (e.g. Percept wipe) between uses by the same patient. Upon patient discharge, the patient dedicated wash basin will be sent to central processing for appropriate decontamination prior to use on another patient. o In Residential Care facilities, if automated washer disinfector is not installed, the receptacles are to be emptied and washed. Receptacles will then be sent to central processing after use for cleaning/disinfection prior to further use o In Residential Care facilities, Peri cloths/Depends will be disposed of by nursing staff within appropriate bins provided Non disposable receptacles containing body fluids (e.g. glass suction canisters), are to be emptied and rinsed with cold water prior to transport to CPS for terminal cleaning and disinfection. Ensure items are transported in a suitable lidded container. Following use, equipment in direct contact with patient skin will be disinfected according to the manufacturers instructions and suggested products e.g. O2 sat finger clip Encourage patients/residents/clients to keep personal belongings on over bed table/bedside lockers to a minimum to allow thorough cleaning of all surfaces
Page 70
Discontinuation of Additional Precautions: When plans are being made to discontinue additional IPC precautions, nurses should arrange for as many items of the patients personal belongings are taken home by the patients family (where possible). Nurses to remove and bag all remaining patient belongings. Open patient wound care products, etc. are to be discarded in the garbage. Items such as used suction bottles and bed pans/urinals will be removed from room prior to housekeeping commencing clean. Ensure: Patient/resident is helped into a clean gown/pajamas and housecoat Hand hygiene is performed by the patient/resident/client and the patient/resident brought out of room The bed space/room is cleaned according to current VIHA Guidelines If possible, the patient/resident is showered/bathed and bathroom subsequently cleaned according to current VIHA Guidelines The patient/resident/client may return to the room once the cleaning is complete and housekeeping has removed the additional precaution sign
3. Housekeeping Responsibilities:
Table 13: Cleaning Solutions Used in Various Types of Cleaning
TYPE OF CLEANING
SOLUTIONS
AREAS
Main Operating rooms Including PAR & Surgical Day Care Labour and delivery rooms Endoscopy Any area where there is a risk of large volumes of blood or body fluid contamination of the environment or invasive surgical procedures are being performed (i.e. cardiac catheter lab). If unsure please discuss individual units with the Infection Control Practitioner All healthcare units Including medical & surgical units Emergency departments Renal Units Intensive care units (both general ICU & cardiac ICU) For all rooms/bed spaces where patients/residents/clients are on additional precautions (Contact, Droplet, Airborne) This clean will follow the Housekeeping Checklist form
Quaternary Ammonium based detergent (e.g. Virex or A456)
Routine Clean
Neutral Detergent (e.g. Stride or 310)
Precaution Clean
Accelerated Hydrogen Peroxide (e.g. Virox or Percept)
Page 71
Precaution Plus Clean
Terminal Clean
Used during an outbreak or increased incidence of infection This clean involves a precaution clean and is followed later in the shift with a clean of the high touch areas At the request of an ICP when additional cleaning is required in order to prevent an outbreak occurring (or over census capacity for a number of days) Second step of cleaning will be performed for high touch areas and bathrooms etc. This clean will follow the Housekeeping Checklist form and includes a curtain change on patient/client/resident discharge, discontinuation of precautions or when visibly soiled The cleaning that occurs when a patient/resident/client is on precautions and: Precautions are discontinued or The patient/resident/client is discharged or transferred to another unit, bed or facility This clean will follow the Housekeeping Checklist form using Accelerated Hydrogen Peroxide and includes a curtain change The cleaning that occurs when a patient/resident/client is discharged and has not been on any additional precautions This clean will follow the Housekeeping Checklist form
Discharge Clean (refer to same areas as in Routine Clean)
Quaternary Ammonium based detergent (e.g. Virex or A456) Neutral Detergent (e.g. Stride or 310)
Please Note: Gloves that meet WorkSafe BC standards for the task are to be used for all work requiring chemicals, cleaners, and disinfectants Please Note: Non-disposable household utility gloves are only acceptable for cleaning in non-patient care areas, with the exception of public washrooms. Housekeeping services are responsible for developing and maintaining written protocols on their use, in accordance with PIDAC guidelines, and ensuring that employees are aware of, and comply with these protocols All housekeeping staff will adhere to VIHAs Policy 15.1 Hand Hygiene Disposable gloves will be changed between bed spaces. If integrity is compromised prior to moving to a new bed space, gloves will be changed immediately Floor bucket with appropriate solution is freshly prepared and frequently changed at a minimum after o two large rooms (4-bed rooms), o three small rooms (2-bed or single bed rooms), or o when cleaning water is visibly dirty
Page 72
Cleaning will be performed commencing with the least soiled areas to the most soiled areas The mop bucket and double bucket are to be washed and rinsed before refilling All cleaning equipment is disinfected at the end of each cleaning period Microfibre cloths are to be dipped into solution only once. After usage, they will be laundered Dry dusting is to be avoided in clinical patient care areas due to the risk of dispensing dust and microorganisms into the environment ALL soap, paper towel dispensers and alcohol based hand rub dispensers, wallmounted and floor model kiosks, will be monitored/cleaned daily. Clean the outside and inside of dispensers when refilling Cleaning of patient/resident/client rooms and equipment will be performed in accordance to the Housekeeping Checklist. The following environmental surfaces and equipment/furniture will be cleaned and disinfected daily. Examples of items have been identified, but this is not an all-inclusive list:
Table 14: Some Equipment/Environmental Surfaces to be Cleaned Daily Central and POD Nursing Stations Bed pan washer / disinfectors Horizontal and contact surfaces, telephones and receivers, hand hygiene sinks including taps and faucets, ABHR dispensers/ kiosks Soiled and clean service rooms, sinks in a similar fashion to patient toilets. The bedpan washer will be cleaned daily as follows: The inside seal of the bedpan washer is cleaned with accelerated hydrogen peroxide (e.g. Virox or Percept) Check drain area for any blockage Clean the exterior sides, front and handle areas with an accelerated hydrogen peroxide wipe Check detergents. If replacement is necessary, replace with full bottle then run machine through full cycle Report any maintenance issues to Unit Clerk and Maintenance Emptied when full - minimum once daily. Cleaned/ disinfected inside and out at a minimum of once per week and when visibly soiled Cleaned/disinfected inside and out daily following removal of the bag liner/ removal of laundry bags
Garbage Cans
Laundry Receptacles
SCHEDULED AND CYCLED CLEANING & DISINFECTION: Cleaning and disinfection of the following items not captured during routine daily or discharge cleaning will be managed on a cyclic basis and following additional written policies.
Page 73
Care & Assessment Equipment: In some areas, an arrangement has been made with Central Processing and Sterilization departments to clean pumps such as gastric, IVAC, nutrition administration, continuous pumps; crash cart and defibrillator, emergency cart, and continuous renal replacement therapy (CRRT) machines Clean and soiled equipment will be stored/held within separate designated areas on all units. Areas will be identified using clear signage, for example: Clean commodes only (return all other equipment to designated area) Clean equipment only Soiled equipment only Please Note: Clean and soiled areas should be at least 1 metre (3 feet) apart Once a piece of equipment has been cleaned using the appropriate method, a pink Clean tag will be attached. The tag will be removed prior to use of the equipment. The tag will be cleaned appropriately prior to it being stored ready for further use. These are examples of equipment needing to be tagged following cleaning: Commode chairs Intravenous poles Intravenous pumps Wheelchairs Walkers Patient chairs This list is not exhaustive and relates to all equipment. Once a piece of medical equipment is no longer needed by the patient, or a patient is discharged/ discontinuation of precautions, the piece of medical equipment will remain within the patient room/bed space and be removed following the appropriate cleaning process or, if necessary, removed for cleaning in the Dirty Utility Room. If the equipment was in a room where patients/residents were on precautions, it must remain there until appropriately cleaned. The equipment will be tagged clean and stored in the appropriate designated Clean area. SOILED LINEN According to the principles of routine practices, soiled or used linens generated from all sources are considered to be contaminated and must be contained prior to transportation. Clean linen that has been dropped on the floor is considered soiled. When handling linen: Wear non-sterile gloves and disposable gown or apron
Page 74
Position hamper/tote/laundry bag in room (i.e. locate centrally in room and open lid) or as close to the room entrance as possible Ensure that linen is free of biomedical waste (e.g. needles and syringes, soiled wound dressings), instruments and patients personal belongings Roll linen carefully into itself, avoid shaking or fluffing Dispose of immediately into linen tote/hamper Soiled linen hamper/tote/laundry will be closed when full and not over-filled Remove PPE and perform appropriate hand hygiene Please Note: Dirty linen is not to be placed on bedside tables, chairs, floors or in the sink Please Note: Linen that is heavily soiled, saturated or dripping should be placed in a leak proof clear plastic bag and then placed inside the regular hamper/ tote/ laundry bag
LAUNDERING ON THE UNITS Laundering on units is not advocated in acute care setting. Items such as transfer belts, mattress covers, patient slings, etc. will be sent to either the site laundry or an industrial laundry facility. However, in some areas such as residential care settings it may be necessary to launder residents/clients belongings. In these cases, the following is recommended: Washers and dryers of an industrial standard must be used The outside of the machines (i.e. washer and dryer) should be cleaned daily with disinfectant Wash items with detergent on HOT WASH >160F (>71C) cycle for 25 minutes or more If HOT WASH is not available, items MUST be cycled through dryer on a hot setting for 25 minutes or more (not air dried) The laundry area should be in a dedicated space and must not be located in the same area as a dishwasher or fridge (used for food) Ensure that laundry areas have hand washing facilities and products and appropriate PPE available for workers Adhering to routine practices when handling laundry is effective in reducing the risk of disease transmission to patients and staff.
References: MMWR (2003) Guidelines for Environmental Infection Control in Health-Care Facilities, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) nd NHS Estates (2002), Infection Control in the Built Environment Design and Planning (2 edition), Norwich, UK: Wiseman, Sue
Page 75
CLEAN LINEN Please Note: Perform hand hygiene prior to removing clean linen from central supply area or from carts The dedicated linen room should have a door that is kept closed. If this is not possible, dedicated linen cart will have covers that should remain closed when not being accessed o Regular schedule for laundering of cover will be established Clean linen must be stored at least 1metre (3feet) away from any soiled area/items or fire equipment Linen which is removed from the clean supply area/cart is not to be returned to that cart Please Note: Linen will NOT be removed from large linen carts and placed onto small carts stored in hallways. If small carts are used during a shift to distribute linen, remaining linen will be placed in laundry tote at the end of the shift and cart cleaned
HANDLING SOILED LINEN CONTAMINATED WITH HAZARDOUS MATERIALS When hazardous materials are used, stored or disposed of, written safe work procedures must be developed and implemented for preparation, administration and waste handling. Departments intending to return soiled linens that are contaminated with hazardous materials must ensure that there is no potential risk to staff or patients/residents. Hazardous materials include, but are not limited to: Chemicals that are a risk due to being toxic, poisonous, carcinogenic, noxious, flammable, combustible, corrosive or reactive with other chemicals. Radioactive substances that are present on soiled linen will be decontaminated at the site at which the patient resides. Linen contaminated by radioactive substances will not be sent to the Laundry until it is decontaminated by removing the radioactive nuclide contaminants or setting it aside for the appropriate time (i.e. ten half lives). Chemotherapy drugs (i.e. Antineoplastics). Any contaminated linen identified by the user site as not able to be safely laundered will be safely disposed of by the user and the Regional Laundry informed of the disposal.
Reference: Fraser Health Authority, Acute Care Infection Prevention and Control Manual, 2008
Please Note: Items of linen from patients/residents/clients with unusual infections (e.g. Anthrax, Lassa Fever) should not be disposed of without consulting either the Medical Microbiologist in the first instance or the Infection Control Practitioner.
Page 76
B.
EVALUATING PRODUCTS
Prior to purchasing new patient care/medical equipment, written guidelines will be obtained from the manufacturer prior to the IPC team reviewing the product in order that a thorough assessment may be completed. IPC team will consider how easily the product may be cleaned/disinfected. Responsibility for cleaning must be established prior to purchase and installation.
Evaluation of new products will be done in cooperation and consultation with Environmental Support Services, Infection Prevention and Control and Purchasing.
2.
Bed Bug Infestation
If a bed bug infestation is suspected, contact the Housekeeping Supervisor through the call centre. Review Beg Bug information on Environmental Support Services web page
A.
Pests and Infestations in Home and Community Care
If pest infestation is suspected or confirmed, inform the Home and Community Care leader. Although pests are not generally associated with transmission of disease, health care workers will need to avoid becoming a vehicle for their transfer to other homes. If an infestation is suspected/confirmed, clinician bags will remain in the vehicle. If the infested home is in an apartment building, inform Environmental Health (through Public Health Unit) as other apartments may also become infested.
Page 77
PART 5: ANTIBIOTIC RESISTANT ORGANISMS

1. Introduction
Antibiotic resistant organisms (AROs), also known as multi-drug resistant organisms (MDROs), are defined as microorganisms that are resistant to one or more classes of antimicrobial agents. Although the names of certain AROs describe resistance to only one agent these pathogens are frequently resistant to a number of antimicrobial agents.
Examples of resistant bacteria are:

Methicillin Resistant Staphylococcus aureus (MRSA) Vancomycin Resistant Enterococci (VRE) Bacteria containing Extended Spectrum Beta-Lactamase (ESBL) Or any bacteria resistant to usual antibiotic therapy, such as Burkholderia cepacia.
2.
Definitions
Colonization Colonization is the presence, growth and multiplication of the organism in one or more body sites without observable clinical symptoms. Infection Infection occurs when microorganisms invade a body site, multiplying in tissue and causing clinical manifestations of local or systemic inflammation e.g. fever, redness, heat, swelling, pain.
3.
Acute Care Screening Protocol
All patients/residents admitted to acute care hospitals will be screened using the ARO Screening Questionnaire. Persons identified as having risk factors for MRSA acquisition will be swabbed for MRSA. Based on your assessment, perform actions as required collect cultures and implement additional precautions where appropriate.
Note: Notify Infection Prevention and Control of all patients/residents placed on additional precautions. Check the Patient Record disease alert field. This will be blank unless the patient has previously been positive for an ARO.
Page 78
If an ARO alert is present, the type of resistant organism will be identified according to the following codes: As soon as initial nursing risk assessment is complete, nursing staff can place patients/residents on appropriate precautions (no need to wait for physicians directive).
Table 15: List of Organisms with Corresponding Precautions and Other Considerations
ARO Alert
MRSA VRE ESBL KPC MRAB MRPA VRSA BCEP
Name of Organism
Methicillin Resistant Staphylococcus aureus Vancomycin Resistant Enterococcus Extended Spectrum Beta Lactamase Klebsiella pneumoniae carbapenemases Multi Drug Resistant Acinetobacter baumannii Multi Drug Resistant Pseudomonas aeruginosa Vancomycin Resistant Staphylococcus aureus Burkholderia cepacia
Precautions and Other Considerations in acute care10
Contact or Droplet Precautions dependent on location of organism Precaution Cleaning
Cystic fibrosis patients/residents/clients are placed on Contact Precautions, in a Private Room, do not cohort with another diagnosed cystic fibrosis patient Precaution Cleaning Droplet Precautions Preferably Private Room Precaution Cleaning Airborne Precautions Negative Pressure Room Routine Cleaning Discuss with IPC practitioner Dependent on Organisms involved
MRSP
Multi Drug Resistant Pneumococcus
MRTB
Multi Drug Resistant Tuberculosis
Other ARO Multiple AROs
New organism not listed above Unusual combination of AROs listed above
10
Precautions are based on the acute care setting. In other settings, routine practices are generally sufficient, unless identified differently by the IPC Practitioner.
Page 79
4.
ARO Screening and Collecting Swabs

Screening Questionnaire YES
Table 16: Screening and Specimen Collection

Encounter
Admission to acute care
ARO Screening Cultures

If positive response to screening questionnaire
MRSA
Nares Groin Wound Sputum if productive cough No only if known MRSA as per VIHAs Policy 15.4 Management of Residents with MRSA (Residential Care) Nares Groin Wound Sputum if productive cough
VRE
NO
ESBL
Urine, Rectum Wound, Sputum if productive cough, stoma, device NO
CRGNB
Urine (if catheterized or sign/symptom of UTI), Rectum, Wound Sputum if productive cough if directed by ARO Screening Questionnaire NO
Admission to Residential Care
NO
If known MRSA positive, swab as per VIHAs Policy 15.4 Management of Residents with MRSA (Residential Care) All admissions, discharges or transfers from another VIHA or external hospital
NO
Admission, discharge to/from NICU, PICU, CCU, CVU, ICU
NO
NO
NO
Yes only if direct admission from a hospital within a high risk area. Please refer to VIHAs Policy 15.5 Management of Patients with New Carbapenem Resistant Gram Negative Bacillus (CRGNB) Yes only if direct admission from a hospital within a high risk area. Please refer to VIHAs Policy 15.5 Management of Patients with New Carbapenem Resistant Gram Negative Bacillus (CRGNB) All admissions who have been transferred from another hospital within a high risk area. Please refer to VIHAs Policy 15.5 Management of Patients with New Carbapenem Resistant Gram Negative Bacillus (CRGNB)
In-Patient Renal
NO
All admissions, discharges or transfers from another VIHA or external hospital
Nares Groin Wound Sputum if productive cough
Rectum and wounds if present
NO
Transfer between VIHA hospitals or other hospitals
NO
All admissions who have been transferred from another hospital (within or external to VIHA)
Nares Groin Wound Sputum if productive cough
NO
NO
Page 80
5.
Overview of Antibiotic Resistant Organisms
In most instances, infections due to AROs have clinical manifestations that are similar or the same as infections caused by susceptible pathogens. However, options for treating patients/residents with these infections are often extremely limited due to their multiple resistances to antibiotics. The result is that infections due to AROs often cause increased morbidity and mortality, as well as increased length of hospital stay and costs. The following factors contribute to emergence of resistance in this setting: intensive, prolonged use of broad spectrum antibiotics high intensity of medical care provided in the close physical confines of a hospital a more vulnerable population, especially patients/residents suffering chronic illness, those critically ill, those with invasive devices in place, those requiring intensive medical or surgical care
A.
Methicillin-Resistant Staphylococcus aureus (MRSA)
Staphylococcus aureus (S. aureus) is a common cause of infection in hospital and the community, causing a spectrum of problems from minor skin and wound infections, to serious deep infections such as osteomyelitis and blood stream infection, which may be associated with significant morbidity and mortality. Staphylococcus aureus can survive on the skin, particularly the anterior nares, skin folds, hairline, perineum and umbilicus, without causing infection. This is known as colonization. Methicillin-Resistant Staphylococcus aureus (MRSA) are strains of S. aureus that are resistant to antibiotics such as cloxacillin and cephalosporins. Cloxacillin is considered to be identical to Methicillin (the drug used by the laboratory to detect resistance). MRSA are cross-resistant to all cephalosporins, imipenem, meropenem, aminoglycosides, erythromycin and quinolones, and they may also be resistant to many other antibiotics. Certain strains of community-acquired MRSA can cause much more serious infections (eg. Necrotizing pneumonia) than typical MSSA, in part due to a number of toxins of virulence factors, including Panton Valentine Leukocidin (PVL) toxin. In community settings the prevalence is unknown; however the following represent high-risk groups: injection drug users dialysis or chemotherapy patients/residents individuals living in Residential Care Facility persons living on the street or using shelters individuals in correctional facilities individuals taking frequent and/or prolonged courses of broad spectrum antibiotics
Page 81
chronically ill persons will a skin infection that was difficult to treat individuals discharged from healthcare facilities that were in hospital for a period longer than 48 hours individuals who have had a medical procedure in a medical clinic or who have been hospitalized anywhere outside of Canada
B.
Vancomycin-Resistant Enterococci (VRE)
Enterococci are part of the normal flora of the gastrointestinal tract. They are organisms of low virulence but can cause infections such as urinary tract infection, bacteraemia and endocarditis, particularly in debilitated patients/residents. Acquired resistance to Vancomycin has emerged in enterococci. Most enterococcal infections arise from the patients endogenous flora, but cross infection between hospital patients/residents does occur. Contact transmission, either directly from person to person or indirectly via contaminated inanimate objects such as commodes or bedpans, plays an important role in mode of transmission.
C.
Extended Spectrum Beta-Lactamase (ESBL) Organisms
Extended Spectrum Beta-Lactamase is a bacterial enzyme with the ability to break down (inactivate) a wide variety of antibiotics, including penicillins and all first, second and thirdgeneration cephalosporins. When present, this enzyme results in the bacteria being resistant to antibiotic therapy. ESBL enzymes are most commonly found in two bacteria Escherichia coli (otherwise known as E. coli) and Klebsiella pneumoniae, but can also be found in bacteria such as Salmonella, Proteus, Morganella, Enterobacter, Citrobacter, Serratia, and Pseudomonas. In many cases, ESBL bacteria can colonize the gut and other body sites without producing disease. Significant infections include urinary tract infections and surgical wound infections. Patients/residents whose gastrointestinal flora has been altered by previous antibiotic treatment are predisposed to acquiring these pathogens.
Page 82
6.
ARO Room Placement
Figure 6: ARO Room Placement

Room Placement for a Patient Positive for an Antibiotic Resistant Organism
Colonized Patient
Infected Patient
*YES
Single Room Available?
Single Room Available?
*YES
NO Place in Single Room
NO Place in Single Room
YES
Double Room Available?
Double Room Available?
YES
Place in Double Room. Prepare to manage personal space.
NO
Place in Double Room. Prepare to manage personal space.
Place in multi-bed room. Prepare to manage personal space.
NO
Consult with Infection Prevention & Control
Place in multi-bed room. Confine patient to bed space with curtains drawn. Consult with Infection Prevention & Control when available
*If more than one patient with same ARO on ward, it may be preferable to cohort in a semi-private or multi-bed room as appropriate
Page 83
Due to the limited number of single rooms available, where patients/residents must be placed in a double or multi-bedded room, priority for the single room assignment should be as follows (in priority order): 1. 2. 3. 4. 5. 6. Clostridium difficile infection Diarrhea cause not yet diagnosed MRSA infection Patient colonized with multiple AROs MRSA Colonization Infection from other source
Special Considerations in Bed Placement for VRE

In some instances, VRE infected or colonized patients/residents will need VRE management (i.e. patients/residents in a designated renal unit, an adult Intensive Care Units or pediatric or neonatal Intensive Care Unit). In these instances, please refer to VIHAs Policy 15.3 Management of Patients with VRE (Acute and Residential) for bed placement procedures.
Page 84
7.
Key Management Issues

MRSA Methicillin Resistant Staphylococcus aureus Infection or colonization of any site on the body; most often skin and wound infections A patient is colonized with MRSA when the culture report is positive for Staphylococcus aureus resistant to Cloxacillin with no clinical signs/symptoms or infection. Notice of previous colonization within a VIHA facility will be recorded in: The Health Record encounters and/or Powerchart The Admission Record which shows ALERT for ARO status Contaminated environmental surfaces (high touch areas: over bed tables, blood pressure machine, wheelchairs, etc.) may also serve as a reservoir. Therefore, routine cleaning of the environmental surfaces is necessary to reduce the potential bacterial load. Direct and indirect contact (see Part 2: Transmission) The primary mode of transmission is from one patient to another are hands that have become transiently colonized by either: after direct contact with colonized or infected patients/residents/clients while performing care when removing gloves when touching contaminated surfaces Droplet transmission is possible with patients/residents/clients that have a productive cough and are MRSA colonized within their nares/respiratory system. The likelihood of transmission increases in patients/residents/clients with: Draining wounds or open skin lesions Poor respiratory hygiene and coughing Fecal or urinary incontinence, diarrhea, ileostomy or colostomy, poor hygiene Invasive devices in place Requiring intensive contact care, i.e. post CVA, dementia, post major surgery, Intensive Care treatment Requiring mobility assistance, i.e. paraplegic, amputee Infection due to greater number of organisms present As these patients/residents/clients are more likely to disperse large numbers of organisms into the environment
Table 17: Key Management Issues for MRSA and ESBL Presentation
ARO Status
Reservoirs
Likelihood of Transmission
Page 85
Precautions Needed for Patients
Routine practices are to be applied at all times and all staff must adhere to VIHAs Hand Hygiene Policy. In acute and residential care, contact precautions must be put in place including donning a gown/apron and gloves for all contact with the patient and their physical environment. Ensure Contact Precautions sign is posted Droplet precautions should be put in place if the patient has a cough with or without productive sputum All patients/residents/clients admitted to acute care will be screened using the ARO Screening Questionnaire. All patients/residents/clients identified At Risk will be swabbed Swab sites will include o Nares o Groin (creases at junction of torso with the legs, on either side of pubic area) o Open wound(s) o Urine (if catheter present) All patients/residents/clients admitted to an intensive care unit or designated in-patient renal unit will be swabbed at specific time frames please refer to page 2 of VIHAs Policy 15.2 Management of Patients with MRSA (Acute Care) Screening/swabbing is not required for residents being admitted to or transferred from acute care to Residential care Residents previously identified as MRSA positive will be swabbed one month after admission/transfer Policy 15.4 Management of Patients with MRSA (Residential Care) The infection prevention and control measures to prevent the spread of MRSA are the same, whether the patient is colonized or infected Unit staff will initiate and maintain nursing orders for Additional Precautions Ensure ongoing communication of the patients status with other relevant healthcare workers (e.g. diagnostics, housekeeping, etc) Place the patient in an appropriate room (see patient placement) Provide the patient with dedicated toilet/commode facilities Encourage the patient with meticulous hand hygiene, particularly on leaving the room and after toilet, etc Staff Must: Complete a point of care risk assessment Wear gloves and gown/apron for contact with the patient/resident/client and/or their environment. A surgical grade mask (120 mmHg) with visor may be required Visitors Must: Visitors must speak with the patients/residents/clients primary nurse before visiting patient so that proper Additional Precautions and procedures can be discussed, including the importance of hand hygiene Visitors are required to adhere to contact precautions and wear protective clothing only when providing close personal care.
Page 86
Patients/Residents/Clients Must: Wear clean dressing gown/clothing when exiting the room Wear shoes or slippers; no bare feet Have a clean dry dressing covering any skin/soft tissue infections Acute Care Patients: The patient may be out of their room for tests, mobilization or rehabilitation Patient must perform hand hygiene on exiting and re-entering their room They must not visit public areas within the facility (unit kitchen, cafeteria, shops/kiosks in main entrance, etc) Are encouraged not to visit any other patients rooms Residential Care Patients The resident/client can leave their room for all activities, but is to be excluded from food preparation activities All patients/resident/client found to be MRSA positive will be considered for topical decolonization treatment, in an attempt to eradicate MRSA and reduce the risk of subsequent infection. Decolonization Please refer to VIHAs Policy 15.2 - Management of Patients with MRSA (Acute Care) for acute care and VIHAs Policy 15.4 Management of Residents with MRSA (Residential Care) for residential care For infected patients/residents/clients, treatment is determined by the Most Responsible Physician (MRP). Please refer to the Antimicrobial Prescribing Guide for Adult Patients: System Wide Initiative (SWI) booklet for more detail For colonized patients/residents/clients, wait 7 days post completion of any antibiotic treatment (topical, oral or injectable) or following decolonization. Separate swabs from nares, groin and any other sites previously found to be positive Two negative sets of swabs 7 days apart (the first swabs must be negative before doing the second set). Please refer to VIHAs Policy 15.2 - Management of Patients with MRSA (Acute Care) and Policy 15.4 - Management of Residents with MRSA (Residential Care) for further information If first swab is positive, consider decolonization if not already done so, wait 7 days before doing another swab Notify the Infection Control Practitioner if the swabs have been done and are negative For infected patients/residents/clients, wait 30 days post completion of any antibiotic treatment (topical, oral or injectible) prior to initial set of swabs being taken. Then follow the above steps The MRP may discharge the patient/resident/client as soon as their physical condition permits The receiving facility or home care must be notified prior to transfer for patients/residents/clients colonized or infected
Page 87
Treatment
Discharge or Transfer
Environment
with MRSA. The Most Responsible Nurse must record status on the Home Care Transfer Form If cultures remain positive on discharge, decolonization may be continued following consultation with MRP Laundry Waste Cleaning Patient Care Equipment once patient/resident/client has been discharged or precautions have been discontinued, precaution signage will remain in place and all patient equipment will remain in the room. Equipment will be removed by housekeeping only after appropriate disinfection.
Presentation
ESBL Extended Spectrum Beta Lactamase A variety of gram negative bacteria, most commonly Escherichia coli and Klebsiella species, have acquired antibiotic resistance and are classed as Extended Spectrum Beta Lactamase (ESBL). Usually found in lower gastrointestinal tract and/or in urine and moist wounds. A patient is colonized with ESBL when a culture report is positive for Extended Spectrum Beta Lactamase with no clinical symptoms or infection Notice of previous colonization within a VIHA facility will be recorded in: The Health Record encounters and/or Powerchart The Admission Record which shows ALERT for ARO status Contaminated environmental surfaces (high touch areas: over bed tables, blood pressure machine, wheelchairs, etc.) may also serve as a reservoir. Therefore, routine cleaning of the environmental surfaces is necessary to reduce the potential bacterial load. Direct and indirect contact (see Part 2: Transmission) ESBL producing bacteria can be spread by direct contact with feces and secretions (i.e. wound drainage, sputum and urine) from an infected person. The primary mode of transmission is from one patient to another are hands that have become transiently colonized by either: after direct contact with colonized or infected patients/residents/clients while performing care when removing gloves when touching contaminated surfaces The likelihood of transmission increases in patients/residents/clients with: Draining wounds or open skin lesions
Page 88
ARO Status
Reservoirs
Likelihood of Transmission
Fecal or urinary incontinence, diarrhea, ileostomy or colostomy, poor hygiene Invasive devices in place Requiring intensive contact care, i.e. post CVA, dementia, post major surgery, Intensive Care treatment Requiring mobility assistance, i.e. paraplegic, amputee Infection due to greater number of organisms present
As these patients/residents/clients are more likely to disperse large numbers of organisms into the environment Routine practices are to be applied at all times and all staff must adhere to VIHAs Hand Hygiene Policy. Once colonization is confirmed: In acute and residential care, contact precautions must be put in place including donning a gown/apron and gloves for all contact with the patient and their physical environment. Ensure Contact Precautions sign is posted Measures to prevent the spread of ESBL are the same, whether the patient is colonized or infected In residential care, apply contact precautions for all close personal care Notify the Infection Control Practitioner Ensure ongoing communication of the patients status with other relevant healthcare workers (e.g. diagnostics, housekeeping, etc) Place the patient in an appropriate room (see patient placement) Provide the patient with dedicated toilet/commode facilities Encourage the patient with meticulous hand hygiene, particularly on leaving the room and after toileting, etc Staff Must: Complete a point of care risk assessment Wear gloves and gown/apron for contact with the patient/resident/client and/or their environment Visitors Must: Provided that visitors of patients/residents/client with ESBL are healthy, there is no restriction on visiting, and it carries no risk. Visitors must speak with the patients/residents/clients primary nurse before visiting so that proper Additional Precautions and procedures can be discussed, including the importance of hand hygiene upon entering and exiting the patients/residents/clients room. Visitors are required to adhere to contact precautions and wear protective clothing only when providing close personal care.
Precautions Needed for Patients
Page 89
Patients/Residents/Clients Must: Wear clean dressing gown/clothing when exiting the room Wear shoes or slippers; no bare feet Have a clean dry dressing covering any skin/soft tissue infections Acute Care Patients: The patient may be out of their room for tests, mobilization or rehabilitation Patient must perform hand hygiene on exiting and re-entering their room They must not visit public areas within the facility (unit kitchen, cafeteria, shops/kiosks in main entrance, etc) Are encouraged not to visit any other patients rooms Decolonization There is no decolonization therapy for ESBL. For patients/residents/clients infected with ESBL, treatment and repeat cultures should be ordered by the Most Responsible Treatment Physician (MRP) in consultation with the Medical Microbiologist. Wait 7 days post completion of any antibiotic treatment (topical, oral or injectable). Separate swabs from rectum and any other sites previously found to be positive Mid-stream or catheter specimen of urine, specifying an ESBL screen Two negative sets of results 7 days apart (the first swabs/specimens must be negative before doing the second set) If first swab/ specimen is positive, wait 7 days before doing another swab/specimen Notify the Infection Control Practitioner if the swabs/specimens have been done and are negative
Discharge or Transfer
Environment
For infected patients/residents/clients, wait 30 days post completion of any antibiotic treatment (topical, oral or injectible) prior to initial set of swabs being taken. Then follow the above steps The MRP may discharge the patient/resident/client as soon as their physical condition permits The receiving facility or home care must be notified prior to transfer for patients/residents/clients colonized or infected. The Most Responsible Nurse must record status on the Home Care Transfer Form Laundry Waste Cleaning Patient Care Equipment once patient/resident/client has been discharged or precautions have been discontinued, precaution signage will remain in place and all patient equipment will remain in the room. Equipment will be removed by housekeeping only after appropriate disinfection.
Page 90
PART 6: OUTBREAK MANAGEMENT

VIHAs Infection Prevention and Control Program would like to thank Capital Health Region in Alberta, Canada for generously sharing their Outbreak Prevention, Control and Management in Acute Care Facilities document with us. The shared materials greatly assisted us in our development of this section of our manual.
1.
Introduction
Early recognition of unusual clusters of illness and swift actions in response to these episodes are essential for effective management of outbreaks. It is vital that all healthcare workers collaborate to facilitate prompt identification, reporting, specimen collection, and implementation of appropriate infection prevention and control measures to help minimize the impact of an outbreak. Early recognition of suspected outbreaks is important. Patients/residents and staff should be assessed on an ongoing basis for signs/symptoms of an infectious disease (see algorithm). An outbreak may be declared anytime that the number of individuals presenting with similar signs/symptoms exceeds the normal expected number of cases. Contact your Outbreak Lead any time you are suspicious that an outbreak may be occurring within your unit. The majority of outbreaks that occur are either respiratory or gastrointestinal. The following case definitions were developed to assist in the early identification of unusual clusters of influenza-like (ILI) or gastrointestinal (GI) illness and/or outbreaks. The purpose of this section of the manual is to provide current best practice/evidence-based guidelines to assist staff with outbreak prevention, control, and management of outbreaks. The information is divided into four sections: Section A General guidelines for management of any suspected outbreak activity. Subsequently, these basic recommendations may be enhanced or modified depending on identification of the causative agent. Section B Specific recommendations for the prevention, control, and management of influenza outbreaks. Section C Specific recommendations for the prevention, control, and management of outbreaks of gastrointestinal illness. Section D Specific recommendations for the prevention, control and management of Clostridium difficile (CDI) and Scabies outbreaks.
Page 91
2.
General Guidelines for Outbreak Management

A. Reporting a Suspected Outbreak
Prompt reporting permits early identification and interventions to interrupt transmission, reducing morbidity and mortality. Report any suspicion of an outbreak to the necessary authority as soon as possible. The table below identifies whom to contact for your area.
Table 18: Contact List
Type of Facility VIHA Acute Care Infection Prevention and Control Contact VIHA Infection Prevention and Control VIHA Infection Prevention and Control Public Health: CD Nurses (ILI); CD Environmental Health Officers (NLI) Medical Physician Contact VIHA Infection Prevention and Control Physician VIHA Infection Prevention and Control Physician Public Health Medical Health Officers (MHO)
VIHA Amalgamated LTCF (Owned/Operated) VIHA Affiliated LTCF, Private LTCF, and Community
After hours contact Medical Microbiologist on-call covers all medical microbiology calls and any URGENT infection prevention and control issues that cannot wait until the IPC practitioner is available. (Paged through the RJH switchboard (250-370-8000). Weekends/Stat Holidays IPCP On-Call from 0930-1730 hours, for all acute care hospitals, St. Josephs Acute and Residential, and all VIHA-owned residential facilities. Contact via your manager-on-call who has the number for the IPCP on-call. Medical Health Officer on-call Covers all questions from affiliated continuing care facilities. (MHO Numbers)
1. Initial Infection Prevention and Control Precautions

Routine practices are to be used at all times with all patients/residents. In addition, based on the type of outbreak, appropriate Additional Precautions will need to be implemented as soon as possible.
Page 92
It is essential to NOT wait until the causative agent is identified before implementing Additional Precautions. Initiate appropriate additional precautions as soon as a patient presents with symptoms.
The appropriate type of precautions (e.g. contact and/or droplet) must be determined by the presenting symptoms and the procedure being undertaken (e.g. mask with visor for any cough inducing procedure for suspected ILI). Precaution signs should be posted on the entrance to each affected room and elsewhere as directed by your Outbreak Lead.
The Suspected Respiratory Infection or Gastroenteritis Outbreak algorithm provides guidance as to what initial infection prevention and control precautions are required in the event of any ILI/GI outbreak.
Page 93
Figure 7: Suspected Respiratory Infection or Gastroenteritis Outbreak Algorithm
Page 94
2. Confirming an Outbreak
The Infection Control Practitioner, in consultation with the Infection Prevention and Control Physician and/or the Infection Prevention and Control Manager, will review the data and confirm that an outbreak is occurring. The IPCP will notify other areas of the organization that the unit/facility is on Outbreak Status (i.e. sending out a memo and/or in the case of Residential Facilities, posting on Healthspace).
3. Outbreak Management
In the event of an outbreak in a VIHA facility, Infection Prevention and Control will work collaboratively with the outbreak team to investigate, identify, and plan the management of the outbreak.
4. Compiling a Post-Outbreak Investigation Summary

Within VIHA facilities, the Infection Prevention and Control Team will lead the preparation of an outbreak summary once the outbreak is declared over. The Clinical Coordinator, Manager, Team Leader and the Occupational Health & Safety representative are expected to be key contributors to the summary. Once a summary is complete it is reviewed by the Infection Prevention and Control Team and key issues/concerns and/or successes are escalated to the Infection Prevention and Control Quality Committee for its review.
B.
Influenza-Like Illness (ILI) Outbreaks

1. Introduction
Outbreaks of influenza generally occur in Canada between fall and early spring. Influenza viruses cause disease among all age groups. Rates of serious illness and death are highest among persons aged 65 years or older and in persons of any age who have medical conditions that place them at increased risk from complications of influenza. In most local outbreaks, complications and/or deaths related to influenza A occur in the elderly, immunocompromised and pediatric patients/residents. It is recommended that each facility have a process in place to ensure eligible inpatients receive influenza immunization each year. Annual influenza immunization is the primary tool for preventing influenza and its severe complications. According to the Canadian National Advisory Committee on Immunization (NACI) statement on influenza vaccination, all healthcare workers have a duty to promote, implement, and comply with influenza immunization recommendations to decrease the risk of infection and complications in vulnerable populations for which they provide care.
Page 95
NACI considers the provision of influenza immunization for healthcare workers to be an essential component of the standard of care. To prevent transmitting influenza to those at high risk of influenza related complications, all healthcare providers should receive annual influenza immunization, unless contraindicated. Outbreaks of influenza can be propagated when staff immunization rates are low even though immunization rates in patients/residents may be high. The optimal time for delivering organized immunization campaigns for both patients/residents and staff is in the autumn. Effectiveness of the influenza vaccine is dependent on the age and immunocompetence of the person receiving the vaccine and the similarity of the virus strains in the vaccine and those in circulation during the influenza season. Although elderly persons and those with chronic diseases may have a lower immune response to the vaccine than healthy young adults, the vaccine is still very effective in preventing lower respiratory tract infections such as pneumonia and other secondary complications, thereby reducing the risk for hospitalization and death. The influenza virus changes from year to year so the vaccine is adjusted to match with the viruses expected to be circulating during the current influenza season. Each spring the World Health Organization, CDC Atlanta, and the Public Health Canada Agency decide on the three components of the vaccine. For the current influenza vaccine information see the National Advisory Committee on Immunization (NACI) and for FAQs the BC Healthfiles
2. Confirming an ILI Outbreak

The following two tables help to differentiate between signs and symptoms of influenza and other respiratory organisms.
Table 19: Common Differences between Influenza and Common Cold Symptoms
Symptoms/Description Fever Chills, aches, pain Loss of appetite Cough Sore throat Sniffles or Sneezes Involves whole body Symptoms appear quickly Extreme Tiredness Complications Frequent Sometimes Usual Sometimes Sometimes Often Always Common Pneumonia - can be life threatening Influenza Usually high Slight Sometimes Sometimes Sometimes Common Never More gradual Rare Sinus infection Ear infection Common Cold Sometimes
Page 96
Table 20: Respiratory Infections

ORGANISM INFLUENZA TYPE A or B SYMPTOMS Sudden onset of respiratory illness with fever and cough and with one or more of the following: sore throat, athralgia (painful joints), myalgia (muscle pain), runny nose, headache, prostration Note: Fever may not be prominent in those >65 years or in paediatric populations or those who are immunocompromised In children under 5, gastrointestinal symptoms may also be present RESPIRATORY SYNCYTIAL VIRUS (RSV) Similar to common cold symptoms; usually mild but can be moderate to severe. Severe lower respiratory tract disease can occur in the elderly. Person to person usually by direct or close contact with contaminated secretions which may involve droplets or fomites. Virus may live on environmental surfaces for many hours and for a halfhour or more on hands. 2 to 8 days, average 4 to 6 days MODE OF TRANSMISSION Person to person by droplets or direct contact with articles recently contaminated with respiratory secretions. INCUBATION PERIOD 1 to 4 days PERIOD OF COMMUNICABILITY Adults: Usually 24 hours prior to symptoms and up to 4 days after clinical onset Pediatric & Immunocompromised: Usually 24 hours prior to symptoms and up to 7 days after clinical onset RESTRICTIONS Precautions: Droplet Cases should remain on precautions until they are over the acute illness and have been afebrile for 48 hours (minimum of 5 days from onset of acute illness). Unit restrictions for an influenza outbreak remain in place for 6 days after onset of symptoms in the last case. Period of viral shedding is usually from 3 to 8 days but may be longer in pediatric and those who are immunocompromised. Precautions: Adults: Droplet precautions Pediatrics: Droplet precautions while symptomatic In pediatric settings, unit restrictions may be recommended by Infection Prevention and Control. Cases should remain on precautions until they are over the acute illness. PARAINFLUENZA Type 1, 2, 3, 4 Similar to common cold symptoms. Can also cause serious lower respiratory tract disease with repeat infection (e.g. pneumonia, bronchitis, and bronchiolitis) in the elderly. It is the most common etiologic agent of croup and viral bronchitis in young children. Person to person through direct contact with infected persons or exposure to respiratory secretions on contaminated surfaces or objects. 2 to 6 days Varies with different types. Adults: Droplet precautions Pediatrics: Droplet and contact precautions while symptomatic In pediatric settings, unit restrictions may be recommended by Infection Prevention and Control. Cases should remain on precautions until they are over the acute illness.
Page 97
ORGANISM ADENOVIRUS
SYMPTOMS Similar to common cold symptoms; usually mild but can be moderate to severe.
MODE OF TRANSMISSION Person to person through direct contact with infected persons or exposure to respiratory secretions on contaminated surfaces or objects.
INCUBATION PERIOD 2 to 14 days
PERIOD OF COMMUNICABILITY While symptomatic.
RESTRICTIONS Adults: Droplet precautions Pediatrics: Droplet precautions while symptomatic In pediatric settings, unit restrictions may be recommended by Infection Prevention and Control. Cases should remain on precautions until they are over the acute illness.
HUMAN METAPNEUMOVIRUS
Similar to common cold symptoms; usually mild but can be moderate to severe. Note: unlike influenza, patients/residents usually maintain a normal appetite.
Person to person through direct contact with infected persons or exposure to respiratory secretions on contaminated surfaces or objects.
2 to 8 days
While symptomatic
Adults: Droplet precautions Pediatrics: Droplet and Contact Precautions while symptomatic In pediatric settings, unit restrictions may be recommended by Infection Prevention and Control. Cases should remain on precautions until they are over the acute illness, for a minimum of 5 days.
Reference: John Hopkins University, Infection Prevention Guidelines for Healthcare Facilities with Limited Resources.
Page 98
Table 21: Case Definition for ILI and an ILI Outbreak

Influenza-like Illness (ILI) Case Definition Patient/resident/client on your shift with new or worsening cough with fever (>38C) or a temperature that is abnormal for that individual AND one or more of the following: Sore throat Athralgia (painful joints) Myalgia (muscle pain) Nasal discharge Headache Prostration Temp > 38 may not always be present in infected elderly persons. Subjective report of fever may be sufficient in some cases. ILI Outbreak Suspected If you discover 2 patients/residents/clients and/or staff with ILI symptoms occurring within 7 days which are epidemiologically linked (e.g. room / floor / common area / staff), then case definition has been met and an outbreak can be declared.
Note: Symptomatic staff cases must have worked within the outbreak facility or area during the 4 days prior to onset of symptoms (i.e. during their incubation period). Please refer to the Influenza Outbreak Declared algorithm for further instructions for staff.
3. ILI Outbreak Management

All ILI illness is to be treated as if it is Influenza A or B until proven otherwise. Once influenza is ruled out it is quite possible that Infection Prevention and Control will require all the following restrictions to remain in place save for those that are described for unvaccinated staff. Always consult with Infection Prevention and Control to determine what precautions or restrictions are required.
Practices and Precautions Routine practices are used for the care of all patients/residents at ALL times.
Influenza can be spread by contact and droplet routes, consequently, droplet precautions are required.
Droplet precautions include: Thorough hand washing before and after any patient contact Wearing of a gown and gloves Surgical grade mask with attached visor or face shield Appropriate hand washing while removing protective attire. This is important as contamination from used attire may occur during removal
Page 99
Room/Unit Closures The Infection Prevention and Control Team in collaboration with the Clinical Coordinator/Manager of Patient Care and members of the Outbreak Management Team will determine room and unit closures.
Patient Line Listings Infection Prevention and Control requires a daily completion of line listings. It is the responsibility of the Clinical Coordinator/Manager of Patient Care (or designate) to ensure that the line listings are filled out completely at the beginning of each day, and submitted to the Infection Control Practitioner by 1000 hrs, by either fax or email as agreed. Information required includes: Identification of the unit Date of completion Contact person and details Patient information Name Date of birth Room number Symptoms, and onset date Specimens sent Influenza immunization information Line listing paperwork should be kept up to date and be available within the affected area, and faxed/emailed daily to identify any new cases, and current symptom status of all patients/residents affected. The reporting period is 0700 hrs the previous day to 0700 hrs of day of faxing/emailing. If there are no new cases within a 24 hour period, this should be stated on the line listing. Discontinue daily faxing/emailing of line listings only when instructed by the Infection Control Practitioner.
Staff Line Listings Occupational Health & Safety requires daily completion of staff line listings. It is the responsibility of the Clinical Coordinator/Manager of Patient Care (or designate) to ensure the following information is completed each day, and forwarded to Occupational Health & Safety: Identification of the unit Date of completion Contact person and details Staff details
Page 100
Full name Telephone number Date last worked Symptoms and onset date Number of shifts missed Specimen information Influenza immunization information. Discontinue daily faxing/emailing of line listings only when instructed by Occupational Health & Safety.
Lost Bed Days It is the responsibility of the Clinical Coordinator/Manager of Patient Care (or designate) to ensure that the bed days lost is recorded at the beginning of each period (0700-0700).
Restrictions on Patient Activities Patients/residents symptomatic with a respiratory illness should be restricted to their room, on droplet precautions for a minimum of five (5) days after the start of the illness, or until the symptoms are no longer present, whichever time period is longer. All group activities will be cancelled during the course of the outbreak. Patients/residents may be transferred to other healthcare facilities for a higher level of care (e.g. Emergency), should their condition require and with communication with that unit/facility. The transport company and receiving facility must be notified of the precautions required. The patient must wear a mask for transport. The Infection Prevention and Control Team should also be informed of the transfer. Any offsite appointments are discouraged, unless absolutely necessary. Where necessary, the receiving department or facility is to be notified beforehand. The patient must wear a mask, and the transport company and receiving facility must be notified of precautions required.
Working Restrictions for Asymptomatic Healthcare Workers Working Restrictions for Asymptomatic Staff, immediately following the identification of the outbreak:
Working on the Outbreak Unit (VIHA policy No. 5.8.6PR, Influenza Prevention Program Procedure)
Page 101
Unvaccinated staff are subject to exclusion from work within the outbreak facility or reassignment until the outbreak is declared over. An exception to exclusion of unvaccinated staff may be made if the unvaccinated staff take antiviral medication as prescribed and the antiviral medication is continued until the outbreak is declared over. These workers must be alert to the signs and symptoms of influenza, particularly in the first two (2) days after starting antiviral prophylaxis, and should be excluded from the patient care environment should they develop symptoms11. During an outbreak of laboratory confirmed influenza12, unvaccinated healthcare workers or those vaccinated within two (2) weeks of the onset of outbreak13 must obtain antiviral medication, if they are to work on the outbreak unit.
Working on a Non-Outbreak Unit Asymptomatic healthcare workers, who are not vaccinated for influenza and have worked on an outbreak unit within three (3) days of the outbreak declaration, will be unable to work on another unit/facility for three (3) days after the last shift they worked on that unit. This is to ensure that they remain free from infection following their last exposure. Once the three days has lapsed, and if they remain without symptoms, they may work on a non-outbreak unit or facility. This includes casual staff who work in several areas.
Working Restrictions for Symptomatic Healthcare Workers All symptomatic staff (including students and physicians) must remain off work for a minimum of five (5) days after onset of illness or until asymptomatic, whichever is the longer time period.
Students Students on healthcare worker programs14 will be permitted to attend outbreak units, if they have previously received instruction on Infection Prevention and Control principles. The students and Educational Facility Instructor must abide by the same requirements for vaccine and/or antiviral medication, and the same work restrictions as those of all other healthcare workers. The Educational Facility Instructor is responsible to provide completed student vaccination lists to Occupational Health & Safety and to ensure student compliance with healthcare worker restrictions.
11
Unvaccinated staff can use the form letter Family Physicians ordering Health Care Worker Anti -viral Medication to obtain prophylactic medication. Note: the cost of antiviral medication is not covered by the employer. 12 If the presentation meets the outbreak definition for ILI then one should assume it is influenza, until proven otherwise by the MHO or IPCT 13 Those considered not protected at the time the outbreak commences. Vaccinated staff should discuss with Occupational Health & Safety about when they can discontinue taking prophylactic medication. 14 This includes all professions of caregivers, including medical students
Page 102
Visitors/ Volunteers Visitation to an outbreak unit should be restricted to 2 visitors per patient at any one time during scheduled visitation hours. Patients/residents should be reviewed and visitors/volunteers determined on an individual basis, considering the needs and medical condition of the patient. Staff must be consistent with their approach to facility visitation throughout the outbreak. Visitors/volunteers choosing to enter the facility must be free of symptoms of illness, and encouraged to be vaccinated. However, it must be noted that maximum protection takes at least 2 weeks from vaccination. Visitor/volunteers must be educated in the correct procedure for hand hygiene and on the correct use of PPE if required. Visitors/volunteers will not visit other patients/residents/patient rooms, must not visit public areas within the facility (unit kitchen, cafeteria, shops/kiosks in main entrance etc.) and SHALL NOT use the patient/resident bathroom. It is important to consider the needs of the patients/residents and possible staffing shortages, and weigh these against the concern about community spread of the disease.
Meals Symptomatic patients/residents should dine in their room with tray service and be restricted from the dining room and communal activities involving food preparation. The trays are managed according to direction for individuals on droplet precautions.
Pets No pets are allowed on affected units.
Housekeeping For ILI, routine cleaning is required. Attention to detail must be given, especially with horizontal surfaces and bedside curtains (which must be changed on discharge of the patient or discontinuation of precautions). Other housekeeping requirements may also be requested. See also the Housekeeping Cleaning table.
Linen No special handling/cleaning of linen is required.
Page 103
Collection and Transportation of Nasopharyngeal Swabs Specimen results directly impact outbreak management strategies for outbreaks of ILI. Take samples from residents who are newly symptomatic (within 72 hours) or as directed. Before performing any nasopharyngeal swab, ensure there are no contraindications (e.g. facial surgery or trauma). Collect a nasopharyngeal swab from newly symptomatic patients/residents, preferably within 2472 hours of onset of symptoms (see directions below). Specimens must be transported directly to the laboratory as soon as possible. Using established methods for transporting STAT laboratory specimens (i.e. with a cold pack). Return samples to the laboratory, either by courier during regular business hours or by taxi after hours and on weekends. The laboratory covers cost of transportation of specimens back to a VIHA laboratory. They will provide instruction on the process at the time. Purpose: This procedure describes how to collect a nasopharyngeal swab for influenza testing. Collect specimens from patient presenting with Influenza like illness within 72 hours of onset of symptoms Routine diagnostic swabs in transport media are NOT acceptable Calcium alginate swabs used for Bordetella pertussis are NOT acceptable. Residues present in the swabs may inhibit PCR assays Nasopharyngeal swabs are available from the Microbiology Laboratory at RJH, NRGH, CRH, and from the Laboratory at CDH, VGH, SPH, LMH, WCGH, and SJGH
Supplies Obtain an Influenza Outbreak kit from the Laboratory Flocked viral swab with Viral transport media (COPAN Red Top) VIHA inpatient Microbiology requisition If not available, use Herpes viral swab with viral transport media (Blue Top)
Page 104
Procedure 1 2 3 Explain procedure to the patient. Protect yourself (fluid resistant mask with visor, gloves and disposable gown). If the patient has a lot of mucous, ask them to use a tissue to gently blow their nose prior to specimen collection. 4 Influenza is found in the cells that line the nasopharynx, not in the mucous
With head supported, push the tip of the nose upwards. Insert the swab backwards and downwards to a depth of 2-4 cm into one nostril. Rotate the swab gently for 5-10seconds.
Place the swab into the virus transport media, snap off the top of swab, tighten cap securely. Label container with sample type and a minimum of two patient identifiers: First/Last Name, DOB, PHN, or use patient label with bar graph demographics label. Instruct the patient to use a tissue to contain cough and mucous. Provide hand hygiene for the patient after the procedure
References: 1. BCCDC H1N1 Specimen Collection Guidelines. 2. Vancouver Coastal Health, Influenza-like Illness Outbreak Specimen Collection.
Staff will obtain an Influenza outbreak kit from the laboratory which will include appropriate swabs and requisition forms. Please ensure that you include the facility and relevant outbreak unit on the requisition. This will ensure the test is done promptly and correctly reported. Continue collecting specimens from newly symptomatic patients/residents until the laboratory confirms the organism or you are instructed to stop by the Infection Prevention and Control Team, Public Health, Medical Health Officer, Microbiologist or Infectious Disease/Control Physician.
Page 105
Prophylaxis for Laboratory Confirmed Influenza Prophylaxis is the prevention of a disease (in this case influenza) through the use of medication. As the type of anti-viral medication used varies based on the strain of influenza and patterns of organism resistance, it is important that the prophylaxis used is the one recommended by the Medical Health Officer during the current influenza season. Check the protocol to ensure that it contains this years date. Also, as patients/residents kidney function may change, it is important that both the Physicians prepared order form and the patients creatinine levels are updated annually.
C.
Gastrointestinal Illness (GI) Outbreaks

1. Introduction
Infectious gastrointestinal (GI) illness or gastroenteritis (gastro) can be associated with a high incidence of morbidity and mortality. Many of these infections are attributable to Norovirus (previously known as Norwalk-like virus). Norovirus is extremely communicable and outbreaks are common. Outbreaks can present in sporadic episodes, or as intensely concentrated events occurring all at once. Attack rates can be quite high (> 50%) in both staff and patients/residents. Symptoms of Gastroenteritis include any combination of nausea, vomiting, diarrhea, and/or abdominal pain, which may be accompanied by myalgia, headache, low-grade fever, and malaise. Although most gastroenteritis cases are mild and self-limiting, serious dehydration and/or aspiration pneumonia secondary to emesis can occur in debilitated individuals. Transmission usually occurs via the fecal/oral or vomitus/oral route, but can also include fomite (objects or environmental surfaces) or droplet spread.
2. Confirming a GI Outbreak
Outbreaks of diarrhea in hospitals, nursing homes and NICUs have been associated with a wide variety of organisms including salmonella, shigella, Clostridium difficile, vibrio (cholera), Staphylococcus aureus, cryptosporidium, rotavirus and other enteroviruses. Some of the most common bacterial and viral agents causing infectious diarrhea, their incubation period and most prominent clinical characteristics are listed in the Table below Common Bacterial and Viral Causes of Gastroenteritis.
Page 106
Table 22: Common Bacterial and Viral Causes of Gastroenteritis

Organism name Salmonella (salmonellosis) Description Produces fever, nausea and vomiting followed by diarrhea that frequently contains mucus (whitish and stringy), but rarely blood, in stools. The incubation period is less than 72 hours (3 days) when large doses of organisms are eaten in contaminated food or drinks. Outbreaks among children, however, are commonly the results of contact transmission, and about 50% of exposed infants will develop illness once a case is introduced in a nursery. Adults, on the other hand, usually get salmonellosis from contaminated food, drinks or inadequately cleaned and disinfected medical instruments such as endoscopes. Once several patients/residents or staff are infected, transmission by contact to new susceptibles may be very rapid. Salmonellosis is a common cause of infectious diarrhea, accounting for more than 50% of all diarrhea outbreaks in nursing homes in which the causative agent was identified (Levine et al 1991). Control of outbreaks may be difficult; some nurseries or units have had to restrict new admissions. Safe food handling is essential for prevention, especially raw (uncooked) eggs or egg products (e.g.homemade mayonnaise or tartar sauce). Antibiotic treatment prolongs the time the infected person may carry the organism in her/his GI system, but antibiotic treatment may be necessary for septic or severely ill patients/residents. Produces rapid onset of diarrhea, with stools containing mucus and often blood. Infected persons are often more sick than is typical for other infecting agents. The incubation period is 16 days, and the usual source is fecal/oral transmission from acutely infected patients/residents. Outbreaks are less common than with salmonella or viral agents, and patients/residents shed the organisms only for a short period after becoming symptomatic. Has increasingly become an important cause of diarrhea. It may be the cause of nearly half of all cases of nosocomial diarrhea in adult hospitalized patients/residents. The diarrhea ranges from mild and self-limiting to severe pseudomembranous colitis, which can be fatal. Because C. difficile is present in the stools of infants and preschool children, colonization without clinical disease apparently occurs. Its presence in the GI tract gradually decreases with age. In addition, C. difficile may become endemic in the nursery and other high-risk units. No nosocomial outbreaks have been associated with food borne transmission, suggesting that contact transmission from contaminated articles or the hands of staff is responsible. For example, one report noted that when culture-negative patients/residents were placed in a hospital room currently or previously occupied by a person with C.difficile diarrhea, they were more likely to develop this type of diarrhea than patients/residents placed in rooms where no patient had had C. difficile diarrhea. This suggests the organism can persist on inanimate articles (e.g. lamps, door handles or bed rails) for some time unless rooms are thoroughly cleaned between patients/residents. Strains that cause acute diarrhea have not been reported to be nosocomially transmitted. Toxic strains have been transmitted in restaurants from contaminated meat that was not cooked sufficiently to kill the organisms and could be a problem in healthcare facilities that prepare their own meals from raw meat. Subgroups produce acute, severe diarrheal disease characterized by local outbreaks, widespread epidemics and occasional individual outbreaks. Cholera is usually associated with contaminated water sources.
Shigella (shigellosis)
Clostridium difficile (formerly called antibiotic-resistant diarrhea or pseudomembranous colitis)
Escherichia coli
Vibrio cholerae
Page 107
Organism name Rotavirus
Description Cause sudden onset of vomiting and diarrhea within 4872 hours (23 days) after exposure. Fever and upper respiratory symptoms are present in about half the cases. In addition the virus may be present in the sputum or secretions for several days. This may account for the extremely rapid transmission and seasonal peak in infections during winter. Symptoms subside in a few days, but the stool may contain virus for up to 2 weeks. Rotaviruses are the most common cause of diarrhea in children under five. Because it is highly infectious, during nursery outbreaks nearly all infants will become infected. Like C. difficile, the virus survives well on inanimate surfaces and may become endemic in hospitals.
Reference: John Hopkins University, Infection Prevention Guidelines for Healthcare Facilities with Limited Resources
Table 23: Gastrointestinal Illness Case Definition

Gastrointestinal Illness (GI) Case Definition Norovirus Like Illness: A resident or healthcare worker experiencing sudden unexplained vomiting or diarrhea in the absence of a functional cause. Diarrhea is considered two or more stools greater than the number normally experienced in a day, and in the absence of laxatives 15 or other bowel stimulating products . Diarrhea should be liquid enough to take the shape of the container. Note: To be defined as a case, the person must have been present in the facility during the period of time it takes to incubate the disease. If a staff member has not been in the facility within the past 3 days, even if they have gastro symptoms, they do not qualify as a Norovirus case for the purposes of 16 facility tracking . They may have Norovirus, but it would be considered a community, not workplace, associated case. GI Outbreak Suspected if: An outbreak should be suspected if the following 17 occurs on a designated geographical unit : The onset among patients/residents and/or staff of 3 or more symptomatic cases of gastroenteritis within a 4 day period. 18 Cases must be confirmed with the Infection Prevention and Control Team. Once they are confirmed and the number of cases within the correct time period validated, an outbreak will be declared and restrictions imposed.
3. GI Outbreak Management
All GI illness is to be treated as if it is Norovirus until proven otherwise. Once Norovirus is ruled out it is quite possible that Infection Prevention and Control may modify some of the
15
Although antibiotics can cause diarrhea also, gastroenteritis should be suspected, especially once antibiotic associated diarrhea is excluded. 16 This person may be the index case or initiator of an outbreak and their information should be communicated to the Infection Prevention and Control/ Public Health Lead and Employee Occupational Health & Safety or staffing person. 17 Outbreak Unit designation varies based on the design and layout of the physical structure. The boundaries of the Outbreak Unit will be established by the Outbreak Lead/Medical Lead in collaboration with the Responsible Physician and the facility administrator. 18 Cases must meet the case definition and then the number of cases must be adequate to meet the outbreak definition. Note: In this document the term patient is inclusive of patient, resident or client.
Page 108
restrictions/precautions in place. Always consult with the Infection Prevention and Control Team to determine what actions are required.
Practices and Precautions Routine practices are used for the care of all patients/residents at all times. Norovirus can be spread by contact and droplet routes, consequently Droplet Precautions are required for vomiting and handling body fluids only.
Droplet precautions include: Thorough hand washing before and after any patient contact Wearing of a gown and gloves Surgical grade mask with attached visor or face shield Appropriate hand washing while removing protective attire. This is important as contamination from used attire may occur during removal Where there is explosive diarrhea and vomit, the wearing of a fluid repellent gown is required
Room/Unit Closures The Infection Prevention and Control Team in collaboration with the Clinical Coordinator/Manager of Patient Care and members of the Outbreak Management Team will determine room and unit closures.
Patient Line Listings Infection Prevention and Control requires a daily completion of line listings It is the responsibility of the Clinical Coordinator/Manager of Patient Care (or designate) to ensure that the line listings are filled out completely at the beginning of each day, and submitted to the Infection Control Practitioner by 1000hrs, by either fax or email as agreed.
Information required includes: Identification of the unit Date of completion Contact person and details
Page 109
Patient information Name Date of birth Room number Symptoms, and onset date Specimens sent Line listing paperwork should be kept up to date and be available within the affected area, and faxed/emailed daily to identify any new cases, and current symptom status of all patients/residents affected. The reporting period is 0700 hrs the previous day to 0700 hrs of day of faxing/ emailing. If there are no new cases within a 24 hour period, this should be stated on the line listing. Discontinue daily faxing/emailing of line listings only when instructed by the Infection Control Practitioner.
Staff Line Listings Occupational Health & Safety requires daily completion of staff line listings. It is the responsibility of the Clinical Coordinator/Manager of Patient Care (or designate) to ensure the following information is completed each day, and forwarded to Occupational Health & Safety: Identification of the unit Date of completion Contact person and details Staff details Full name Telephone number Date last worked Symptoms and onset date Number of shifts missed Specimen information Discontinue daily faxing/emailing of line listings only when instructed by Occupational Health & Safety.
Lost Bed Days It is the responsibility of the Clinical Coordinator/Manager of Patient Care (or designate) to ensure that the bed days lost is recorded at the beginning of each period (0700-0700).
Page 110
Restrictions on Patient Activities Patients/residents symptomatic for a GI illness should remain in their room on droplet precautions for a minimum of 2 days (48 hours) after symptoms have ended, unless going off the unit for tests which are in the interests of the patients well being (however, if the test or treatment can be provided in the room this should be the first consideration). These patients/residents should dine in their room with tray service and not attend communal activities/dining room. If the person shares a room with someone who is not yet symptomatic, a commode or alternate unshared toilet facility should be provided to prevent further crosscontamination. Patients/residents should be reminded about, and assisted with hand washing if necessary. Note: Norovirus can appear to relapse frequently, i.e. experience onset of gastroenteritis symptoms after being asymptomatic for 24 48 hours. This relapse is likely due to malabsorption following infection, rather than a recurrence or reinfection of Norovirus. These patients/residents should be isolated again until they are symptom free for 48 hours, as cross infection may still occur. The recurrence of symptoms should be noted on the line listing. All group activities will be cancelled during the course of the outbreak. Patients/residents may be transferred to other healthcare facilities for a higher level of care (e.g. Emergency), should their condition require and with communication with that unit/facility. The transport company and receiving facility must be notified of the precautions required. The Infection Prevention and Control Team should also be informed of the transfer. Offsite appointments are discouraged, unless absolutely necessary. Where necessary, the receiving department or facility is to be notified beforehand. The transport company and receiving facility must be notified of precautions required.
Working Restrictions for Staff Working Restrictions for Staff, please review the GI/Norovirus Algorithm for Staff on the Infection Prevention and Control internal web site. This algorithm covers information on: Working on the Outbreak Unit Working on a Non-Outbreak Unit Symptomatic Healthcare Workers
Students Students of healthcare worker programs19 will be permitted to attend outbreak units, if they have previously received instruction on Infection Prevention and Control practices. The students and Educational Facility Instructor must abide by the same work restrictions as those of all other healthcare workers set out in the GI/Norovirus Algorithm for Staff. The
19
This includes all professions of caregivers, including medical students Page 111
Educational Facility Instructor is responsible for ensuring student compliance with healthcare worker restrictions.
Visitors/ Volunteers Visitation to an outbreak unit should be restricted to 2 visitors per patient at any one time, during scheduled visitation hours. Patients/residents should be reviewed and visitors/volunteers determined on an individual basis, considering the needs and medical condition of the patient. Staff must be consistent with their approach to facility visitation throughout the outbreak. Visitors/volunteers choosing to enter the facility must be symptom free of any communicable illness (respiratory illness, diarrhea/vomiting, rash, etc). Visitor/volunteers must be educated in the correct procedure for hand hygiene and on the correct use of PPE if required. Visitors/volunteers will not visit other patients/residents/patient rooms, must not visit public areas within the facility (unit kitchen, cafeteria, shops/kiosks in main entrance etc.) and SHALL NOT use the patient/resident bathroom. It is important to consider the needs of the patients/residents and possible staffing shortages, and weigh these against the concern about community spread of the disease.
Meals Symptomatic patients/residents should dine in their room with tray service and be restricted from the dining room and communal activities involving food preparation. The trays are managed according to direction for individuals on droplet precautions.
Pets No pets are allowed on affected units.
Housekeeping During a GI outbreak, units must be cleaned using a precaution plus clean. Attention during cleaning must be given to frequent-touch areas, specifically horizontal surfaces and bathrooms. See Housekeeping Cleaning table. A thorough clean of the unit following a GI outbreak should not begin until 4 days (96 hours) following the cessation of symptoms.
Linen No special handling/cleaning of linen is required.

Page 112
Collection and Transportation of Stool Specimens Management strategies for outbreaks of gastrointestinal illness are not dependent on laboratory confirmation. However, it is valuable to collect stool specimens from cases during outbreaks to try to identify the etiology, if possible. As directed by Outbreak Lead/Medical Lead, collect stool specimens from patients/residents that are acutely ill with GI symptoms, preferably within 24-48 hours of onset of symptoms. Collect one stool specimen from up to 6 symptomatic patients/residents. This number of specimens is usually sufficient to determine the etiology of the outbreak. Specimens must be transported to the laboratory as soon as possible using established methods for transporting STAT laboratory specimens.
Obtaining An Outbreak Number A unique outbreak identifier number is assigned to each specific GI outbreak. Contact the Infection Prevention and Control Team to get your number.
How To Collect A Stool Specimen Gather supplies including a dry specimen container and a clean tongue depressor or plastic spoon Pre-label specimen container accurately including patient information and date of collection Ensure Outbreak Number is on the requisition Perform hand hygiene and don appropriate PPE Scoop the specimen into the container with a disposable tongue depressor or plastic spoon Fill the container with stool up to one third or approximately one-tablespoon full Keep the outside of the container clean, screw the lid tightly onto the plastic container If possible, have a second person waiting outside the room holding open a biohazard bag to drop the specimen container into. Have the second person seal the bag Remove PPE appropriately and perform hand hygiene Send the specimen and the requisition to the laboratory in a biohazard bag marked STAT
Note: only stool specimens will be tested. Emesis is no longer acceptable as a suitable specimen for confirmation of GI.
Page 113
Figure 8: Requisition Form for GI Testing
Under examination required, check Other, and write Norovirus PCR One BCCDC virus isolation requisition must be completed for each specimen. Also include: Facility From Outbreak Unit_________(state Unit) Patient identifiers Facility contact person This will ensure the test is done promptly and correctly reported. Continue collecting specimens from newly symptomatic patients/residents until the laboratory confirms the organism or you are instructed to stop by the Infection Prevention and Control Team/Public Health, Medical Health Officer, Microbiologist or Infectious Disease/Control Physician.
Page 114
D.
Outbreaks Caused by Other Organisms

1. Clostridium Difficile Outbreak
Clostridium difficile illness (CDI) should be considered when a patient experiences sudden unexplained diarrhea in the absence of a functional cause. The case definition for CDI is: Acute onset of diarrhea (3 or more loose stools within a 24 hr period) without another etiology (diarrhea should be liquid enough to take the shape of the container). And one or more of the following Laboratory confirmation (positive toxin), or Diagnosis of typical pseudo-membranes on sigmoidoscopy or colonoscopy or histological/pathological diagnosis of CDI, or Diagnosis of toxic megacolon.
It is assumed that any stool sent to the laboratory for CDI testing is from a patient that has had at least 3 episodes of loose stools in a 24 hour period. It is accepted that the surveillance protocol may overestimate the number of cases as some patients/residents may have had only one or two loose stools prior to a specimen being collected.
Confirming a CDI Outbreak The outbreak definition for CDI is: 3 or more cases who meet the above case definition within a defined geographical area and are found to be hospital acquired on the same unit (i.e. does not include community acquired cases or those readmitted or transferred from a different unit). The Infection Prevention and Control Team will review and validate that an outbreak exists.
Laboratory samples Stool that is liquid enough to assume the shape of the container is the acceptable specimen and must be specifically requisitioned for CDI testing. If the results of the test are Antigen Positive and Toxin Negative and symptoms persist, another specimen should be sent for CDI testing. Send repeat samples only on patients/residents that meet the definition of relapse or reinfection (based on a symptom-free interval). Relapse or reinfection is defined as a reoccurrence of symptoms within 30 days of a previous diagnosed cases of CDI.
Page 115
Testing for cure is not required.
2. Work Restrictions
There are no staff work restrictions associated with a CDI outbreak. Practices and Precautions Contact precautions in private room or cohorting with other confirmed cases Emphasize the importance of hand washing for patients/residents, staff and visitors. ABHRs are less effective for killing C. difficile spores; hand washing must be encouraged using a neutral soap and water Precaution Plus cleans are required in any rooms with affected patients/residents. Attention is required especially to frequent touch areas and bathrooms/toilet facilities
3. Scabies
Definitions Clinical features of infestation skin penetration visible as papules or vesicles burrows formed by mites under the skin are visible as linear tracts lesions are seen most frequently in inter-digital spaces, anterior surfaces of wrists and ankles, axillae, folds of skin, breasts, genitalia, belt-line and abdomen. Infants may have lesions of the head, neck, palms and soles of the feet itching does not always occur with a primary infestation, but when it does it is most intense at night itching may continue for approximately 6 weeks after treatment. This does not mean treatment was not successful Suspected case Patient has the above clinical features of scabies infestation Clinically diagnosed case Patient has the above clinical features of scabies but skin scraping does not positively confirm the presence of scabies Confirmed case Patient with skin scraping showing mites, eggs or fecal pellets, or a written opinion by a dermatologist based on signs and symptoms
Page 116
Close contact Unprotected, prolonged, direct contact with skin, clothing or linens of a person with untreated scabies Crusted (Norwegian) scabies Is usually seen in immunocompromised people, this form of scabies is characterized by widespread, extensive crusting and scaling of the skin. Rash may be present and on any area of the body and thousands of mites may be present This form of scabies is highly contagious An outbreak is considered when: Two or more patients/residents diagnosed with scabies on one unit within a 2-week period or One patient plus one or more staff members on one unit are diagnosed with scabies within a 2-week period
Specific Interventions Validation The Infection Prevention and Control Team will validate an outbreak and its extent. This may involve consultation with a dermatologist to attempt to confirm the diagnosis by obtaining skin scrapings Assessment of all current patients/residents, staff, volunteers and students on the unit for symptoms must be carried out prior to administration of treatment or prophylaxis of cases or contacts. All patients/residents cared for on the unit and staff assigned on the unit in the previous 6 weeks will be tracked and contacted Administration will be informed of a suspected outbreak by the Infection Prevention and Control team
Laboratory Samples Skin scrapings are obtained by a person trained in collection of the specimen using a kit requested from the Microbiology Laboratory
Control Measures Upon validation of an outbreak, the unit will be closed to admissions and transfers. Discharged patients/residents should be assessed for symptoms and advised of the need for treatment or prophylaxis Only patients/residents who have symptoms or have positive skin scrapings need to be placed on contact precautions until 24 hours after initiation of treatment.
Page 117
Patients/residents with Crusted Scabies remain on precautions until symptoms have abated Treatment of symptomatic cases and prophylaxis of all contacts (including asymptomatic patients/residents, healthcare workers, volunteers and visitors) must take place within the same 24-hour period
Symptomatic Patients/Residents Treatment Staff, using contact precautions and working in teams, will bathe and dry patients/residents, clip the patients/residents fingernails, and clean under their nails. Examine the scalp for crusted lesions in confirmed cases. Apply medication as ordered and according to the drug information insert. Simultaneously the patient bed must be stripped, cleaned and remade and clothing is bagged In accordance with contact precautions, staff must wear long sleeved gowns and gloves, which are changed between patients/residents Follow-up baths to remove medication are done at either 8 or 12 hours after treatment, dependent on the treatment used. Bed is again stripped and remade
Asymptomatic Patients/Residents Prophylaxis Prophylaxis of asymptomatic patients/residents is limited to the involved unit. These patients/residents receive one application of medication and follow-up bath. Linens and clothing are changed per routine
Symptomatic Staff Treatment Every employee case must be reported to Occupational Health & Safety, who can facilitate dermatology consultation and staff case management. Staff and students who have worked on this unit over the previous 6 weeks must be contacted and assessed Staff diagnosed with scabies are relieved of direct patient contact until 24 hours after initiation of treatment Household, sexual and other close contacts (skin to skin contact or sharing clothes or bed linens) of a staff case should receive treatment (if symptomatic) or prophylaxis during the same 24-hour period as the staff treatment Pet prophylaxis is not needed, as animal scabies is a different species
Environment All linen, towels and clothing used in the previous 4 days should be washed in hot water (60C) and heat dried. Items that cannot be washed in hot water should be stored in a plastic bag for at least 7 days before washing and reusing
Page 118
There is no need for special treatment of furniture, mattresses or rugs. General cleaning and thorough vacuuming is recommended
Asymptomatic Staff, Volunteers and Physicians Prophylaxis For staff apply the medication, and then bath or shower at either 8 or 12 hours, dependent on the treatment used later as per the medication package information insert For volunteers/physicians, need for prophylaxis treatment is determined on the amount of direct contact that the person has with the patient and environment No special handling of clothing or linens is needed Family members of asymptomatic staff do not require prophylaxis
Note: If pregnant, or for children under 2 years of age, consult physician prior to treatment
Environmental Cleaning Special attention should be paid to the items with which infested patients/residents have had direct skin contact in the previous four days. These include clothing, wheelchair cushions, shoes, slippers, coats, lap blankets, etc. Items that cannot be washed in hot water (60C) or sent to laundry are placed in a sealed plastic bag for 7 days or dry-cleaned. General cleaning and thorough vacuuming of furniture is recommended.
Scabies Outbreak Conclusion The unit may be reopened to admissions and transfers when all patients/residents involved have received treatment or prophylaxis and follow-up baths. Symptomatic patients/residents may still be cared for in isolation. Monitoring continues for at least 6 weeks following last exposure for development of new cases.
Reference: Scabies Control Guidelines circular #2005: 02, BC Centre for Disease Control February 2005.
Page 119
PART 7: DEPARTMENTAL GUIDELINES

1. Inpatient Mother and Baby
A. Routine Practices
Routine practices are to be used with all patients/residents at all times. The key to implementing routine practices is to assess the risk of transmission of microorganisms before any interaction with the patient. The elements of routine practices are: Risk Assessment Risk Reduction Education Hand hygiene is the single most effective method of reducing cross infection. The healthcare setting provides an ideal opportunity to educate parents on the importance, methods and situations for hand hygiene.
B.
Additional precautions are required when routine practices are not sufficient to prevent the transmission of certain microorganisms. It may be necessary to isolate both mother and baby into a single room. Where this is not possible, additional precautions can be implemented in a multi-patient room. However, in this situation it is important to limit the movement of the mother around the room/unit.
Table 24: Common Conditions and Precautions Needed
Note: This list is not exhaustive, but includes conditions of particular importance to this area (see also Appendix A)
CONDITION Ophthalmia neonatorum Pustules/cellulitis Toxoplasma, Rubella, Cytomegalovirus and Herpes Virus (TORCH) Syndrome Varicella Herpes (Non-Genital and Genital)
20
PRECAUTIONS / PRACTICES Contact Precautions Routine Practices Droplet Precautions
COMMENTS Until 24 hours of effective antibiotic therapy No precautions necessary by the parents Between 1021 days
20
Airborne Precautions See algorithm below
Neonates born to mothers with active Varicella should be placed on airborne precautions until 21 days of age (or 28 days if VZIG is given). If a mother develops chicken pox from 5 days before to 3 days after delivery, consult the physician regarding the possible administration of VZIG to the neonate. Neonates (up to 2 months of age) of antibody positive mothers, who are exposed to varicella do not require isolation.
Page 120
C.
Herpes
Figure 9: Precautions Required When Caring for Mother with Non-Genital Herpes
Mother with Non-Genital Herpes
Lesions dry / crusted
Lesions open / weeping
ROUTINE PRACTICES
NO
Good personal hygiene?
YES CONTACT PRECAUTIONS Single room isolation Instruction regarding hygiene measures
NO
Can lesions be covered with dressing or mask?
YES
ROUTINE PRACTICES Reinforce need to cover lesions
Figure 10: Precautions Required When Caring for Mother with Genital Herpes
Mother with Genital Herpes
No open lesions; No recent positive culture
Lesions present; or recent positive for HSV
ROUTINE PRACTICES
CONTACT PRECAUTIONS Single room isolation
1. Staff Precautions
Staff must be free from any transmissible infection. This includes dermatitis, which can be colonized with microorganisms, and skin cells are readily shed.
Page 121
Staff with herpes lesions must not work while they are in the early stages of disease (wet blistered lesions). Lesions must be dry and scabbed, and preferably covered with a dressing prior to returning to work. Information relating to staff immunization can be obtained from Occupational Health & Safety. Any further advice should be sought from Occupational Health & Safety.
D.
Antibiotic Resistant Organisms
AROs are defined as microorganisms that are resistant to one or more classes of antimicrobial agents. a. Methicillin Resistant Staphylococcus aureus (MRSA) b. Vancomycin Resistant Enterococci (VRE) c. Bacteria containing Extended Spectrum Beta Lactamase (ESBL) All admissions to the maternity unit must be screened for AROs by completing the ARO Screening Questionnaire. It is the responsibility of the nurse/midwife completing this questionnaire to collect the swabs as required. If swabs are required from the mother, a vaginal swab for MRSA is also required. The vagina is a significant site as a source of transmission to the newborn. In the instance that a parent or family member living in the home is identified as having an ARO, there is a significant risk that the baby will become colonized during their hospitalization. For this reason, the baby should also be treated as if positive, and appropriate additional precautions put in place.
E.
Outbreaks
The Infection Prevention and Control Team will investigate all outbreaks in close liaison with the Clinical coordinator/Clinical Nurse Leader/Unit Manager (Outbreak Team). In order to bring control, and reduce/prevent further cross infection, it is essential to alert the Infection Prevention and Control Team as soon as there is any suspicion there could be an outbreak.
An outbreak is defined as the occurrence of two or more related cases of the same infection, or where the number of infections is greater than would normally be expected.
Page 122
2.
Neonatal Intensive Care and Special Care Baby Units

Due to the vulnerability and increased invasive procedures required, the neonate is at great risk from acquiring an infection. Routine practices are to be used with all patients/residents at all times The key to implementing routine practices is to assess the risk of transmission of microorganisms before any interaction with the patient. The elements of routine practices are: Risk Assessment Risk Reduction Education Hand hygiene is the single most effective method of reducing cross infection. Parents must be taught and encouraged to perform hand hygiene before any contact with their baby.
B.
Visitors
Parents, visitors or staff believed to be incubating or infectious with a communicable illness must be restricted from visiting the nursery. Staff should contact Occupational Health & Safety for further information and advice Parents, visitors or staff with open skin lesions should be assessed and counseled prior to having contact with the neonate. Staff should contact Occupational Health & Safety for further information and advice Mothers believed to be incubating or infectious with a communicable illness should be assessed by the physician to confirm prior exposure and advice on where visitation may occur All visitors must be discouraged from visiting other parents at their babys cot or incubator at any time
C.
Additional precautions are required when routine practices are not sufficient to prevent the transmission of certain microorganisms. It may be necessary to isolate the neonate into a single room. Where this is not possible, additional precautions can be implemented in a multi-patient room with the use of an incubator.
Page 123
It is usually not necessary for parents to wear gloves for contact with their baby, but hand hygiene must precede and follow any contact with the baby. A long sleeved gown should be worn when additional precautions are required, to prevent contamination of their clothing and therefore transmission to the environment.
1. Contact Precautions
Contact precautions are implemented for pathogenic organisms, which are principally spread through direct (hands) or indirect (equipment, environmental) contact. Label the cot, incubator or room with the yellow precautions sign Gloves and gown are worn for all contact with the neonate and their physical environment Ensure the isolation cart is positioned appropriately for easy access to protective clothing and other equipment, but not in a position where it will become contaminated Dedicate equipment to the neonate. Where equipment cannot be dedicated, it must be thoroughly decontaminated after use Notify housekeeping as special cleaning will be required. See Housekeeping Cleaning table
2. Droplet Precautions
Droplet precautions are implemented for pathogenic organisms, which are transmitted by aerosol of respiratory secretions, emesis or diarrhea, through forceful expulsion of these body fluids. Label the cot, incubator or room with the green precautions sign Gloves and gown are worn for all contact with the neonate and their physical environment. A mask with visor may be necessary, particularly if the neonate is not in an incubator Ensure the isolation cart is positioned appropriately for easy access to protective clothing and other equipment, but not in a position where it will become contaminated Dedicate equipment to the neonate. Where equipment cannot be dedicated, it must be thoroughly decontaminated after use Notify housekeeping as special cleaning will be required. See Housekeeping Cleaning table
3. Airborne Precautions
Airborne precautions are implemented for pathogenic organisms, which are transmitted by way of the respiratory tract. The neonate is cared for in an isolation room with negative pressure ventilation. The Infection Prevention and Control Team should be consulted, and will advise where a negative pressure room is unavailable
Page 124
Label the room with the blue precautions sign All staff are directed to wear an appropriate mask if susceptible to the confirmed or suspected infection Doors to the room must remain closed
Table 25: Common Conditions and Precautions Needed
Note: This list is not exhaustive, but includes conditions of particular importance to this area (see Appendix A)
CONDITION Ophthalmia neonatorum Pustules/cellulitis TORCH Syndrome Varicella PRECAUTIONS/ PRACTICES Contact Precautions Routine Practices Droplet Precautions Airborne precautions COMMENTS Until 24 hours of effective antibiotic therapy No precautions necessary by the parents Between 10-21 days21
D.
AROs are defined as microorganisms that are resistant to one or more classes of antimicrobial agents Examples of Antibiotic Resistant Organisms include: Methicillin Resistant Staphylococcus aureus (MRSA) Vancomycin Resistant Enterococci (VRE) Bacteria containing Extended Spectrum Beta Lactamase (ESBL) All admissions to the Neonatal/Special Care Baby Unit must be screened for AROs by completing the Neonatal ARO Screening Questionnaire. It is the responsibility of the nurse/midwife completing this questionnaire to collect the swabs as required. ESBL is very rare in neonates and therefore screening swabs for these organisms are not required from the neonate. In the instance that a parent or family member living in the home are identified as having an ARO, there is a significant risk that the baby will become colonized during hospitalization. For this reason, the baby should also be treated as if positive and appropriate additional precautions put in place.
21
Neonates born to mothers with active Varicella should be placed on airborne precautions until 21 days of age (or 28 if VZIG is given). If a mother develops chicken pox from 5 days before to 3 days after deliver, consult the physician regarding the possible administration of VZIG to the neonate. Neonates (up to 2 months of age) of antibody positive mothers, who are exposed to varicella do not require isolation. Note: In this document the term patient is inclusive of patient, resident or client.
Page 125
The parents of the baby being isolated for TORCH syndrome or hepatitis are not required to wear protective clothing for handling their child, as they have already been exposed and are therefore either immune or infected. It is still important for parents to wash their hands following contact to reduce the risk of further contamination of the environment through contact.
E.
Outbreaks
The Infection Prevention and Control Team will investigate all outbreaks in close liaison with the Clinical coordinator/Clinical Nurse Leader/Unit Manager (Outbreak Team). In order to bring control, and reduce/prevent further cross infection, it is essential to alert the Infection Prevention and Control Team as soon as there is any suspicion there could be an outbreak. An outbreak is defined as the occurrence of two or more related cases of the same infection, or where the number of infections is greater than would normally be expected.
3.
Pediatrics
Due to the vulnerability and increased invasive procedures required, children are at great risk from acquiring an infection. Routine practices are to be used with all patients/residents at all times. The key to implementing routine practices is to assess the risk of transmission of microorganisms before any interaction with the patient. The elements of Routine Practices are: Risk Assessment Risk Reduction Education Hand hygiene is the single most effective method of reducing cross infection. The healthcare setting provides an ideal opportunity to educate children and their parents/visitors on the importance, methods and situations for hand hygiene.
B.
Additional precautions are required when routine practices are not sufficient to prevent the transmission of certain microorganisms.
Page 126
The implementation of additional precautions into pediatric units and departments presents some unique challenges. Unfortunately, it is very difficult to set specific rules as precautions taken often depend upon the age and developmental stage of the child. Young children have a limited understanding of infection prevention and control, because it is difficult for them to comprehend cause and effect relationships between germs and illness. These children require greater restrictions on their activities, as they cannot be relied upon to practice routine infection prevention and control practices, such as cough etiquette or hand hygiene after using the bathroom. It is essential to communicate honestly and openly with parents, to harness their cooperation and support in limiting the childs activities. Older children understand causality better, and can be provided with factual information. However, compliance with infection prevention and control principles can still be problematic, and often requires great skill to encourage the child. Communication and education of family members and visitors is essential to ensure compliance with routine practices and any additional precautions implemented. Decisions to isolate and add precautions must be fully explained to the family, with the underlying rationale for doing so.
1. Contact Precautions
Contact precautions are implemented for pathogenic organisms, which are principally spread through direct (hands) or indirect (equipment, environmental) contact. Where possible isolate the child in a single room, or cohort with other children with the same infectious illness. Where this is not possible: Precautions should be put in place in a multi-bedded room and the Infection Control Practitioner informed Label the room with the yellow precautions sign Gloves and gown are worn for all contact with the child and their physical environment Ensure the isolation cart is positioned appropriately for easy access to protective clothing and other equipment, but not in a position where it will become contaminated Dedicate equipment to the child. Where equipment cannot be dedicated, it must be thoroughly decontaminated after use Notify housekeeping as special cleaning will be required. See Housekeeping Cleaning table
2. Droplet Precautions
Droplet precautions are implemented for pathogenic organisms, which are transmitted by aerosol of respiratory secretions, emesis or diarrhea, through forceful expulsion of these body fluids.
Page 127
Where possible isolate the child in a single room, or cohort with other children with the same infectious illness. Where this is not possible, precautions should be put in place in a multi-bedded room and the Infection Control Practitioner informed Label the room with the green precautions sign A mask with visor may be necessary Ensure the isolation cart is positioned appropriately for easy access to protective clothing and other equipment, but not in a position where it will become contaminated Dedicate equipment to the child. Where equipment cannot be dedicated, it must be thoroughly decontaminated after use Notify housekeeping as special cleaning will be required. See Housekeeping Cleaning table
3. Airborne Precautions
Airborne precautions are implemented for pathogenic organisms, which are transmitted by way of the respiratory tract. The child is cared for in an isolation room with negative pressure ventilation. The Infection Prevention and Control Team should be consulted, and will advise where a negative pressure room is unavailable Label the room with the blue precautions sign All staff are directed to wear an appropriate mask if susceptible to the confirmed or suspected infection Doors to the room must remain closed
C.
Communicability Periods
Note: this list is not exhaustive, but includes conditions of particular importance to this area (See Appendix A)
Susceptible Contacts of
Chickenpox Diphtheria Mumps Polio Streptococcal Pharyngitis Rubella (German Measles) Rubeola (Measles) Tuberculosis (pulmonary)
From (days after first contact)

10 days 2 days 12 days 0 days 1 day 14 days 7 days 4 weeks
To (days after last definitive contact)

21 days (28 days if VZIG given) 14 days if no culture or until bacteriology confirms absence of carrage 25 days When stools negative 1 day (treated) 3 days (untreated) 23 days 18 days Until bacteriology confirms absence of infection Page 128
Pertussis (Whooping Cough)
5 days
14 days after last exposure or until cases and contacts have received a minimum of 14 days course of appropriate antibiotics
Precautions are not required before and after the above established incubation periods. During the presumed infectious period, elective admission should be avoided. Patients/residents admitted during these times shall be treated with appropriate precautions.
D.
AROs are defined as microorganisms that are resistant to one or more classes of antimicrobial agents. Examples of Antibiotic Resistant Organisms include: Methicillin Resistant Staphylococcus aureus (MRSA) Vancomycin Resistant Enterococci (VRE) Bacteria containing Extended Spectrum Beta Lactamase (ESBL) All admissions to the Paediatric unit must be screened for AROs by completing the ARO screening questionnaire. It is the responsibility of the nurse completing this questionnaire to collect the swabs as required. In the instance that a parent or family member living in the home are identified as having an ARO, there is a significant risk that the baby will become colonized during hospitalization. For this reason, the child should also be treated as if positive and appropriate additional precautions put in place. In the instance that a parent (mother, father or mothers partner) is identified as having an ARO, there is a significant risk that the child will become colonized during hospitalization. For this reason, the child should also be treated as if positive and appropriate additional precautions put in place.
E.
Outbreaks
The Infection Prevention and Control Team will coordinate all outbreaks in close liaison with the Clinical coordinator/Clinical Nurse Leader/Unit Manager. In order to bring control, and reduce/prevent further cross infection, it is essential to alert the Infection Prevention and Control Team as soon as there is any suspicion there could be an outbreak. An outbreak is defined as the occurrence of two or more related cases of the same infection, or where the number of infections is greater than would normally be expected.
Page 129
4.
Infection Prevention and Control Practices for Surgical Service Areas

A. Rationale
Surgical procedures are associated with risk of introducing infection to the patient as a result of disruption of normal host barriers. Hence, use of appropriate sterile technique by all personnel is necessary to reduce the risk of introducing infection to the patient. However, given the invasive nature of operative procedures, there is also significant risk of exposure and contamination of healthcare staff and the environment in surgical care areas by blood, body fluids and tissue (including airborne skin and other epithelial cells colonized with microbes) from patients/residents undergoing surgery. Consequently, strict adherence to infection prevention and control practices is necessary to protect staff and other patients/residents. This includes following strict aseptic technique, the appropriate use of PPE, as well as thorough cleaning and disinfection of the surgical environment (from preanaesthetic to operative to post-anaesthetic areas) between patients/residents. The basic standard of infection prevention and control and housekeeping practices should be sufficient in most cases to prevent the transmission of infection. This is particularly relevant for antibiotic resistant organisms (AROs), since a patients colonization status may not be known at the time of their surgical procedure. Patients/residents who require additional precautions in the operating room are those who have clinical signs and symptoms consistent with infection with a communicable pathogen, whether directly related to the nature of the surgical procedure or not (e.g. a patient with diarrhea undergoing pacemaker implantation), or who are known to be colonized with a pathogen that represents an increased risk of transmission (e.g. AROs).
B.
Principles
Routine practices are exercised by all staff at all times. Additional precautions will be dictated by prior knowledge of ARO colonization status and patient assessment of risk for transmission of communicable disease (evidence of infection, whether directly related to the surgical procedure or not). Only anaesthetic/OR equipment and supplies needed for the surgical procedure are to be brought into the operating suite. Equipment that cannot be removed should be located as far from the procedure table as possible. If within a one metre distance, they should be draped to protect them from splashes. The drape is removed and replaced during post-case cleaning. Personal items (e.g. computers, brief cases, backpacks, etc.) are not to be brought into the operating suite.
Page 130
Use of appropriate barrier precautions by staff at all times is essential to protect staff and reduce risk of communicable disease transmission. Patient isolation is generally unnecessary and potentially detrimental to patient care. Cleaning and disinfection must be performed for all cases sufficient to eradicate most pathogens (including AROs) from the surgical environment and must be performed between each case. Accelerated hydrogen peroxide (1:16) is the agent advocated for cleaning of all surgical care areas. This will likely have significant potential impact on flow through the operating rooms. Precaution cleaning (for VRE or diarrheal illnesses) using accelerated hydrogen peroxide may be necessary in particular instances for patients/residents requiring Additional Precautions, on the recommendation of Infection Prevention and Control. See Housekeeping Cleaning table Where feasible, cases involving patients/residents who require additional precautions should be booked at the end of the slate. If the case cannot be delayed, thorough cleaning and disinfection of the surgical care areas must be assured between cases.
Page 131
Figure 11: Surgical Booking Procedure

Booking Request
Contact Precautions - Gloves - casual contact - Gowns - close contact - Hand hygiene after any contact
No Infection ARO- or unknown
No Infection ARO+
Infection ARO+ or ARO-
Airborne Infection Only ARO+ or ARO-
Airborne AND other infection
Book for Routine Discharge Cleaning
Book for Routine Discharge Cleaning
Book for Routine Discharge Cleaning + Walls
Book Negative Pressure Room & Routine Discharge Cleaning
Book Negative Pressure Room & Routine Discharge Cleaning + Walls
Droplet Precautions - Gloves & gown for all contact - Mask with shield if within 3 feet - Hand hygiene after any contact
Patient Reassessment for Communicable Disease (Infection) Risk (Pre-admit Clinic, Anesthesiologist, Surgeon, Admitting Nurse)
Airborne Precautions - N95 Mask - Negative pressure room *TB/Chickenpox & other infection
No Infection
No Infection
Infection
*TB/Chickenpox ARO+ or ARO-
Routine Practices
Contact Precautions
Contact / Droplet Precautions
Airborne Precautions plus Contact Precautions (if required)
Airborne AND Contact / Droplet Precautions
Routine Discharge Cleaning
Routine Discharge Cleaning + Walls
Routine Discharge Cleaning + Walls
Airborne AND Contact / Droplet Precautions: - N95 Mask - Negative air room - Gloves & gown for all contact - Shield or protective eye wear within 3 feet - Hand hygiene after any contact
*Most common airborne organisms. Schedule case at end of day or allow an extra 10 minutes for cleaning.
When a surgical booking is made, increased risk of communicable disease transmission should be identified by the booking surgeon (i.e. infection, see the following Table: Assessment for Increased Risk of Communicable Disease Transmission ).
Table 26: Assessment for Increased Risk of Communicable Disease Transmission
Determine from the booking surgeon (at time of booking) and patient and/or unit staff (hospitalized patient) if the patient has:
Page 132
TB or Chicken Pox
Airborne Precautions Droplet Precautions Contact Precautions Contact Precautions Routine Practices
Fever & Cough

Skin Infection, open wound, boil or abscess Diarrhea in the past 2 days No risk factors for communicable disease transmission
If on contact precautions, determine from the patient and/or unit staff if the patient has: C.difficile VRE
Note: If there is a Norovirus outbreak in the facility/unit from which the patient is coming, check with Unit Manager/Infection Control Practitioner.
Cases where there is NO known colonization with an ARO and no identified increased risk of communicable disease transmission (i.e. infection, see Table 21: Assessment for Increased Risk of Communicable Disease Transmission) may be booked at ANY TIME with direction for Routine Discharge Cleaning. See Housekeeping Cleaning table Cases where there is known colonization with an ARO but no identified increased risk of communicable disease transmission (i.e. infection, see Table 21: Assessment for Increased Risk of Communicable Disease Transmission) may be booked at any time with direction for Routine Discharge cleaning. See Housekeeping Cleaning table. OR/PAR staff to use Contact Precautions. If there is identified increased risk of communicable disease transmission (i.e. infection, see Table 21: Assessment for Increased Risk of Communicable Disease Transmission), determine if the infection is known or thought due to tuberculosis (TB) or chickenpox. If so, book as an Airborne case at any time in a negative pressure OR suite, with direction for Routine Discharge Cleaning. See Housekeeping Cleaning table. If there is an infection other than TB or chickenpox, the case may be booked as a contact or droplet case at any time with direction for Routine Discharge Cleaning with the addition of wall surfaces. Additional time for such cleaning to be done (add an approximate additional 10 minutes) should be added. Cases with infections where precaution cleaning is required (i.e. Norovirus, clostridium difficile, etc.), should be booked at the end of the slate if possible. Where feasible, it should be recommended that ALL patients/residents have a preoperative bath or shower with antiseptic soap the night before and the morning of surgery. This is
Page 133
mandatory for elective cases, but not anticipated to be feasible for non-elective cases. Chlorhexidine (4%) is the antiseptic agent recommended.
C.
Procedure Pre-Operatively
See also Assessment for Increased Risk of Communicable Disease Transmission
1. Cases Without Identified Need for Additional Precautions

The patient should have a preoperative bath or shower with antiseptic soap the night before and the morning of surgery. This is mandatory for elective cases, but not anticipated to be feasible for non-elective cases. Chlorhexidine (4%) is the antiseptic agent recommended. All slated Same Day Admit or Daycare patients check in and are prepared in the normal fashion, including hand hygiene on arrival. They should be instructed on admission on hand hygiene and instructed to clean toilet surfaces after personal use with accelerated hydrogen peroxide wipes. For non-elective cases, if possible, the patient should be instructed to wash hands or use ABHR on arrival to the preoperative area. Patients/residents should be assessed for presence of increased risk of communicable disease transmission (i.e. infection; see Assessment for Increased Risk of Communicable Disease Transmission). If present, follow the appropriate algorithm (see Surgery Booking Request) The need for additional precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). Routine practices are to be used by all personnel unless otherwise indicated. Cleaning/disinfection of environmental surfaces in all pre-operative care areas contaminated or potentially contaminated by the patient should be performed prior to next patient use.
Page 134
2. Cases Known to be Colonized with an ARO Without Evidence of Infection

See Assessment for Increased Risk of Communicable Disease Transmission. The patient should have a preoperative bath or shower with antiseptic soap the night before and the morning of surgery. This is mandatory for elective cases, but not anticipated for nonelective cases. Chlorhexidine (4%) is the antiseptic agent recommended. All slated Same Day Admit or Daycare patients check in and are prepared in the normal fashion, including hand hygiene on arrival. They should be instructed on admission on hand hygiene and instructed to clean toilet surfaces after personal use with accelerated hydrogen peroxide wipes. For non-elective cases, if possible, the patient should be instructed to wash hands or use ABHR on arrival to the preoperative area. Patients/residents should be treated with contact precautions when close personal care is being provided (from pre-anaesthetic to operative to post-anaesthetic areas. The need for contact precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). The patient chart will be transported in a pillowcase. When removed from the pillowcase, the chart should be placed on a clean surface away from patient contact surfaces (such as the bed and any over bed table, etc.). Hand hygiene should be performed before and after handling the chart. The chart may be returned to the same pillowcase used for transport, as long as the inside of the pillowcase has not been contaminated. Patients/residents should be assessed for presence of increased risk of communicable disease transmission (i.e. infection; see Assessment for Increased Risk of Communicable Disease Transmission). If present, follow the appropriate algorithm (see Surgery Booking Request); this may require additional precautions. The need for additional precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). Cleaning/disinfection of environmental surfaces in all pre-operative care areas contaminated or potentially contaminated by the patient should be performed prior to next patient use.
3. Cases Where Patient has Evidence of Infection: Contact or Droplet Precautions

See Assessment for Increased Risk of Communicable Disease Transmission. The patient should have a preoperative bath or shower with antiseptic soap the night before and the morning of surgery. This is mandatory for elective cases, but not anticipated to be feasible for non-elective cases. Chlorhexidine (4%) is the antiseptic agent recommended.
Page 135
Patients/residents known to have an infection or who are already under additional precautions should be transferred under contact or droplet precautions directly into the OR or to the OR holding area (not the pre-operative area) on their bed or stretcher. Cleaning of that environment may be necessary if there is obvious contamination. If the patient is in the Emergency Department (ED) and transfer on the ED stretcher is not feasible, if possible, the patient should be transported on a stretcher from the post-anaesthetic area, brought from the post-anaesthetic area to ED by the porter. The patient chart will be transported in a pillowcase. When removed from the pillowcase, the chart should be placed on a clean surface away from patient contact surfaces (such as the bed and any over bed table, etc.). Hand hygiene should be performed before and after handling the chart. The chart may be returned to the same pillowcase used for transport, as long as the inside of the pillowcase has not been contaminated. Patients/residents should continue to be treated with contact or droplet precautions when close personal care is being provided (from pre-anaesthetic to operative to post-anaesthetic areas). The need for and type of contact or droplet precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). Patients/residents should be assessed for presence of increased risk of communicable disease transmission (i.e. infection) other than that already identified prior to admission to the surgical care area; see Assessment for Increased Risk of Communicable Disease Transmission. If present, follow the appropriate algorithm (see Surgery Booking Request). The need for additional precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). Cleaning of environmental surfaces in all pre-operative care areas contaminated or potentially contaminated by the patient should be performed prior to next patient use. Where additional precautions are required, precaution cleaning using accelerated hydrogen peroxide may be necessary in particular instances for patients/residents requiring Additional Precautions, on the recommendation of Infection Prevention and Control (see the Surgical Housekeeping algorithm and Housekeeping Cleaning table.)
Page 136
Figure 12: Surgical Housekeeping Algorithm
No Infection ARO+ or ARO-
Cases requiring Airborne Precautions
Infection Requiring Contact Precautions
Cases requiring Droplet Precautions
Routine Discharge Cleaning with *H2O2 1:16 or QAC
Routine Discharge Cleaning with *H2O2 1:16 or QAC
All horizontal and contact surfaces (both sides) in pre-anesthetic area, OR & postoperative area
All horizontal and contact surfaces (both sides) in pre-anesthetic area, OR & postoperative area
Cleaning of walls if visibly soiled (OR) Cleaning of head space walls and Change bedside drapes when visibly soiled (PAR)
Cleaning of walls (OR) Cleaning of head space walls and Change bedside drapes after patient (PAR)
Two-Step Cleaning for - C.difficile - Norovirus - Diarrhea
*H2O2=Acclerated Hydrogen Peroxide - Preferred cleaning solution and must be used for VRE. QAC=Quaternary Ammonium Compound
D.
Procedure in the Operating Room

1. Routine Practices
Routine practices are to be used by all personnel. All personnel entering and remaining in the OR are to perform hand hygiene (at a minimum) prior to entering the suite. Hand hygiene must be used before and after contact with the
Page 137
patients/residents or their environment. Hand hygiene product should be available at pointof-use for this purpose. All personnel in the OR must wear a fluid-resistant mask within one metre of any potential splash/splatter risk. A mask with face shield must be worn when there is risk of splash with blood or body substances, contaminating mucous membranes, during surgery, placement of venous lines and intubation. Gloves must also be worn at all times where there is risk of contact with blood or body substances (e.g. during intubation). Disposable gloves must be available at point-of-use for this purpose. Shoe covers or footwear dedicated to the surgical care area must be worn at all times and removed prior to leaving the surgical care area followed immediately by hand hygiene. Only anaesthetic/OR equipment and supplies needed for the surgical procedure are to be brought into the operating suite. Equipment that cannot be removed should be located as far from the procedure table as possible. If within a one metre distance, they should be draped to protect them from splashes. The drape is removed and replaced during post-case cleaning. Personal items (i.e. computers, brief cases, backpacks, etc.) are not to be brought into the operating suite. Hand hygiene must be performed before removal of any supply from a drawer or cupboard during surgery. Any supply removed from a drawer or cupboard during surgery is considered contaminated following the surgical procedure. Such unused supplies must be discarded. The patient chart should be placed on a clean surface away from patient contact surfaces (such as the bed). Hand hygiene should be performed before and after handling the chart. Where possible, program the telephone for auto-answer to permit hands-free handling of incoming calls. Gloves should always be removed and hand hygiene performed prior to handling the phone. Remove patient set pans and return them to the Sterile Core (or equivalent) prior to patient arrival. The scrub nurse will contain all instruments, suction bottles and used anaesthetic equipment in the case cart, where case carts are used. The case cart door will remain open until housekeeping closes it prior to its removal for decontamination. Alternatively, where case carts are not available, one or (preferably) two tables well removed from the operative site will be designated for holding and keeping separate sterile and contaminated instruments respectively; these will be covered with a drape at the end of the case. At the end of the case, the cleaners/nurse will remove the cart or table(s) to be delivered to CSD for cleaning/disinfection and the cleaners will perform cleaning of the room.
Page 138
All equipment brought into the room during a case, such as the C-arm, must remain in the room until cleaned/disinfected by the cleaners. Additional needed supplies should be passed directly to OR staff by Sterile Core (or equivalent) personnel from the Sterile Core. Where required, radiology aprons should be worn by scrubbed personnel under sterile gowns for the entire case. Radiology aprons must be handled following hand hygiene. All doors to the OR must be kept closed throughout surgeries. Entry to the OR suite during surgery is strongly discouraged. Appropriate signage on the door (No Entry) should support this. OR staff should not generally enter the Sterile Core. Where necessary OR staff should enter the Sterile Core directly from the OR, not from the outside corridor. All unused sterile equipment must be returned to the Sterile Core or CSD. Cleaning and disinfection must be performed for all cases sufficient to eradicate most pathogens (including AROs) from the surgical environment and must be performed between each case. Accelerated hydrogen peroxide (1:16) is the agent advocated for cleaning of all surgical care areas since it meets this standard. Precaution cleaning using accelerated hydrogen peroxide may be necessary in particular instances for patients/residents requiring Additional Precautions, on the recommendation of Infection Prevention and Control (see the Surgical Housekeeping Algorithm and the Housekeeping Cleaning table.) Routine discharge cleaning practices will include cleaning of all horizontal (both sides) and contact surfaces within the room that have been touched by the patient, surgeon, assistants, and anesthetist, and includes the anesthetic cart, monitors and leads, dust covers on keyboards and on equipment, as well as operating lights and switches. In addition, the floor must be wet mopped. The walls are wiped when visibly soiled. Cleaning of the walls is done daily, preferably at the end of the slate. For any patient with increased risk of communicable disease transmission (i.e. infection, see Assessment for Increased Risk of Communicable Disease Transmission and the Surgical Housekeeping Algorithm), cleaning of the walls is done in conjunction with the Routine Discharge Cleaning. See Housekeeping Cleaning table. The room may be used again as soon as the indicated type of cleaning is complete.
Page 139
2. Patient Known to be Colonized with an ARO Without Evidence of Infection

See Assessment for Increased Risk of Communicable Disease Transmission. Patients/residents should be treated with contact precautions when close personal care is being provided (from pre-anaesthetic to operative to post-anaesthetic areas. The need for Contact Precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). Appropriate signage should be placed on all doors to the OR. In addition to routine dress code outlined above (see Page 138), the anaesthetist and circulating nurse must wear shoe covers dedicated for the particular case. Other personal barrier equipment/ clothing should be used as outlined under contact precautions. The patient chart may be brought into the room and placed on a designated clean surface away from patient contact surfaces (such as the bed and any over bed table, etc.). Hand hygiene should be performed before and after handling the chart. Both the circulating nurse and anesthetist may do charting on this surface, as long as gloves that have touched the patient are removed before doing so and after hand hygiene. The chart may be returned to the same pillowcase used for transport, as long as the inside of the pillowcase has not been contaminated. Gloves are always to be removed after activities where patient contact has occurred (e.g. IV starts, intubations) before contact with clean items/areas. Hand hygiene must be performed before and after glove use. The patient bed or stretcher is to be taken out of the room and covered with a sheet. The appropriate Additional Precautions sign is to be placed on top of the bed. At the end of the case, the sheet should be removed from the bed and placed in the OR linen hamper. If the bed or stretcher needs to be exchanged, housekeeping staff should be notified accordingly and the bed should be stripped in the hall and cleaned (precaution cleaning) before being put back into circulation. See Housekeeping Cleaning table. Following the surgical procedure, the circulating nurse and/or anaesthetist and/or porter will remove or exchange shoe covers and contaminated gloves and discard them before leaving the OR. Hand hygiene with ABHR is to be done immediately following removal of contaminated barrier clothing. Clean gloves must be worn for transport of the patient. Pressing elevator buttons while wearing gloves for patient transport is acceptable, as there is very low likelihood of contamination of the elevator button. Garbage and linen may be collected as routine, unless alternative methods are requested by Infection Prevention and Control. However, there should be no recycling performed. The OR may be used for the next patient once Routine cleaning is completed.
Page 140
3. Cases with Infection Contact and Droplet Precautions

See Assessment for Increased Risk of Communicable Disease Transmission. Patients/residents should be treated with appropriate contact or droplet precautions as warranted at all times while in the surgical care areas (from pre-anaesthetic to operative to post-anaesthetic areas). The need for contact or droplet precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). Appropriate signage should be placed on all doors to the OR. In addition to routine dress code outlined above (see Page 138), the anaesthetist and circulating nurse must wear shoe covers dedicated for the particular case. Other personal barrier equipment/clothing should be used according to contact/droplet precautions. The patient chart may be brought into the room and placed on a designated clean surface away from patient contact surfaces (such as the bed and any over bed table, etc.). Hand hygiene should be performed before and after handling the chart. Charting may be done on this surface by both the circulating nurse and anaesthetist, as long as gloves that have touched the patient are removed before doing so and after hand hygiene. The chart may be returned to the same pillowcase used for transport, as long as the inside of the pillowcase has not been contaminated. Gloves are always to be removed after activities where patient contact has occurred (e.g. IV starts, intubations) before contact with clean items/areas. Hand hygiene must be performed before and after glove use. The patient bed or stretcher is to be taken out of the room and covered with a sheet. The appropriate additional precautions sign is to be placed on top of the bed. At the end of the case, the sheet should be removed from the bed and placed in the OR linen hamper. If the bed or stretcher needs to be exchanged, housekeeping staff should be notified accordingly and the bed should be stripped in the hall and cleaned (precaution cleaning see Housekeeping Cleaning table) before being put back into circulation. Following the surgical procedure, the circulating nurse and/or anaesthetist and/or porter will remove or exchange shoe covers and contaminated gloves and discard them before leaving the OR. Hand washing or hand hygiene with ABHR is to be done immediately following removal of contaminated barrier clothing. Clean gloves must be donned for transport of the patient. Pressing elevator buttons, while wearing gloves for patient transport is acceptable, as there is very low likelihood of contamination of the elevator button. Garbage and linen may be collected as per routine, unless alternative methods are requested by Infection Prevention and Control. However, there should be no recycling performed. The OR may be used for the next patient once Routine Discharge Cleaning including the walls is completed. This will include Routine Discharge Cleaning as outlined above, as well
Page 141
as cleaning of the walls. Precaution cleaning using accelerated hydrogen peroxide may be necessary in particular instances for patients/residents requiring additional precautions, on the recommendation of Infection Prevention and Control. (See the Surgical Housekeeping Algorithm and Housekeeping Cleaning table.)
4. Cases with Infection Airborne Precautions

See Assessment for Increased Risk of Communicable Disease Transmission. Procedures for patients/residents requiring airborne precautions should only be performed if negative air pressure can be assured within the OR relative to the hallway and adjacent rooms. Appropriate signage should be placed on the OR door. In addition to routine dress code outlined above (see Page 138), all personnel in the OR must wear an N95 mask (for which staff have been fit tested) at all times; see airborne precautions. Additional precautions are necessary only if warranted. Routine practices (including housekeeping) should be followed otherwise; see the Surgery Booking Request Algorithm and the Surgical Housekeeping Algorithm.
E.
Procedure in the Post-Anaesthetic Area

1. Routine Practices
Routine practices are to be used by all personnel at all times. A minimal amount of supplies should be stored in the patient stretcher area. Cleaning and disinfection must be performed for all cases sufficient to eradicate most pathogens (including AROs) from the surgical environment and must be performed between each case. Accelerated hydrogen peroxide (1:16) is the agent advocated for cleaning of all surgical care areas since it meets this standard. Routine discharge cleaning practices after discharge of patient from PAR will include cleaning of all horizontal and contact surfaces within the stretcher area that may have been touched by the patient and staff, and includes counters, stretcher, monitors, IV poles, keyboard, etc. In addition, the floor must be wet mopped. Headspace wall is wiped and bedside curtains changed when visibly soiled; see the Surgical Housekeeping algorithm. Cleaning of the headspace wall is done at minimum daily, preferably at the end of the slate. Cleaning of the stretcher area for patients/residents on additional precautions will include the above.
Page 142
Routine discharge cleaning as well as the headspace wall, see the Surgical Housekeeping algorithm. The stretcher area may be used again as soon as the appropriate type of cleaning is complete.
2. Patient Known to be Colonized with an ARO Without Evidence of Infection

See Assessment for Increased Risk of Communicable Disease Transmission. Patients/residents should be treated with contact precautions when close personal care is being provided (from pre-anesthetic to operative to post-anesthetic areas). The need for contact precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). Patients/residents requiring additional precautions generally do not require placement in an isolation room in the post-anesthetic area, but can be managed within the general postanesthetic area, as long as dedicated toileting facility is provided (e.g. dedicated commode) and there is acceptable physical separation from adjacent stretchers (at least two metres/6 feet). Patients/residents on contact precautions requiring nebulized therapy, non-invasive ventilation or who have had a tracheostomy performed (not ventilated) are placed on droplet precautions with a curtain around the stretcher; see Assessment for Increased Risk of Communicable Disease Transmission. Appropriate signage should be placed at the foot of the bed or on the curtain around the stretcher. Appropriate infection prevention and control barriers must be used for direct patient care; see Assessment for Increased Risk of Communicable Disease Transmission. The post-anaesthetic bay may be used for the next patient once routine discharge cleaning is completed; see Surgical Housekeeping algorithm. Bedside curtains are changed if visibly soiled. Precaution cleaning using accelerated hydrogen peroxide may be necessary in particular instances for patients/residents requiring additional precautions, on the recommendation of Infection Prevention and Control. (See Surgical Housekeeping algorithm and Housekeeping Cleaning table.
3. Cases with Infection Contact and Droplet Precautions

See Assessment for Increased Risk of Communicable Disease Transmission.
Page 143
Patients/residents requiring additional precautions generally do not require placement in an isolation room in the post-anesthetic area, but can be managed within the general postanesthetic area, as long as dedicated toileting facility is provided (e.g. dedicated commode) and there is acceptable physical separation from adjacent stretchers (at least two metres/6 feet). Patients/residents on droplet precautions should be managed with additional physical barrier of drawn curtains between patient bays. Patients/residents on contact/droplet precautions requiring nebulized therapy, non-invasive ventilation or who have had a tracheostomy performed (not ventilated) must be placed under droplet precautions with the bedside curtain drawn around the stretcher. Appropriate signage should be placed at the foot of the bed or on the bedside curtain. Appropriate infection prevention and control barriers must be used for direct patient care; see contact/droplet precautions. The post-anesthetic bay may be used for the next patient once routine discharge cleaning, including head space walls is completed; see Surgical Housekeeping algorithm. Where patients/residents have been on droplet precautions, curtains should be changed between patients/residents; see Surgical Housekeeping algorithm. Precaution cleaning using accelerated hydrogen peroxide may be necessary in particular instances for patients/residents additional precautions, on the recommendation of Infection Prevention and Control. (See Surgical Housekeeping algorithm and Housekeeping Cleaning table.)
4. Cases with Infection Airborne Precautions

See Assessment for Increased Risk of Communicable Disease Transmission. Patients/residents requiring airborne precautions should be transferred to the postanaesthetic area wearing a surgical grade mask. Patients/residents requiring airborne precautions should be recovered ONLY in a private room in which negative air pressure can be assured within the room relative to the general post-anesthetic area and adjacent rooms. Appropriate signage should be placed on the isolation room door. Any person entering the isolation room must wear an N95 mask (which staff must be fit tested for) at all times. Additional precautions are necessary only if warranted; see airborne precautions.
Page 144
The post-anaesthetic bay may be used for the next patient once routine cleaning is completed; see the Surgical Housekeeping algorithm.
5.
Burn Unit Recommendations
Infection prevention and control begins at the time the patient is admitted to the hospital and continues until the patients graft sites have healed. Because of the nature of the burn wound (loss of preventive covering of the skin) the burned patient is more susceptible to invasive bacterial infection. The patient is autocontaminated prior to arrival at the hospital by the bacteria that survive in the hair follicles and sweat glands beneath the burned tissues, and by the dirt from the burned clothing or accident environment. In addition, the burn wound provides the media necessary for bacterial growth; food, warmth and moisture. Eliminating reservoirs of infection begins with the patient and we must rely on aseptic technique as a factor in controlling the infection inherent in the patient. All patients/residents in the Burn Unit, Intensive and Intermediate, will be isolated. Unit Isolation Unit doors must be kept closed to maintain positive pressure when there are patients/residents within the unit being treated for burns. All disciplines (including medical staff and hospital services) must ensure they perform thorough hand hygiene upon entering and exiting this unit. It is acceptable to use ABHR or soap and water. Nursing must ensure a clean, freshly laundered uniform is worn at the start of each shift.
Patient Room Each patients room is a separate isolation unit. Before entering: Appropriate and thorough hand hygiene must be carried out before entering and upon leaving room. Hand hygiene stations are provided for this purpose directly outside each individual room. PPE will be donned prior to entry of the patients room. This includes isolation gowns, caps, gloves and all other appropriate protective attire that may be necessary (masks, face shield etc). Upon exiting the patients room, all PPE must be discarded in the appropriate receptacles contained within the room and new attire donned if re-entering. Housekeeping, food service employees and all other auxiliary staff must check with nursing staff for direction prior to entering the patients room.
Page 145
Isolation Protocols Isolation protocols must be instituted for all patients/residents treated for burns: Private room must be used Doors must be kept closed Individual gown technique is imperative for all persons entering room Surgical masks must be worn by all persons entering patient rooms Hands must be washed as per policy by all personnel before entering, after leaving and as otherwise indicated during patient care Gloves must be put on routinely by all personnel before entering and kept on until discarded in a receptacle before leaving the room Attire must be discarded in appropriate receptacle, then hands must be washed upon leaving room
Visitors Visitors entering the Unit: Cap to be worn over hair Clean, disposable protective gowns to be worn Surgical mask to be worn When leaving Unit, visitors will be instructed to discard all attire in laundry/garbage hampers provided in the patients room and wash hands Visitors will be restricted to two persons per patient at a time Visitors will be restricted to immediate family only (any deviation from this must be approved by the person in charge) Visitors will NOT be allowed to visit during treatment hours If children are to visit, parents must be informed of all necessary precautions required and ensure adherence to unit policy for both patient and visitor safety Personal items such as bedding, clothing or any items made of fabric that cannot be decontaminated appropriately are not permitted in the acute private rooms. Advice may be obtained from Infection Prevention and Control for any questions Real plants or flower arrangements are not permitted on the unit Visitors must be instructed not to sit on patients bed Pets are not permitted on the unit at any time
Note: All Visitors must be made aware of the implications of visiting a patient treated for burns and the importance of basic precautions and hand hygiene, especially when it is a new burn and when not covered with a dressing.
Page 146
Equipment and PPE Other aspects of isolation within unit: Sterile gloves are worn for contact with the burn wound Protective gowns must be worn during wound care and hydrotherapy All outside equipment will be cleaned with a disinfecting solution prior to being brought into the unit. If the equipment is to be used for more than one patient, it must be disinfected after each patient use Items from Pharmacy, Central Sterilizing/Processing, Stores and Linen will be considered clean and may be taken directly into unit
6.
Renal Dialysis Department

A. Introduction
There is a high risk of infection from blood borne viruses and transmission of infectious organisms in the dialysis setting from contaminated environmental surfaces and equipment, inappropriate healthcare worker technique and person-to-person transmission. Stringent infection prevention and control principles and procedures must be followed to decrease these risks and ensure a safe level of care.
B.
Policy
Basic infection prevention and control principles must be met at all times to prevent transmission of infectious disease and to ensure protection of patients/residents and staff in the dialysis environment.
1. Guidelines for Patient Care

Ensure all staff are knowledgeable and well-trained and will adhere to the principles of infection prevention and control, including implementation of routine practices Use routine practices for all patients/residents Maintain strict aseptic technique during all dialysis procedures Implement routine monitoring and follow-up for signs and symptoms of any adverse reaction, including local and systemic infection from vascular access or contamination during dialysis Advise patients/residents and visitors to complete hand hygiene prior to entering the dialysis treatment station and on exit from the unit once dialysis is complete; ensure pamphlets and adequate hand hygiene education are provided Ensure appropriate signage with step by step instructions for hand hygiene are visible and ABHR is available on entry and throughout the unit
Page 147
Healthcare workers must follow established guidelines for hand hygiene techniques and procedures Meticulous aseptic technique is critical to prevent vascular access site contamination Hand hygiene must be performed before and after palpating a vascular access site, before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained. Medication Administration Common medication carts must not be used for medication. If trays are used to pass medications, they must be cleaned in between patients/residents Multiple dose medication vials must not be used between patients/residents. When they are used, prepare individual patient doses in a clean area away from dialysis stations and deliver separately to each patient Medications should be mixed and stored in a designated, separate area, separate from any contaminated/used supplies or equipment IV medication or dilution vials labeled for single use should not be punctured more than once. Once a needle has entered this type of vial, the sterility of the product can no longer be guaranteed. Do not pool residual medication from multiple vials
Environment and Supplies Cleaning and disinfection procedures must meet hospital requirements, including the use of hospital approved disinfectants and cleaning solutions. Refer to the cleaning section of the infection prevention and control manual for approved disinfectants Blood spills must be managed appropriately following established VIHA Renal guidelines Clean non-sterile gloves and waste containers should be placed near each dialysis station Sufficient number of sinks with warm water and soap, and ABHR for when hands are not visibly soiled must be available Supply carts should not contain both clean supplies and blood-contaminated items and should not be moved from within one patient space to another or stored in patient care areas Supplies and equipment labeled single use only must be dedicated for single patient use. In instances where equipment is intended for multiple use, disinfection of items must be performed between patients/residents There must be a separate storage area for patients articles
Patient Food and Snacks Snacks supplied by the dialysis unit should be pre-wrapped only
Page 148
Dialysis chairs should be draped for patients/residents given foods that may spill on the chair/bed. Drapes must be changed in between each patient. If a drape is not available, thorough cleaning of the chair must be performed to remove all remnants of food prior to the next patients use Patients/residents should be instructed to perform hand hygiene prior to eating
Waste Discard all fluids and disinfect all surfaces and containers associated with prime waste Waste generated from a hemodialysis facility should be considered potentially infectious and handled according to local and provincial regulations governing medical waste disposal All disposable items containing fluids or biohazardous material should be placed in thick, leak resistant bags and stored in appropriately constructed and labeled receptacles
Equipment Non-disposable items that cannot be cleaned and disinfected (e.g. adhesive tape, cloth covered BP cuffs etc), must be dedicated whenever possible for use on a single patient only. If common use equipment cannot be dedicated, ensure adequate cleaning and disinfection between patients/residents There must be strict adherence to policy and procedures for the use, disinfection and maintenance of hemodialysis machines and all dialysis related equipment Manufacturers recommendations must be followed Refer to VIHA Reprocessing policy for decontamination of critical, semi-critical and non critical equipment. Items taken into a dialysis station, including those placed on top of dialysis machines, should either be disposed of, dedicated for single patient use only, or cleaned and disinfected before the next patient use or returning to storage.
Education Regular updated education must be provided to patients/residents and their families, clarifying their role in health maintenance and the prevention of dialysis-related complications and infections.
2. Guidelines for Care of Vascular Access

Follow Established Guidelines Provided by the National Kidney Foundation Kidney Dialysis Outcomes Quality Initiative (NKF - KDOQI) for Selection and Maintenance of Vascular Access for Hemodialysis.
Page 149
Aseptic Procedure Gloves must be changed between patients/residents and hand hygiene performed Care to be taken to avoid touching surfaces with gloved hands that will later be touched with ungloved hands Staff must wear gowns, full face shields, or masks with eye protection to protect themselves and their clothing when performing procedures in which blood or body fluid splatter may occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers and centrifugation of blood) Discard protective equipment in provided waste receptacles and linen hampers nearest the dialysis station
Skin Antisepsis Fistulas, Grafts and Catheters Disinfect clean skin with an approved antiseptic before needle insertion and during dressing changes Approved antiseptics for cleansing fistula, graft, arterial catheters and central venous catheter (CVC) insertion sites include a 2% chlorhexidine gluconate preparation as a first choice 10% Povidone-Iodine solution or 70% alcohol may be used in the case of skin reaction to chlorhexidine. If iodine is used, it must be allowed to dry for at least 2 minutes prior to skin puncture Sodium Hypochlorite solutions may be used as an alternate antiseptic at the discretion of the Infection Prevention and Control Team Any other solution to be used for vascular access site care must be first approved by Infection Prevention and Control Team
Catheter Site Dressing Regime A new sterile dressing should be applied with each dialysis treatment A topical antibiotic ointment should be applied at the catheter exit sites whenever possible to help reduce the risk of infection A dry gauze dressing is the recommended choice, and should be applied with each dialysis treatment and replaced when site inspection is required or the dressing becomes loosened or soiled Patients/residents should be instructed to keep the CVC dressing clean and dry, to replace the dressing if it becomes damp, soiled or loosened and to report to their healthcare provider any changes in their catheter site or any new discomfort at the site Occlusive transparent dressings: If a transparent dressing is used, chose a product with a high-moisture vapor transmission rate to prevent increased moisture accumulation under the dressing
Page 150
(some types of these dressings are associated with an increase in microbial growth under the dressing and thus an increase risk of infection) Follow established BC Renal Agency guidelines for transparent dressing care policy Occlusive dressings are less compatible with the use of antimicrobial ointment at catheter exit sites
3. Surveillance
Surveillance of important blood borne viruses and AROs will be performed on a routine basis for monitoring and infection prevention and control purposes. ARO Screening for Renal Dialysis Patients/Residents Prevalence Screening Prevalence screening for AROs are organized by Infection Prevention and Control at regularly scheduled time frames Frequency of screening and information collected is reviewed annually and in consultation with the renal dialysis group to establish if there are indications for further surveillance Prevalence screening may be performed more frequently at the direction of Infection Prevention and Control during times of increased incidence, outbreaks and heightened surveillance, etc.
MRSA screening includes: Swabs to be collected prior to commencement of dialysis and then annually on the patients birthday Swab sites include both nares (one swab), rectal swab (one swab), large (draining) wounds.
VRE screening Includes: Swabs to be collected prior to commencement of dialysis and then annually on the patients birthday VRE point prevalence (collecting swabs from all patients/residents at a set point in time) will be performed twice yearly VRE swab sites include a rectal swab, ostomy swab (swab should be stool stained; collect both ostomy and rectal swab only if patient continues to pass fluid/stool through rectum) and any large draining wounds.
Screening Requirements for Patients/Residents Not Known to be ARO Positive Screening for MRSA/VRE is to be completed: On initial admission to any hemodialysis or peritoneal dialysis facility
Page 151
Upon returning from travel (within or outside BC, for any period of time) Upon return from admission to an acute care hospital or residential care facility (unless already collected within the last 48 hours) When peritoneal dialysis patients/residents require temporary hemodialysis unless swabbed within the previous 48 hours Incoming Visiting Patients/Residents (Travelers) The patients current ARO status should be received within 2-4 weeks prior to the patients arrival to the dialysis unit. A risk assessment should be made on arrival to the dialysis unit Visiting dialysis patients/residents should be screened for MRSA and VRE upon their initial arrival to the dialysis unit Patients/residents returning from travel outside Canada should be screened with a risk assessment completed to determine if additional precautions are necessary until negative results are available.
Outgoing Traveling Patients/Residents For patients/residents traveling outside BC: If requested, current ARO culture results should be provided to the receiving dialysis unit along with the patients clinical information
Monitoring ARO Status for Patients/Residents Known to be MRSA or VRE Positive Patients/residents noted to be ARO positive are not routinely screened for the known ARO. However, upon patient or Infection Prevention and Controls request, requirements for alert removal and discontinuation of precautions include: all ARO positive patients/residents must have stopped all antibiotics (topical and oral, including decolonization protocol if MRSA positive) at least one week (or one month if infected) prior to collecting swabs
MRSA Collect two sets of swabs, at least one week apart Wait at least one week after the last positive culture if the patient was colonized Wait one month from the last positive culture if the patient had an ARO infection If both sets of results are negative and the patient has not been on oral/topical antibiotics contact Infection Prevention and Control for further guidance MRSA decolonization is not routinely performed (clinical indications such as large draining wounds require further assessment), but may be an option for some patients/residents.
Page 152
VRE Collect two sets of swabs, at least one month apart Wait at least one month after the last positive culture If both sets of results are negative and the patient has not been on topical/oral antibiotics contact Infection Prevention and Control for further guidance
Consult with Infection Prevention and Control Consult with the Infection Prevention and Control prior to discontinuing precautions for final approval Contact Infection Prevention and Control prior to discontinuing precautions on patients/residents with multi-ARO (e.g. VRE and MRSA) Consult with Infection Prevention and Control for follow up of ESBL
4. Acute Care Patients Receiving Dialysis

Patients admitted to acute care hospitals who meet the admission screening questionnaire criteria should have swabs collected Patients admitted to acute care must have a discharge swab collected
5. Residential Care Residents Receiving Dialysis

Residents admitted to acute care from a residential care facility and meet the admission screening questionnaire criteria should have swabs collected
Note: In instances where Infection Prevention and Control has approved for a patient to personally collect an ARO swab, the patient must be given the appropriate pamphlet with accurate instructions to guide their technique and to ensure VIHA has access to results. Consult with Infection Prevention and Control first.
6. Routine Surveillance, Evaluation and Management of Communicable Diseases

Refer to CDC Recommendations: Guidelines for Vaccinating Kidney Dialysis Patients/Residents and Patients/Residents with Chronic Kidney Disease (Recommendations of the Advisory Committee on Immunization Practices ACIP) for further recommended guidelines for surveillance and patient vaccinations
Page 153
7. Guidelines for Patients/Residents Requiring Additional Precautions

Patients/residents who exhibit the following require additional precautions while receiving treatment at a renal dialysis unit: Known to have a confirmed ARO (MRSA, VRE or ESBL) Confirmed C.difficile Undiagnosed diarrhea Large open draining wounds Productive cough Patient Placement for Dialysis Patients/residents known to be positive with an ARO should be cared for in a private room if available, but may also be cohorted with patients/residents of the same ARO in a shared room or area (complete a risk assessment for signs and symptoms of infection prior to cohorting). The cohorted area is a defined geographical area in the hemodialysis unit with physical separation from other dialysis stations
Note: for patients/residents known to be ARO positive, whether or not cohorting is possible, the patients dialysis station must be thoroughly cleaned prior to the next patients treatment
Visitors In order to maintain a safe patient environment: Visitors will perform hand hygiene on entry and exit to the dialysis unit. Education and pamphlets must be provided to ensure appropriate technique Visitors should don gowns and gloves when providing direct patient care. Information will be given to visitors on the importance of hand hygiene while in the renal dialysis environment Visitors should not enter other patients dialysis stations and should not be present during times when vascular access is occurring
8. Guidelines for Outbreak Management

Patients/residents receiving dialysis who are transferred from an outbreak unit must be placed on the appropriate precautions with the appropriate cleaning provided when the patient has left the station. Patients/residents should be dialyzed in an area separate from others whenever possible.
Page 154
9. Guidelines for Cleaning and Disinfection

The following cleaning practices must be met performed between all patients/residents: Clean and disinfect dialysis station (chairs, beds, tables, machines) between each patient with a recommended disinfectant Special attention to be paid to cleaning control panels on the dialysis machines and other surfaces that are frequently touched and potentially contaminated with patients/residents blood Discard all fluids, clean and disinfect all surfaces, tubing and containers associated with the prime waste (including buckets attached to the machines if applicable) Dialysis machines: o Surface must be cleaned between each patient; interior to be cleaned by technician or designated personnel daily or immediately if contaminated, according to the Association for the Advancement of Medical Instrumentation (AAMI), the Canadian Standards Association (CSA) and manufacturers recommendations Curtains should be changed when visibly soiled and routinely on a monthly basis. In areas where patients/residents known to be ARO positive are cohorted change curtains weekly Telephones, keyboards and general office surfaces must be cleaned daily. All keyboards should be covered. Use alcohol swabs or hydrogen peroxide wipes for covered keyboards. Nursing staff/Unit clerks to provide additional cleans throughout the day following use For patients/residents with undiagnosed diarrhea or symptoms of diagnosed Norovirus or C.difficile, a precaution clean is necessary (see Housekeeping Cleaning table.) For patients/residents known to be VRE positive, precaution cleaning is implemented between patients/residents (see Housekeeping Cleaning table).
Table 27: Disinfection Procedures Recommended for Commonly Used Items or Surfaces in Hemodialysis Units
Item or Surface
Gross blood spills or items contaminated with visible blood Hemodialyzer port caps Water treatment and distribution system Scissors, hemostats, clamps, blood pressure cuffs, stethoscopes
Low level Disinfection
Intermediate level disinfection 22 X X
X X
X 23 X 24
22
Careful mechanical cleaning to remove debris should always be done before disinfection. If item is visibly contaminated with blood, use a tuberculocidal disinfectant. 23 Water treatment and distribution systems of dialysis fluid concentrates require more extensive disinfection if significant biofilm is present within the system. 24 If item is visibly contaminated with blood, use a tuberculocidal disinfectant.
Page 155
Environmental surfaces, including exterior surfaces of hemodialysis machines
Adapted from: CDC MMWR Vol 50/No.RR-5, 2001
Care and Maintenance of the Dialysis System AAMI and CSA standards must be followed Manufacturers recommendations must be followed
Water Treatment for Dialysis Dialysis units must meet or exceed AAMI and CSA standards for hemodialysis water purity, quality and monitoring Water samples should be collected at the point where water enters the dialysate concentrate proportioning unit Dialysis fluid samples should be taken from the entry or exit point of the dialyzer during or at termination of dialysis If acceptable levels are exceeded, disinfection of the water system must occur and repeat samples taken prior to use Written procedures must be available, outlining all testing policy and procedures, actions performed if contamination levels are exceeded and how documentation and records are maintained
10. Guidelines for Peritoneal Dialysis

Infection prevention and control Considerations: Strict use of aseptic technique and sterile dressings are required for the operative wound and exit sites until well healed Perform aseptic manipulation of the sterile disposable lines that deliver dialysis fluid into the peritoneal cavity for peritoneal dialysis and aseptic connection of the tubing to the patients/residents catheter Wear gloves whenever there is any potential contact with dialysis effluent, during exit-site care, and when drawing blood or taking dialysate samples. Wear gloves, gown and face shield when disposing of the effluent Peritoneal effluent should be considered potentially infectious for bloodborne pathogens PD drains must be used for draining peritoneal/dialysate only Patients/residents must be instructed on proper use of these sinks and shown where sinks designated for personal care and hand washing are located.
Page 156
Peritoneal Dialysis sinks: On a weekly basis, peritoneal dialysis sinks will be disinfected using a bleach solution of 100 mL of 5% household bleach diluted in 900 mL of water (for a 1:9 ratio of 1 part bleach to 9 parts water out of a total of 10 parts). Pour the solution down the sink drain, let it sit for 510 minutes, and follow with a water flush. Notify maintenance immediately if there is any residue or clogs noted in the drain.
Sources: American Institute of Architects. (2006). Renal Dialysis unit (acute and chronic) Guidelines for design and construction of healthcare facilities. (pp.93-96). Washington, DC: American Institute of Architects. Association for Advancement of Medical Instrumentation. (2003). AAMI standards and recommended practices, dialysis. Arlington, VA: American National Standards Institute Association for Professionals in Infection Control and Epidemiology. (2004). Infection control in ambulatory care. (pp.98-107). Washington, DC: Association for Professionals in Infection Control and Epidemiology. Association for Professionals in Infection Control and Epidemiology. (2005). Dialysis. APIC text of infection nd control and epidemiology 2 edition. (pp.1-15). Washington, DC: Association for Professionals in Infection Control and Epidemiology. Bender, F., Bernardini, J., & Piraino, B. (2006) Prevention of infectious complications in peritoneal dialysis: Best demonstrated practices. Kidney International, 70, 44-54. Bianchi, P,. Buoncristiani, E., Buoncristiani, U. (2007). Disinfection by sodium hypochlorite: Dialysis applications. Contributions to Nephrology. 154, 1-6. BC Renal Agency. (2008). Prevention, treatment and monitoring of vascular access related infection in hemodialysis patients: Vascular access guideline Brunch, M. (2007. Toxicity and safety of topical sodium hypochlorite. Contributions to Nephrology, 154, 24-38. Center for Disease Control. (2001). Recommendations for preventing transmission of infections among chronic hemodialysis patients. Morbidity and Mortality Weekly Report. 50 (RR-5), 1-43. Center for Disease Control. (2002). Guidelines for prevention of intravascular catheter related infections, Morbidity and Mortality Weekly Report. 51(RR-10), 1-26. Center for Disease Control. (2003). Guideline for environmental infection control in health care facilities. Center for Disease Control. (2006). Guidelines for vaccinating kidney dialysis patients and patients with chronic kidney disease (summarized from recommendations of the advisory committee on immunization practices) . Department of Health. (2002). Good practice guidelines for renal dialysis/transplantation units: Prevention and control of blood borne virus infection. De Vos, J., Elseviers, M., Harrington, M., Zampieron, A., Vlaminck, H., Ormandy, P., et al. (2006). Infection control practice across Europe: Results of the European practice database project. EDTNA/ERCA Journal, 32 (1), 38-41. Health Canada. (1999). Infection control guidelines: Routine practices and additional precautions for preventing the transmission of infection in health care. Canada Communicable Disease Report. Vol. 25S4. Lam, L. D., Newman, A., & CHICA Dialysis Interest Group. (2005). A survey of infection control practices in hemodiaysis units in Canada. Canadian Journal of Infection Control, 20(3), 118-136.
Page 157
Mendoza-Guevara, L., Castro-Vazquez, F., Aquilar-Kitsu, A., Morales-Nava, A., Rodriguez-Leyva, F. SanchezBarbosa, J.L. (2007). Amuchina 10% solution, safe antiseptic for preventing infections of exit-site of Techkhoff catheters, in the pediatric population of a dialysis program. Contributions to Nephrology. 154, 139-144. National Center for Infectious Diseases. (1999). National surveillance of dialysis-associated diseases in the united states. Atlanta, Georgia: Public Health Service, Department of Health and Human Services. National Kidney Foundation. (2006). Clinical practice guidelines for peritoneal dialysis adequacy: Update 2006 . National Kidney Foundation. (2006). Kidney dialysis outcomes quality initiative, clinical practice guidelines for vascular access: Update 2006. Peleman, R., Vogelaers, D., & Verschraegen, G. (2000). Changing patterns of antibiotic resistance-update on antibiotic management of the infected vascular access. European Renal Association European Dialysis and Transplant Association, 15, 1281-1284. Taal, M,. Fluck, R., & McIntyre, W. (2006). Preventing catheter related infections in hemodialysis patients. Current Opinion in Nephrology and Hypertension. 15, 599-602. Vancouver Coastal Hospital Infection Prevention and Control Manual. (2006). Vancouver coastal infection control guidelines for hemodialysis patients with antibiotic resistant organisms ( revised December 2005 and January 2006). Zuckerman, M. (2002). Surveillance and control of blood-borne virus infections in haemodialysis units. Journal of Hospital Infection, 50, 1-5.
Page 158
7.
Respiratory Department Guidelines

A. Introduction
Prevention and control of hospital-acquired infections associated with respiratory therapy is dependent upon adequate procedures for maintenance and operation, including the use of strict aseptic technique, routine practices and appropriate reprocessing methods.
B.
Equipment
Microorganisms found in respiratory equipment often come from the patient during breathing or coughing into the system. It is essential that this contamination be destroyed or removed from all reusable apparatus Routine practices must be used for handling all used equipment. All contaminated equipment must be cleaned and decontaminated before attempting sterilization Follow the manufacturers recommendations for disassembling equipment and for cleaning and decontamination The outside surfaces of large pieces of equipment should be cleaned and disinfected after use (e.g. nebulizers, oxygen tents, humidifiers, incubators, compressors etc.). Clean thoroughly using a hospital approved detergent and/or disinfectant that is consistent with manufacturers recommendations Cover and protect all equipment when not in use For guidelines regarding the appropriate care and use of specific respiratory equipment, solutions and products, refer to established VIHA Respiratory Therapy policy and procedure If an outbreak is suspected, notify Infection Prevention and Control. The Infection Control Practitioner will coordinate all swabs collected from equipment for laboratory analysis
C.
Disposable Equipment
A wide variety of disposable equipment is available and should be used whenever possible, especially in the care of patients/residents where there is a risk of contact with potentially infectious body fluids, excretions and secretions Single use items must not be reprocessed, according to VIHA Reprocessing Manual.
D.
Respiratory Patients/Residents Requiring Additional Precautions
A risk assessment must be completed prior to initiating any respiratory procedure to determine which additional precautions are necessary.
Page 159
For all respiratory procedures, such as sputum induction, nasal-pharyngeal washes/specimen collection, use of nebulizers etc, refer to established VIHA Respiratory Therapy policy and procedure.
1. Guidelines for Ventilator Associated Pneumonia (VAP)

Definition Ventilator associated pneumonia is defined by CDC as a condition in patients/residents on mechanical ventilation for > 48hrs, who present with fever, cough and new onset of purulent sputum, combined with: Radiologic evidence of a new or progressive pulmonary infiltrate Leukocytosis A suggestive Gram's stain Growth of bacteria in cultures of sputum, tracheal aspirate, pleural fluid, or blood.
Reference: CDC Guidelines for Preventing Health-care associated Pneumonia, 2003
VAP Prevention Strategies Surveillance Infection Prevention and Control conducts ongoing surveillance for all new cases of pneumonia, including patients/residents at high risk for healthcare related pneumonia such as those admitted to ICU, mechanically ventilated patients/residents or high risk surgical patients/residents Goals of surveillance: Identify outbreaks early Ensure the appropriate precautions and education are put into place Determine trends and help identify practices that require closer review and education.
Cross Contamination Routine Practices must be adhered to at all times, including: Use of gloves before handling respiratory secretions or contaminated objects Appropriate hand hygiene (soap and water or ABHR) before and after any contact with the patient or equipment in the patients environment; before and after contact with mucous membranes or any respiratory secretions Use of gown (impermeable) when contact with respiratory secretions are anticipated Use of mask when contact with respiratory secretions are anticipated and when performing procedures that induce coughing or create aerosol
Page 160
Airway Management Perform orotracheal rather than nasotracheal intubation, unless contraindicated Ensure secretions are removed from above the cuff prior to deflating the cuff of an ET tube when repositioning or removing
Gastric Reflux Prevention Maintain elevation of the head of the bed between 30 45 degrees unless contraindicated Ensure routine verification of placement of feeding tube
Equipment For maintenance care, ensure there is periodic draining and discarding of any condensate collected in the tubing Ensure condensate is not able to drain toward the patient
Oral Care Ensure standard practice for thorough oral care/decontamination is available and utilized
Sources: Centre for Disease Control. (2003), Guidelines for environmental infection control in health care facilities. Morbidity and mortality weekly report, 52(RR10), 1-42. Chulay, M. (2005). VAP prevention: The latest guidelines. RN, 68(3), 53-56. Evans, E. (2005). Best-practice protocols: VAP prevention. Nursing Management, 36(12), 10-16. Favero, M.S., Bond, W.W. (1991). Sterilization, disinfection and antisepsis in the hospital manual of clinical microbiology. Washington, DC: American Society for Microbiology. Ohana, S., Denys, P., Guillemot, D., Lortat-jacob, S., Ronco, E., Rottman, M., et al. (2006). Control of an ACC1-producing Klebsiella pneumonia outbreak in a physical medicine and rehabilitation unit. Journal of Hospital Infection, 63, 34-38. OKeefe-McCarthy, S. (2006). Evidence-based nursing strategies to prevent ventilator-acquired pneumonia. Canadian Association of Critical Care Nurses, 17(1), 8-11. Powers, J. (2006). Managing VAP effectively to optimize outcomes and costs. Nursing Management Supp, 37, 48b-48f. Vancouver Island Health Authority. (2008). Respiratory therapy policy and procedure.
Page 161
PART 8: Specific Procedural Recommendations

1. Asepsis
Aseptic technique can be defined as all the measures we take to purposefully reduce the number of microorganisms to an irreducible number for the purpose of preventing transmission of infection. The strictness (or level) of aseptic technique increases as you perform more invasive procedures. For example, taking a blood pressure requires only clean technique, while procedures that enter a sterile body cavity require sterile technique. Microorganisms Live In and On Our Bodies Transient microorganisms are easily picked up on hands, clothing, inanimate objects, etc., and are easily removed by hand washing and cleaning (physical removal of "germs"), antisepsis and disinfection. Antisepsis (or hand washing and pre-op skin preparation) is the removal of transient microorganisms from the skin with a reduction in the resident flora. Resident or Normal Flora are those microorganisms that are constantly present on our bodies; no amount of scrubbing will totally remove them (the skin cannot be made sterile). These organisms cause "trouble" when introduced into normally sterile areas (like the bladder or bloodstream). Pathogens: Microorganisms that nearly always produce disease. For example: Salmonella and Shigella cause diarrheal illness upon ingestion of enough organisms. Normal flora can become pathogenic when introduced into areas where they don't belong, for example, through insertion of a catheter or through surgery. S. epidermidis, normal flora of the skin, causes most central line infections and hip implant infections.
The Seven Keys of Asepsis Know what is clean Know what is contaminated Know what is sterile Keep clean, contaminated and sterile items separated Keep sterile sites sterile Resolve contamination immediately Train yourself to realize when you have broken technique
Know what is clean Clean techniques are any procedures that involve contact with intact skin or mucous membranes only. For example, when you are taking blood pressure or temperature, these articles need to be clean only.
Page 162
Know what is contaminated Certain procedures like dressing changes produce contaminated materials. These contaminated materials must be disposed of properly by incineration or autoclave. Touching non-intact skin is a contaminated procedure; wear clean gloves unless a sterile procedure (like a dressing change) is being done.
Know what is sterile During certain procedures (for example, the insertion of an IV or urinary catheter), sterile technique must be used. The level of sterile procedures increases with the level of invasiveness. For example, surgical procedures require stricter aseptic technique than starting an IV. Sterile gloves are required for sterile procedures.
Keep clean, contaminated and sterile items separated Keep contaminated articles from touching clean or sterile items. Store clean and sterile items separately from contaminated areas or items. Keep sterile items from touching anything but a sterile field or another sterile item.
Keep sterile sites sterile Once a tube has been inserted into the body, care must be given to mitigate the travel of microorganisms up the catheter or tube. Give dressing changes or catheter care and replace catheters per your facility's policy and procedure.
Resolve contamination immediately If sterile technique cannot be used or is broken (e.g. during an emergency), resolve contamination when it occurs. For example, if an IV is inserted during an emergency, replace the IV as soon as possible after the code is completed.
Train yourself to realize when you have broken technique If a technique is broken, remedy the problem if possible. For example, if during the insertion of an IV the catheter is contaminated by touching a non-sterile surface, replace the catheter before insertion. If contamination cannot be resolved, report it to the proper person. For example, if the bowel is nicked during surgery, the case classification will change from clean or clean-contaminated to contaminated and extra care should be given to prevent infection. For details on approved disinfectants and antiseptics for different procedures see the Table below Approved Antiseptic Agents and Procedures.
Page 163
Reference: Rhodes, M. (2003) The ABCs of Infection Control. Infection control Today Magazine
Table 28: Approved Antiseptic Agents and Procedures

PURPOSE OF SKIN PREPARATION Patients personal hygiene AGENT(S) Neutral soap CONTACT TIME 10-15 seconds COMMENTS Hand hygiene to be promoted after toileting and before meals Hand hygiene to be promoted after toileting and before meals Attention to nails. Remove rings and watches. Perform when hands visibly soiled and when managing C.difficile patients/residents. Use as first line or routine approach to hand hygiene. *Do not use if hands visibly soiled or when managing C.difficile. To be performed prior to aseptic procedures. If alcohol based hand rub used, 2-3 liberal applications rubbed all surfaces-hands, wrists, forearms Care not to retouch prepared skin surface
Alcohol antisepsis
15 seconds
Staff hygiene Social hand wash
Neutral soap
10-15 seconds
Hand antisepsis Alcohol based hand rub
Approved alcohol based hand rub
15 seconds
Aseptic hand scrub or rub
CHG 2% detergent Povidone Iodine 10% Approved alcohol based hand rub
3-5 minutes 3-5 minutes 2-3 minutes
Preparation of skin for intramuscular or subcutaneous injections Preparation of skin for peripheral venous access Preparation of skin for: Withdrawal of blood for culture and sensitivity Withdrawal of blood for other studies Preparation of skin site before insertion of arterial, central, or epidural lines, hemodialysis access or any inserting any scope through the skin
70% Isopropyl alcohol
Until dry
CHG 2% with 70% isopropyl (preferred) or 70% Isopropyl alcohol Povidone Iodine 10%, followed by 70% Isopropyl alcohol 70% Isopropyl alcohol
Until dry
For neonates or if allergic to Povidone Iodine: 2% CHG with 70% Isopropyl alcohol
Until dry (at least 2 minutes)
Until dry
Adults: 2% CHG with 70% Isopropyl alcohol Neonates: 2% CHG (no alcohol)
Until dry
Amuchina 10% (Except Plus) for hemodialysis patients/residents with skin allergy or sensitivity
Page 164
PURPOSE OF SKIN PREPARATION Ongoing care of sites used for line access to a sterile space Care of wounds post surgical or trauma Care of pin sites
AGENT(S) 2% CHG with 4% alcohol preservative
CONTACT TIME Until dry
COMMENTS
Sterile normal saline
Wipe dry with sterile gauze Until dry
Sterile normal saline and/or hydrogen peroxide 3%; or Povidone Iodine 10% Sterile normal saline or CHG 2% solution or Povidone Iodine 10% None (see comments)
Care of decubiti
Open containers to be discarded and replaced after 24 hours Ortho: Cleanse daily and prn with normal saline; gently remove scabbing. Other Specialties: Check with MRP for orders. Saline used if discharge is present
Preparation for gynecologic examination Urinary Catheterization/Urology Pre-operative skin prep In-house
Good perineal washing. Colposcopy Povidone Iodine 10%. Good perineal washing
Normal Saline (see comments)
CHG 4% (see comment)
Shower night before and morning of surgery with CHG 4%. Rinse well. 3 minutes Coach patient to allow lather to remain on skin for 3 minutes Apply once to surgical area for 3 minutes. Rinse area thoroughly. As per VIHA Nursing Policy & Procedure Manual.
Same day surgical admissions: Patient arrives with: only 1 application of CHG 4%
Patient arrives with: no applications of CHG 4% completed; or allergy to CHG 4%
CHG 4% (see comment) PCMX; or Povidone Iodine scrub.
Note: Once opened, bottles of sterile normal saline should be dated, and used up or discarded, preferably by the end of each shift and certainly within 24 hours of opening.
Page 165
2.
Environment and Furniture

A. Storage of Decorative Items
Decorations must be stored in a designated area, which is not used to store clean supplies or linen Decorations will be cleaned prior to storage Damaged or broken decorations will be discarded as they cannot be cleaned All decorations will be stored within a lidded, cleanable box Decorations which cannot be cleaned and are displayed in areas where they are handled or on the floor will be discarded at the end of the celebration
B.
General
Furniture
All furniture should be constructed in a way that permits cleaning of all surfaces The size, shape and design of the furniture must allow easy access to cleaning staff
Risk Levels Vinyl is required for furnishings in high risk areas High level of risk applies to any area specifically used by patients/residents (i.e. patient rooms, waiting rooms) and any area where a healthcare worker goes after providing direct patient care (e.g. nursing station, staff lounge, report area, conference rooms, offices within patient care areas Durable, cleanable fabrics are appropriate in low risk areas Low level of risk applies to any office areas where staff are not providing direct patient care, or return to after providing direct patient care
Fabric Fabric must be impermeable to water, stain resistant and made of a material that does not promote the growth of microorganisms The material should be durable, easily cleaned and withstand cleaning with institutional cleaning/disinfecting solutions. Their selection should be based on an understanding of the principles of decontamination and maintenance requirements (e.g. able to withstand multiple application of diluted disinfectants over time) Limit the amount of pleating in fabric and make sure the seams are sealed There should be limited off-gassing from the fabric
Page 166
Other Materials Plastic laminate furniture offer good designs and realistic wood grain patterns. Another option combines polyurethane sealed woods on vertical surfaces with solid surfacing on horizontal surfaces The purchasing of new wood furniture is not recommended. Existing wood furniture must be assessed regularly to assure that the finish remains sealed (note: wood furniture requires regular maintenance to keep lacquer intact)
Note: The above criteria apply to all clinical areas throughout the healthcare system patient rooms, waiting rooms, unit offices (i.e. social worker, coordinator, manager), nurses station, staff rooms and conference rooms. Fabric, if desired, is acceptable in administrative/executive offices and related meeting areas.
C.
General
Fixtures and Fittings
All fixtures and fittings should prevent the collection of dust and growth of mold, mildew and other microorganisms They must be easy to maintain, and have proven durability under actual conditions of use and maintenance in healthcare facilities
Curtains and blinds Curtains can easily become contaminated with microorganisms. All curtains must be able to withstand a washing process at disinfection temperatures (71 c for 25 minutes or more), or be able to withstand the washing/drying sanitizing processes that occur in an industrial or institutional setting Venetian horizontal blinds are not recommended as they become dusty and difficult to clean. Certain vertical blinds may be acceptable if design allows appropriate cleaning Blinds need to be of a construction that allows cleaning of all surfaces and functional parts
Fittings The use of lamps with fabric shades is not recommended If fabric shades used, the fabric must be removable and be able to withstand washing temperatures of 71 c for 3 minutes or 65 c for 10 minutes It is recommended to avoid lamps that have pull strings for operation, unless it is a material that is easily cleaned and will not rust
Page 167
Ceiling lights and wall mounted fixtures should have lenses and enclosed housings
Vanity tops Vanity top within patient bathrooms must be constructed of a solid surface material, with integrated bowl and backsplash
Hand Wash Facilities For all new construction and renovations all dedicated hand wash sinks will follow requirements outlined in CSAs Z8000 standards
Handrails and Other Hardware Stainless steel remains the material of choice for handrails and other hardware, because of its durability and ease of maintenance Wood is acceptable if sealed, but requires ongoing maintenance
Ceilings The ceiling must be cleanable and built to prevent the infiltration of dust from the plenum space The ceiling should be made of a material that does not promote the growth of microorganisms
Walls Low volatile organic compound (VOC) scrub-able paint must be used If vinyl wall covering is selected, it should have minimal texture to facilitate thorough cleaning All wall coating/covering and adhesives used must have antimicrobial treatments where available
Floors Sheet vinyl flooring with welded seams and an integral cove base Carpeting in patient care areas is strongly discouraged
Page 168
Posted Signage and Other Posted Materials Most signage presents a very low risk for transmission of organisms. Determination of whether a sign/poster that is posted should be laminated is based upon the following considerations: Length of time it is likely to be posted Whether the signage is for long term use and is stored between uses Whether the signage would require a wipe down of its surfaces when area is cleaned Risk of contamination based on where it will be posted low frequency or high frequency touch areas Where it will be used patient care area, staff rooms, office/business area. When a poster/sign is developed for posting and a decision needs to be made regarding lamination, the following four basic principles should be considered: 1. Laminate the poster/sign if it will be posted for a long-term period (30 days or greater), or stored and re-used (i.e. precaution signs) 2. Dont laminate if poster/sign is to be posted for short term (less than 30 days) 3. If not laminated, remove and replace if it becomes dirty, tattered, or torn 4. If the poster/sign is to be posted in a patient or staff bathroom or dirty utility room, it must be laminated regardless of the duration of use
Please note: Sheet protectors are not recommended as an alternate to lamination because they cannot be easily cleaned and require tape to seal the top.
Page 169
APPENDICES
APPENDIX A: Type and Duration of Additional Precautions Where Recommended for Selected Infections and Conditions
Legend: Precautions used in addition to Routine Practices
Type of Precautions:
A C D R AIRBORNE CONTACT DROPLET ROUTINE PRACTICES
Duration of Precautions: CN DI DE U Unknown Until off antimicrobial treatment and culture negative Duration of illness (with wound lesions, DI means until wounds stop draining) Until the environment is completely decontaminated Until time specified in hours (hrs) after initiation of effective therapy Criteria for establishing eradication of pathogen has not bee determined
Adapted from: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: preventing Transmission of Infectious Agents in Healthcare Settings, June 2007
Page 170
TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition Precautions
Type
Abscess Draining, major C
Duration
DI
Comments No dressing or containment of drainage; until drainage stops or can be contained by dressing. Dressing covers and contains drainage. Post-exposure chemoprophylaxis for some blood and body fluid exposures. Not transmitted from person to person.
Draining, minor or limited Acquired human immunodeficiency syndrome (HIV) Actinomycosis Adenovirus infection (see agentspecific guidance under gastroenteritis, conjunctivitis, pneumonia) Amebiasis
R R
Person to person transmission is rare. Transmission in settings for the mentally challenged and in a family group has been reported. Use care when handling diapered infants and mentally challenged persons. Infected patients/residents do not generally pose a transmission risk. Transmission through non-intact skin contact with draining lesions possible, therefore use Contact Precautions if large amount of uncontained drainage. Handwashing with soap and water preferable to use of waterless alcohol based antiseptics since alcohol does not have sporicidal activity. Not transmitted from person to person. DE Until decontamination of environment complete. Wear respirator (N95 mask or PAPRs), protective clothing; decontaminate persons with powder on them. Hand hygiene: Handwashing for 30-60 seconds with soap and water or 2% chlorhexidine gluconate after spore contact (alcohol based hand rubs inactive against spores). Post-exposure prophylaxis following environmental exposure: 60 days of antimicrobials (either doxycycline or ciprofloxacin) and post-exposure
Anthrax Cutaneous Anthrax
R R
Pulmonary Anthrax Environmental Anthrax: aerosolizable spore-containing powder or other substance
R R
Page 171
Type
Antibiotic-associated colitis (see Clostridium difficile) Antibiotic Resistant Organisms (AROs), infection or colonization (e.g. MRSA, VRE, VISA/VRSA, ESBLs, resistant S. pneumoniae) R/C
Duration
Comments vaccine under IND.
AROs judged by the Infection Prevention and Control Program, based on local, provincial or national recommendations, to be of clinical and epidemiologic significance. Contact Precautions recommended in settings with evidence of ongoing transmission, acute care settings with increased risk for transmission or wounds that cannot be contained by dressings. Not transmitted from person to person except rarely by transfusion, and for West Nile virus by organ transplant, breastmilk or transplacentally. Install screens in windows and doors in endemic areas. Use DEET-containing mosquito repellents and clothing to cover extremities. Not transmitted from person to person. Contact Precautions and Airborne Precautions if massive soft tissue infection with copious drainage and repeated irrigations required.
Arthropod-borne viral encephalitides (eastern, western, Venezuelan equine encephalomyelitis; St. Louis, California encephalitis; West Nile Virus) and viral fevers (dengue, yellow fever, Colorado tick fever)
Ascariasis Aspergillosis
R R
Avian influenza (see influenza, avian, below) Babesiosis Blastomycosis, North American, cutaneous or pulmonary Botulism Bronchiolitis (see respiratory infections in infants and young children) Brucellosis (undulant, Malta, Mediterranean fever) R R R C DI Not transmitted from person to person except rarely by transfusion. Not transmitted from person to person. Not transmitted from person to person. Use mask according to Routine Practices. (Droplet precautions if patient coughing). Not transmitted from person to person except rarely via banked spermatozoa and sexual contact. Provide antimicrobial prophylaxis following laboratory exposure and monitor serology.
Campylobacter gastroenteritis (see gastroenteritis)

Page 172
Type
Candidiasis, all forms including mucocutaneous Cat-scratch fever (benign inoculation lymphoreticulosis) Cellulitis Chancroid (soft chancre) (H.ducreyi) Chickenpox (see varicella) Chlamydia trachomatis Conjunctivitis Genital (lymphogranuloma Venereum) Pneumonia (infants 3 months of age or less) Chlamydia pneumoniae Cholera (see Gastroenteritis) Closed-cavity infection Open drain in place; limited or minor drainage No drain or closed drainage system in place Clostridium C. botulinum C. difficile (see Gastroenteritis) C. perfringens Food poisoning Gas gangrene R R R C R R R R R R R R R R A
Duration
Comments
Not transmitted from person to person.
Transmitted sexually from person to person.
Outbreaks in institutionalized populations reported, rarely.
Contact Precautions if there is copious uncontained drainage.
Not transmitted from person to person DI Not transmitted from person to person. Transmission from person to person rare; one outbreak in a surgical setting reported. Use Contact Precautions if wound drainage is extensive. Not transmitted from person to person. Not transmitted from person to person. Not transmitted from person to person. Until 1 year of age Routine Practices if nasopharyngeal and urine cultures repeatedly negative after 3 months of age.
Coccidioidomycosis (valley fever) Draining lesions Pneumonia Colorado tick fever Congenital rubella R R R C
Conjunctivitis
Page 173
Type
Acute bacterial Chlamydia Gonococcal Acute viral (acute hemorrhagic) R R R C
Duration
Comments
DI
Adenovirus most common; Enterovirus 70, Coxsackie virus A24, also associated with community outbreaks. Highly contagious; outbreaks in eye clinics, pediatric and neonatal settings, institutional settings reported. Eye clinics should follow Routine Practices when handling patients/residents with conjunctivitis. Routine use of infection prevention and control measures in the handling of instruments and equipment, and disinfection of eye equipment between patients/residents, will prevent the occurrence of outbreaks in this and other settings.
Corona virus associated with SARS (SARS-CoV) (see severe acute respiratory syndrome) Coxsackie virus disease (see enteroviral infection) Creutzfeldt-Jakob disease (CJD, vCJD) R Use disposable instruments or special sterilization/ disinfection for surfaces, objects contaminated with neural tissue if CJD or vCJD suspected and has not been ruled out; No special burial procedures.
Croup (see respiratory infections in infants and young children) Crimean-Congo Fever (see Viral Hemorrhagic Fever) Cryptococcosis Cryptosporidiosis (see also gastroenteritis) Cysticercosis Cytomegalovirus infection, including in neonates and immunosuppressed patients/residents. Decubitus ulcer (see pressure ulcer) Dengue fever R R C R R Not transmitted from person to person. No additional precautions for pregnant Healthcare Workers (requires saliva contact for transmission). Not transmitted from person to person. Not transmitted from person to person. Not transmitted from person to person.
R R
Page 174
Type
Diarrhea, acute-infective etiology suspected (see gastroenteritis) Diphtheria Cutaneous Pharyngeal Ebola virus (see viral hemorrhagic fevers) Echinococcosis (hydatidosis) Echovirus (see enteroviral infection) Encephalitis or encephalomyelitis (see specific etiologic agents) Endometritis (endomyometritis) Enterobiasis (pinworm disease, oxyuriasis) Enterococcus species (see multidrugresistant organisms if epidemiologically significant or vancomycin resistant) Enterocolitis, C. difficile (see C. difficile, gastroenteritis) Enteroviral infections (i.e. Group A and B Coxsackie viruses and Echo viruses) (excludes polio virus) Epiglottitis, due to Haemophilus influenzae type b Epstein-Barr virus infection, including infectious mononucleosis Erythema Infectiosum (also see Parvovirus B19) Escherichia coli gastroenteritis (see gastroenteritis) Food poisoning Botulism C. perfringens or welchii Staphylococcal R R R R R R R C D
Duration
Comments
CN CN
Until 2 cultures taken 24 hrs apart negative Until on appropriate treatment and 2 cultures taken 24 hrs apart negative.
Use Contact Precautions for diapered or incontinent children for duration of illness and to control institutional outbreaks. U 24 hrs See specific disease agents for epiglottitis due to other etiologies)
D R
Pregnant staff should not provide care.
Not transmitted from person to person. Not transmitted from person to person. Not transmitted from person to person.
Page 175
Type
Furunculosis, staphylococcal R
Duration
Comments Contact Precautions if drainage not controlled. Follow institutional policies if MRSA.
Infants and young children Gangrene (gas gangrene) Gastroenteritis
C R C/D
DI Not transmitted from person to person. Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks for gastroenteritis caused by all of the agents below. Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. DI Discontinue antibiotics if possible. Do not share electronic thermometers; ensure consistent environmental cleaning and disinfection. Hypochlorite solutions are required for cleaning for all cases. Handwashing with soap and water preferred because of the absence of sporicidal activity of alcohol in alcohol-based hand rubs.
Adenovirus
Campylobacter species
Cholera (Vibrio cholerae)
C. difficile
Cryptosporidium species E. coli Enteropathogenic O157:H7 and other shiga toxin-producing strains Other species
C R
DI Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional Page 176
Giardia lamblia
Type
Noroviruses C/D
Duration
outbreaks. DI
Comments Use Contact Precautions for all infected and exposed cases for the duration of illness and to control institutional outbreaks. Persons who clean areas heavily contaminated with feces or vomitus may benefit from wearing masks since virus can be aerosolized from these body substances; ensure consistent environmental cleaning and disinfection with focus on bathrooms even when apparently unsoiled. Hypochlorite solutions are required for cleaning for all cases. Alcohol is less active, but there is no evidence that alcohol based hand rubs are not effective for hand decontamination. Cohorting of affected patients/residents to separate airspaces and toilet facilities may help interrupt transmission during outbreaks. Ensure consistent environmental cleaning and disinfection and frequent removal of soiled diapers. Prolonged shedding may occur in both immunocompetent and immunocompromised children and the elderly. Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. Use Contact Precautions for diapered or incontinent persons for the duration Page 177
Rotavirus
DI
Salmonella species (including S. typhi)
Shigella species (Bacillary dysentery)
Vibrio parahaemolyticus
Viral (if not covered elsewhere)
C/D
Yersinia enterocolitica
Type
Duration
Comments of illness or to control institutional outbreaks.
German measles (see rubella; see congenital rubells) Giardiasis (see gastroenteritis) Gonococcal Ophthalmia neonatorum (gonorrheal Ophthalmia, acute conjunctivitis of newborn) Gonorrhea Granuloma inguinale (Donovanosis, granuloma venereum) Guillain-Barr syndrome Haemophilus influenzae (see disease-specific recommendations) Hand, foot and mouth disease (see enteroviral infection) Hansens Disease (see Leprosy) Hantavirus pulmonary syndrome Helicobacter pylori Hepatitis, viral Type A R Provide Hepatitis A vaccine postexposure as recommended by Public Health. Maintain Contact Precautions in infants and children less than 3 years of age for duration of hospitalization; for children 3 14 years of age for 2 weeks after onset of symptoms; more than 14 years of age for 1 week after onset of symptoms. See specific recommendations for care of patients/residents in hemodialysis centres See specific recommendations for care of patients/residents in hemodialysis centres. R R Not transmitted from person to person R Not an infectious condition. R
Incontinent patients/residents with diarrhea
Type B HbsAg positive; acute or chronic Type C and other unspecified non-A, non-B Type D (seen only with hepatitis B) Type E
R R Use Contact Precautions for all symptomatic individuals and incontinent individuals for the duration of illness.
Type G
R Page 178
Type
Herpangina (see enteroviral infection) Hookworm Herpes simplex (Herpesvirus hominis) Encephalitis Mucocutaneous, disseminated or primary, severe Mucocutaneous, recurrent (skin, oral, genital) Neonatal R C R
Duration
Comments
Until lesions dry and crusted Until lesions dry and crusted Until lesions dry and crusted Also, for asymptomatic, exposed infants delivered vaginally or by CSection and if mother has active infection and membranes have been ruptured for more than 4 to 6 hrs until infant surface cultures obtained at 2436 hrs of age are negative.
Herpes zoster (varicella-zoster) (shingles) Disseminated disease in any patient. Localized disease in immunocompromised patient until disseminated infection ruled out A/C DI Susceptible healthcare workers should not enter room if immune caregivers are available; no recommendation for protection of immune healthcare workers; no recommendation for type of protection, i.e. surgical mask or respirator, for susceptible healthcare workers. Susceptible healthcare workers should not provide direct patient care when other immune caregivers are available. Not transmitted from person to person. Post-exposure chemoprophylaxis for some blood and body fluid exposures. DI HAI reported, but route of transmission not established. Assumed to be Contact / Droplet transmission as for RSV since the viruses are closely related and have similar clinical manifestations and epidemiology. Wear masks according to Routine Practices.
Localized in patient with intact immune system with lesions that can be contained/ covered. Histoplasmosis Human immunodeficiency virus (HIV) Human metapneumovirus
DI
R R C
Impetigo
U 24 hrs
Page 179
Type
Infectious mononucleosis Influenza Human (seasonal influenza) D R
Duration
Comments
5 days except
DI in immunocompromised persons
Single patient room when available or cohort; avoid placement with high-risk patients/residents; mask patient when transported out of room; chemoprophylaxis / vaccine to control / prevent outbreaks. Use gown and gloves according to Routine Practices; may be especially important in pediatric settings. Duration of precautions for immuno-compromised patients/residents cannot be defined; prolonged duration of viral shedding (i.e. for several weeks) has been observed; implications for transmission are unknown. See www.cdc.gov/flu/avian/professional/infe ct-control.htm for current avian influenza guidance.
Avian (e.g. H5N1, H7, H9 strains)
Pandemic influenza (also a human influenza virus) Kawasaki syndrome Lassa fever (see viral hemorrhagic fevers) Legionnaires disease Leprosy Leptospirosis Lice Head (Pediculosis) Body
5 days
See http://www.pandemicflu.gov for current pandemic influenza guidance. Not an infectious condition.
Not transmitted from person to person. R R Not transmitted from person to person. http://www.cdc.gov/ncidod/dpd/parasite s/lice/default.htm C R U 4 hrs Transmitted person to person through infested clothing. Wear gown and gloves when removing clothing; bag and wash clothes according to CDC guidance above. Transmitted person to person through sexual contact. Person-to-person transmission rare; cross-transmission in neonatal settings and endoscopy. Not transmitted from person to person. Page 180
Pubic Listeriosis (listeria monocytogenes)
R R
Lyme disease
Type
Lymphocytic choriomeningitis Lymphogranuloma venereum Malaria R R R
Duration
Comments Not transmitted from person to person. Not transmitted from person to person except through transfusion rarely and through a failure to follow Routine Practices during patient care. Install screens in windows and doors in endemic areas. Use DEET-containing mosquito repellents and clothing to cover extremities.
Marburg virus disease (see viral hemorrhagic fevers) Measles (rubeola) A 4 days after onset of rash; DI in immunocompromised Susceptible healthcare workers should not enter room if immune care providers are available; no recommendation for face protection for immune healthcare worker; no recommendation for type of face protection for susceptible healthcare workers, i.e. mask or respirator. For exposed susceptibles, post-exposure vaccine within 72 hrs or immune globulin within 6 days when available. Place exposed susceptible patients/residents on Airborne Precautions and exclude susceptible healthcare workers from duty from day 5 after first exposure to day 21 after last exposure, regardless of post-exposure vaccine. Not transmitted from person to person. Contact Precautions for infants and young children.
Melioidosis, all forms Meningitis Aseptic (nonbacterial or viral; also see enteroviral infections) Bacterial, gram-negative enteric, in neonates Fungal Haemophilus influenzae, type B, known or suspected Listeria monocytogenes (See Listeriosis) Neisseria meningitidis (meningococcal) known or
R R R
R D R D U 24 hrs See meningococcal disease below U 24 hrs
Page 181
Type
suspected Streptococcus pneumoniae M. tuberculosis R R
Duration
Comments
Concurrent, active pulmonary disease or draining cutaneous lesions may necessitate addition of Contact and/or Airborne Precautions. For children, Airborne Precautions until active tuberculosis ruled out in visiting family members (see tuberculosis below). U 24 hrs Post-exposure chemoprophylaxis and immunoprophylaxis for household contacts, healthcare workers exposed to respiratory secretions. See www.cdc.gov/ncidod/monkeypox for most current recommendations. Transmission in hospital settings unlikely. Pre- and post-exposure smallpox vaccine recommended for exposed healthcare workers.
Other diagnosed bacterial Meningococcal disease: sepsis, pneumonia, meningitis
R D
Molluscum contagiosum Monkeypox
R A/C A-Until monkeypox confirmed and smallpox excluded; C-Until lesions crusted
Mucormycosis Multidrug-resistant organisms (MDROs) (See Antibiotic Resistant Organisms) Mumps (infectious parotitis)
U 9 days
After onset of swelling susceptible healthcare workers should not provide care if immune caregivers are available. Note: Recent assessment of outbreaks in health 18-24 year olds has indicated that salivary viral shedding occurred early in the course of illness and that 5 days of Additional Precautions after onset of parotitis may be appropriate in community settings; however, the implications for healthcare personnel and high-risk patient populations remain to be clarified. Not transmitted from person to person.
Mycobacteria, non-tuberculosis (atypical) Pulmonary Wound R R
Page 182
Type
Mycoplasma pneumonia Necrotizing enterocolitis Nocardiosis, draining lesions, or other presentations Norovirus (see gastroenteritis) Norwalk agent gastroenteritis (see gastroenteritis) Orf Parainfluenza virus infection, respiratory in infants and young children Parvovirus B19 (Erythema Infectiosum) R C D R R
Duration
DI
Comments Contact Precautions when cases clustered temporally. Not transmitted from person to person.
DI
Viral shedding may be prolonged in immuno-suppressed patients/residents. Maintain precautions for duration of hospitalization when chronic disease occurs in an immuno-compromised patient. For patients/residents with transient aplastic crisis or red-cell crisis, maintain precautions for 7 days. Duration of precautions for immunosuppressed patients/residents with persistently positive PCR not defined, but transmission has occurred. Pregnant staff should not provide care.
Pediculosis (lice)
U 24 hrs after treatment U 5 days Single patient room preferred. Cohorting an option. Post-exposure chemoprophylaxis for household contacts and healthcare workers with prolonged exposure to respiratory secretions. Recommendations for Tdap vaccine in adults (pediatric nurses, doctors) under development.
Pertussis (whooping cough)
Pinworm infection (Enterobiasis) Plague (Yersinia pestis) Bubonic Pneumonic Pneumonia Adenovirus
R R D U 48 hrs Antimicrobial prophylaxis for exposed healthcare worker. Outbreaks in pediatric and institutional settings reported. In immunoPage 183
D/C
DI
Type
Duration
Comments compromised hosts, extend duration of Droplet and Contact Precautions due to prolonged shedding of virus.
Bacterial not listed elsewhere (including gram-negative bacterial) B. cepacia in patients/residents with Cystic Fibrosis (CF), including respiratory tract colonization
Avoid exposure to other persons with CF; private room preferred, including clinic visits. Criteria for discontinuing Precautions not established. Use Precautions for duration of hospitalization if other CF patients/residents on the unit. See CF Foundation guideline.
B. cepacia in patients/residents without Cystic Fibrosis (see Antibiotic Resistant Organisms) Chlamydia Fungal Haemophilus influenzae, type b Adults Infants and children Legionella spp. Meningococcal Multidrug resistant bacterial (see Antibiotic Resistant Organisms) Mycoplasma (primary atypical pneumonia) Pneumococcal pneumonia D R DI Use Droplet Precautions if evidence of transmission within a patient care unit or facility. R C R D U 24 hrs See meningococcal disease above U 24 hrs R R
Pneumocystis jiroveci (Pneumocystis carinii) Staphylococcus aureus Streptococcus, group A
R R For MRSA, see Antibiotic Resistant Organisms For Invasive Group A Streptococcus, Contact or Droplet Precautions for 24 hrs until appropriate antibiotic treatment given. Includes pneumonia, toxic shock syndrome, necrotizing fasciitis, but not cellulitis. Page 184
Type
Adults D
Duration
U 24 hrs
Comments See streptococcal disease (group A streptococcus) below. Contact Precautions if skin lesions present. Contact Precautions if skin lesions present.
Infants and young children Varicella-zoster (See Varicellazoster) Viral Adults Infants and young children (see respiratory infectious disease, acute, or specific viral agent) Poliomyelitis Pressure ulcer (Decubitus ulcer, pressure sore) infected Major
U 24 hrs
DI
DI
If no dressing or containment of drainage until drainage stops or can be contained by dressing. If dressing covers and contains drainage.
Minor or limited Prion disease (See Creutzfeld-Jacob Disease) Psittacosis (ornithosis) (Chlamydia psittaci) Q fever Rabies
R R R
Person to person transmission rare; transmission via corneal, tissue and organ transplants has been reported. If patient has bitten another individual or saliva has contaminated an open wound or mucous membrane, wash exposed area thoroughly and administer post-exposure prophylaxis. Not transmitted from person to person.
Rat-bite fever (Streptobacillus moniliformis disease, Spirillum minus disease) Relapsing fever Resistant bacterial infection or colonization (see Antibiotic Resistant Organisms)
Page 185
Type
Respiratory infectious disease, acute (if not covered elsewhere) Adults Infants and young children Respiratory syncytial virus infection, in infants, young children and immuno-compromised adults R C C
Duration
Comments
DI DI Wear mask according to Routine Practices. In immuno-compromised patients/residents, extend the duration of Contact Precautions due to prolonged shedding. Not an infectious condition. Not an infectious condition. DI Droplet most important route of transmission. Outbreaks have occurred in NICUs and LTCFs. Add Contact Precautions if copious moist secretions and close contact likely to occur (e.g. young infants). Not transmitted from person to person except through transfusion, rarely. Not transmitted from person to person. Rarely, outbreaks have occurred in healthcare settings (e.g. NICU, rehabilitation hospital. Use Contact Precautions for outbreak. DI See staphylococcal disease, scalded skin syndrome below. Not transmitted from person to person except through transfusion, rarely.
Reyes syndrome Rheumatic fever Rhinovirus
R R D
Rickettsial fevers, tickborne (Rocky Mountain spotted fever, tickborne typhus fever) Rickettsialpox (vesicular rickettsiosis) Ringworm (Dermatophytosis, dermatomycosis, tinea)
R R
Ritters disease (staphylococcal scalded skin syndrome) Rocky Mountain spotted fever Roseola infantum (exanthem subitum; caused by HHV-6) Rotavirus infection (see gastroenteritis) Rubella (German measles) (also see congenital rubella)
C R R
U 7 days after onset of rash
Susceptible healthcare workers should not enter room if immune caregivers are available. No recommendation for wearing face protection (e.g. a surgical mask) if immune. Pregnant women who are not immune should not care for these patients/residents. Administer vaccine within three days of exposure to non-pregnant susceptible individuals. Place exposed susceptible Page 186
Type
Duration
Comments patients/residents on Droplet Precautions; exclude susceptible healthcare personnel from duty from day 5 after first exposure to day 21 after last exposure, regardless of postexposure vaccine.
Rubeola (see measles) Salmonellosis (see gastroenteritis) Scabies C U 24 hrs following treatment DI See staphylococcal disease, scalded skin syndrome below. Airborne Precautions preferred; Droplet Precautions if Airborne Infection Isolation Room unavailable. N95 or higher respiratory protection; surgical mask if N95 unavailable; eye protection (goggles, face shield); aerosolgenerating procedures and super shedders highest risk for transmission via small droplet nuclei and large droplets. Vigilant environmental disinfection. (See www.cdc.gov/ncidod/sars) Until all scabs have crusted and separated (34 weeks). Nonvaccinated healthcare workers should not provide care when immune healthcare workers are available; N95 or higher respiratory protection for susceptible and successfully vaccinated individuals; post-exposure vaccine within 4 days of exposure protective. Not transmitted from person to person.
Scalded skin syndrome, staphylococcal Schistosomiasis (bilharziasis) Severe acute respiratory syndrome (SARS)
C R A/D/C
DI plus 10 days
after resolution of fever, provided respiratory symptoms are absent or improving
Shigellosis (see gastroenteritis) Smallpox (variola; see vaccinia for management of vaccinated persons) A/C DI
Sporotrichosis Spirillum minor disease (rat-bite fever) Staphylococcal disease (S. aureus) Skin, wound, or burn Major
R R
DI
No dressing or dressing does not contain drainage adequately. Page 187
Type
Minor or limited Multi-drug resistant (see Antibiotic Resistant Organisms) Pneumonia Scalded skin syndrome R C R
Duration
Comments Dressing covers and contains drainage adequately.
DI
Consider healthcare personnel as potential source of nursery, NICU outbreak. Not transmitted from person to person
Toxic shock syndrome Streptobacillus moniliformis disease (rat-bite fever) Streptococcal disease (group A streptococcus) Invasive Group A Streptococcus (iGAS) (including pneumonia, toxic shock syndrome, necrotizing fasciitis, but not cellulitis)
R R
U 24 hrs
Outbreaks of serious invasive disease have occurred secondary to transmission among patients/residents and healthcare personnel. Contact Precautions for draining wounds as below; follow recommendations for antimicrobial prophylaxis in selected conditions. No dressing or dressing does not contain drainage adequately Dressing covers and contains drainage adequately
Skin, wound, or burn Major Minor or limited Endometritis (puerperal sepsis) Pharyngitis in infants and young children Pneumonia Scarlet fever in infants and young children Streptococcal disease (group B streptococcus), neonatal Streptococcal disease (not group A or B) unless covered elsewhere Multidrug-resistant (see Antibiotic Resistant Organisms) Strongyloidiasis Syphilis R C/D R R D D D R R U 24 hrs U 24 hrs U 24 hrs U 24 hrs
Page 188
Type
Latent (tertiary) and seropositivity without lesions Skin and mucous membrane, including congenital Tapeworm disease Hymenolepsis nana Taenia solium (pork) Other Tetanus Tinea (e.g. Dermatophytosis, dermatomycosis, ringworm) Toxoplasmosis R R R R R R R R
Duration
Comments
Contact Precautions for primary or secondary stage of disease. Not transmitted from person to person. Not transmitted from person to person. Not transmitted from person to person. Not transmitted from person to person. Rare episodes of person-to-person transmission. Transmission from person to person is rare; vertical transmission from mother to child, transmission through organs and blood transfusion rare. Droplet Precautions for the first 24 hrs after implementation of antibiotic therapy if Group A streptococcus is a likely etiology.
Toxic shock syndrome (staphylococcal disease, streptococcal disease) Trachoma, acute Transmissible spongiform encephalopathy (see CreutzfeldJacob disease, CJD, vCJD) Trench mouth (Vincents angina) Trichinosis Trichomoniasis Trichuriasis (whipworm disease) Tuberculosis (M. tuberculosis) Extrapulmonary, draining lesion
R R R R A/C Discontinue precautions only when patient is improving clinically, and drainage has ceased or there are three consecutive (one week apart) negative cultures of continued drainage. Examine for evidence of active pulmonary tuberculosis. Examine for evidence of pulmonary tuberculosis. For infants and children, use Airborne Precautions until active pulmonary tuberculosis in visiting family members ruled out. Discontinue precautions only after consultation with Infection Prevention & Page 189
Extrapulmonary, no draining lesion, meningitis
Pulmonary or laryngeal disease, confirmed
Type
Duration
Comments Control Practitioner (minimum of 2 weeks on treatment, clinical improvement, and three consecutive sputum smears negative for acid-fast bacilli collected on separate days). Reference BCCDC.
Pulmonary or laryngeal disease, suspected
Discontinue precautions only when the likelihood of infectious TB disease is deemed negligible, and either 1) there is another diagnosis that explains the clinical syndrome, or 2) the results of three sputum or BAL smears for AFB are negative. Each of the three specimens should be collected 24 hrs apart, preferably early each morning.
Skin-test positive with no evidence of current active disease Tularemia Draining lesion Pulmonary Typhoid (Salmonella typhi) fever (see gastroenteritis) Typhus Rickettsia prowazekii (Epidemic or Louse-borne typhus) Rickettsia typhi Urinary tract infection (including pyelonephritis), with or without urinary catheter Vaccinia (vaccination site, adverse events following vaccination)
R R
Not transmitted from person to person. Not transmitted from person to person.
Transmitted from person to person through close personal or clothing contact. Not transmitted from person to person.
R R
Only vaccinated healthcare workers have contact with active vaccination sites and care for persons with adverse vaccinia events; if unvaccinated, only healthcare workers without contraindications to vaccine may provide care. R Vaccination recommended for vaccinators; for newly vaccinated healthcare workers: semi-permeable dressing over gauze until scab separates, with dressing change as fluid accumulates, approx. 35 days; Page 190
Vaccination site care (including autoinoculated areas)
Type
Duration
Comments gloves, hand hygiene for dressing change; vaccinated healthcare worker or healthcare worker without contraindication to vaccine for dressing changes.
Eczema vaccinatum Fetal vaccinia Generalized vaccinia Progressive vaccinia Post vaccinia encephalitis Blepharitis or conjunctivitis Iritis or keratitis Vaccinia-associated erythema multiforme (Stevens Johnson Syndrome) Secondary bacterial infection (e.g. S. aureus, group A beta hemolytic streptococcus) Varicella Zoster
C C C C R/C R R
Until lesions dry and crusted, scabs separated
For contact with virus-containing lesions and exudative material
Use Contact Precautions if there is copious drainage.
Not an infectious condition. R/C Follow organism-specific (strep, staph most frequent) recommendations and consider magnitude of drainage. Until lesions dry and crusted Susceptible healthcare workers should not enter room if immune caregivers are available; no recommendation for face protection of immune healthcare workers; no recommendation for type of protection, i.e. surgical mask or respirator for susceptible healthcare workers. In immuno-compromised host with varicella pneumonia, prolong duration of precautions for duration of illness. Post-exposure prophylaxis: provide post-exposure vaccine ASAP but within 120 hours; for susceptible exposed persons for whom vaccine is contraindicated (immuno-compromised persons, pregnant women, newborns whose mothers varicella onset is 5 days or less before delivery or within 48 hrs after delivery) provide VZIG, when available, within 96 hours; if unavailable, use IVIG; Use Airborne Precautions for exposed susceptible persons and exclude exposed susceptible healthcare workers beginning 8 days after first exposure Page 191
A/C
Type
Duration
Comments until 21 days after last exposure or 28 days if received VZIG, regardless of post-exposure vaccination.
Variola (see smallpox) Vibrio parahaemolyticus (see gastroenteritis) Vincents angina (trench mouth) Viral hemorrhagic fevers, due to Lassa, Ebola, Marburg, CrimeanCongo fever viruses R A DI Single-patient negative pressure room preferred. Emphasize: 1) use of sharps safety devices and safe work practices; 2) hand hygiene; 3) barrier protection against blood and body fluids upon entry into room (single gloves and fluid-resistant or impermeable gown, face/eye protection with masks, goggles or face shields); and 4) appropriate waste handling. Use N95 or higher respirators when performing aerosol-generating procedures. Largest viral load in final stages of illness when hemorrhage may occur; additional PPE, including double gloves, leg and shoe coverings may be used, especially in resource-limited settings where options for cleaning and laundry are limited. Notify public health officials immediately if Ebola is suspected.
Viral respiratory diseases (not covered elsewhere Adults Infants and young children (see respiratory infectious disease, acute) Whooping cough (see pertussis) Wound infections Major Minor or limited Yersinia enterocolitica gastroenteritis (see gastroenteritis) Zoster (varicella-zoster) (see herpes zoster) C R DI DI No dressing or dressing does not contain drainage adequately. R
Page 192
Type
Zygomycosis (phycomycosis, mucormycosis) R
Duration
Comments Not transmitted from person to person.
Page 193
APPENDIX B: Glossary of Terms

Admission Restrictions any restrictions placed on unit during an outbreak that limits the normal admission pattern (e.g. no off-service admissions to a unit) Aseptic technique. The measures taken to purposefully reduce the number of microorganisms (germs) to an irreducible number for the purpose of preventing transmission of infection. These include handwashing, disinfection and sterilization Antisepsis/Sanitation. This method of infection prevention and control includes using soap and water to wash the hands and body as well as the use of antiseptics such as alcohol, iodine and betadine to clean the skin for medical procedures, as these inhibit the growth of pathogenic microorganisms. This level of asepsis may kill or inhibit some microbes but is generally not effective against spores. American Institute of Architects. A professional organization that develops standards for building ventilation, The 2001Guidelines for Design and Construction of Hospital and Health Care Facilities, the development of which was supported by the AIA, Academy of Architecture for Health, Facilities Guideline Institute, with assistance from the U.S. Department of Health and Human Services and the National Institutes of Health, is the primary source of guidance for creating airborne infection isolation rooms (AIIRs) and protective environments. Ambulatory care settings. Facilities that provide healthcare to patients/residents who do not remain overnight (e.g. hospital-based outpatient clinics, nonhospital-based clinics and physician offices, urgent care centers, surgicenters, free-standing dialysis centers, public health clinics, imaging centers, ambulatory behavioral health and substance abuse clinics, physical therapy and rehabilitation centers, dental practices and outpatient clinics. Antibiotic Resistant organisms (AROs). Also known as multidrug resistant organisms (MDRO). In general, bacteria that are resistant to several classes of antimicrobial agents and usually are resistant to most commercially available antimicrobial agents (e.g. MRSA, VRE, extended spectrum beta-lactamase [ESBL]-producing or intrinsically resistant gram-negative bacilli). Bed closure a bed space is closed to admissions or transfers in Bioaerosols. An airborne dispersion of particles containing whole or parts of biological entities, such as bacteria, viruses, dust mites, fungal hyphae, or fungal spores. Such aerosols usually consist of a mixture of mono-dispersed and aggregate cells, spores or viruses, carried by other materials, such as respiratory secretions and/or inert particles. Infectious bioaerosols (i.e. those that contain biological agents capable of causing an infectious disease) can be generated from human sources (e.g. expulsion from the respiratory tract during coughing, sneezing, talking or singing; during suctioning or wound irrigation), wet environmental sources (e.g. HVAC and cooling tower water with Legionella) or dry sources
Page 194
(e.g. construction dust with spores produced by Aspergillus spp.). Bioaerosols include large respiratory droplets and small droplet nuclei (Cole EC. AJIC 1998;26: 453-64). Caregivers. All persons who are not employees of an organization, are not paid, and provide or assist in providing healthcare to a patient (e.g. family member, friend) and acquire technical training as needed based on the tasks that must be performed. Cohorting. In the context of this guideline, this term applies to the practice of grouping patients/residents infected or colonized with the same infectious agent together to confine their care to one area and prevent contact with susceptible patients/residents (cohorting patients/residents). During outbreaks, healthcare personnel may be assigned to a cohort of patients/residents to further limit opportunities for transmission (cohorting staff). Colonization. An individual who has been found to be culture positive at one or more body sites but who has no signs or symptoms of infection. Disinfection: The process of using chemical agents or boiling water to destroy or kill pathogenic microbes. Droplet nuclei. Microscopic particles more than 5 microns in size that are the residue of evaporated droplets and are produced when a person coughs, sneezes, shouts, or sings. These particles can remain suspended in the air for prolonged periods of time and can be carried on normal air currents in a room or beyond, to adjacent spaces or areas receiving exhaust air. Engineering controls. Removal or isolation of a workplace hazard through technology. AIIRs, a Protective Environment, engineered sharps injury prevention devices and sharps containers are examples of engineering controls. Epidemiologically important pathogens. Infectious agents that have one or more of the following characteristics: 1) are readily transmissible; 2) have a proclivity toward causing outbreaks; 3) may be associated with a severe outcome; or 4) are difficult to treat. Examples include Acinetobacter sp., Aspergillus sp., Burkholderia cepacia, Clostridium difficile, Klebsiella or Enterobacter sp., extended-spectrum-beta-lactamase producing gram negative bacilli [ESBLs], methicillin-resistant Staphylococcus aureus [MRSA], Pseudomonas aeruginosa, vancomycin-resistant enterococci [VRE], methicillin resistant Staphylococcus aureus [MRSA], vancomycin resistant Staphylococcus aureus [VRSA] influenza virus, respiratory syncytial virus [RSV], rotavirus, SARS CoV, noroviruses and the hemorrhagic fever viruses). Hand hygiene. A general term that applies to any one of the following: 1) handwashing with plain (nonantimicrobial) soap and water); 2) antiseptic hand rub (waterless antiseptic product, most often alcohol-based, rubbed on all surfaces of hands); or 3) surgical hand antisepsis (antiseptic hand wash or antiseptic hand rub performed preoperatively by surgical personnel to eliminate transient hand flora and reduce resident hand flora).
Page 195
Healthcare-associated infection (HAI). An infection that develops in a patient who is cared for in any setting where healthcare is delivered (e.g. acute care hospital, chronic care facility, ambulatory clinic, dialysis center, surgicenter) and is related to receiving healthcare (i.e. was not incubating or present at the time healthcare was provided). In ambulatory and home settings, HAI would apply to any infection that is associated with a medical or surgical intervention within the previous one year. Since the geographic location of infection acquisition is often uncertain, the preferred term is considered to be healthcare-associated rather than healthcare-acquired. Healthcare personnel, healthcare worker (HCW). All paid and unpaid persons who work in a healthcare setting (e.g. any person who has professional or technical training in a healthcare-related field and provides patient care in a healthcare setting or any person who provides services that support the delivery of healthcare such as dietary, housekeeping, engineering, maintenance personnel). Hematopoietic stem cell transplantation (HSCT). Any transplantation of blood or bone marrow-derived hematopoietic stem cells, regardless of donor type (e.g. allogeneic or autologous) or cell source (e.g. bone marrow, peripheral blood, or placental/umbilical cord blood); associated with periods of severe immunosuppression that vary with the source of the cells, the intensity of chemotherapy required, and the presence of graft versus host disease (MMWR 2000; 49: RR-10). High-efficiency particulate air (HEPA) filter. An air filter that removes more than 99.97% of particles more than 0.3 microns (the most penetrating particle size) at a specified flow rate of air. HEPA filters may be integrated into the central air handling systems, installed at the point of use above the ceiling of a room, or used as portable units (MMWR 2003; 52: RR-10). Home care. A wide-range of medical, nursing, rehabilitation, hospice and social services delivered to patients/residents in their place of residence (e.g. private residence, senior living center, assisted living facility). Home health-care services include care provided by home health aides and skilled nurses, respiratory therapists, dieticians, physicians, chaplains, and volunteers; provision of durable medical equipment; home infusion therapy; and physical, speech, and occupational therapy. Immunocompromised patients/residents. Those patients/residents whose immune mechanisms are deficient because of congenital or acquired immunologic disorders (e.g. human immunodeficiency virus [HIV] infection, congenital immune deficiency syndromes), chronic diseases such as diabetes mellitus, cancer, emphysema, or cardiac failure, ICU care, malnutrition, and immunosuppressive therapy of another disease process [e.g. radiation, cytotoxic chemotherapy, anti-graft-rejection medication, corticosteroids, monoclonal antibodies directed against a specific component of the immune system]). The type of infections for which an immunocompromised patient has increased susceptibility is determined by the severity of immunosuppression and the specific component(s) of the immune system that is affected. Patients/residents undergoing allogeneic HSCT and those with chronic graft versus host disease are considered the most vulnerable to HAIs. Immunocompromised states also make it more difficult to diagnose certain infections (e.g.
Page 196
tuberculosis) and are associated with more severe clinical disease states than persons with the same infection and a normal immune system. Infection. The condition when an organism (bacterial, viral, or parasitic) has entered a body site, is multiplying in tissue, is causing the clinical manifestations of disease, such as fever, suppurative wound, or pneumonia, and is documented by positive cultures, such as from blood, sputum, wound or urine cultures Infection Control Practitioner (ICP). A person whose primary training is in either nursing or epidemiology and who has acquired special training in infection prevention and control. Responsibilities may include collection, analysis, and feedback of infection data and trends to healthcare providers; consultation on infection risk assessment, prevention and control strategies; performance of education and training activities; implementation of evidencebased infection prevention and control practices or those mandated by regulatory and licensing agencies; application of epidemiologic principles to improve patient outcomes; participation in planning renovation and construction projects (e.g. to ensure appropriate containment of construction dust); evaluation of new products or procedures on patient outcomes; input into or collaboration with employee health services related to infection prevention; implementation of preparedness plans; communication within the healthcare setting, with local and Provincial health departments, and with the community at large concerning infection prevention and control issues; and participation in research. Certification in infection control (CIC) is available through the Certification Board for Infection Control. Infection prevention and control program. A multidisciplinary program that includes a group of activities to ensure that recommended practices for the prevention of healthcareassociated infections are implemented and followed by Healthcare Workers, making the healthcare setting safe from infection for patients/residents and healthcare personnel. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires the following five components of an infection prevention and control program for accreditation: 1) surveillance: monitoring patients/residents and healthcare personnel for acquisition of infection and/or colonization; 2) investigation: identification and analysis of infection problems or undesirable trends; 3) prevention: implementation of measures to prevent transmission of infectious agents and to reduce risks for device- and procedure-related infections; 4) control: evaluation and management of outbreaks; and 5) reporting: provision of information to external agencies as required by local and Provincial law and regulation (www.jcaho.org). The infection prevention and control program staff has the ultimate authority to determine infection prevention and control policies for a healthcare organization with the approval of the organizations governing body. Long-term care facilities (LTCFs). An array of residential and outpatient facilities designed to meet the bio-psychosocial needs of persons with sustained self-care deficits. These include skilled nursing facilities, chronic disease hospitals, nursing homes, foster and group homes, institutions for the developmentally disabled, residential care facilities, assisted living facilities, retirement homes, adult day healthcare facilities, rehabilitation centers, and longterm psychiatric hospitals.
Page 197
Mask. A term that applies collectively to items used to cover the nose and mouth and includes impermeable procedure masks, surgical masks, and N95 masks (respirators). Negative Pressure Room (NPR). Also known as Airborne infection isolation room (AIIR), a negative pressure room is a single-occupancy patient-care room used to isolate persons with a suspected or confirmed airborne infectious disease. Environmental factors are controlled in NPRs to minimize the transmission of infectious agents that are usually transmitted from person to person by droplet nuclei associated with coughing or aerosolization of contaminated fluids. Negative Pressure Rooms should provide negative pressure in the room (so that air flows under the door gap into the room); and an air flow rate of 612 ACH (6 ACH for existing structures, 12 ACH for new construction or renovation); and direct exhaust of air from the room to the outside of the building or recirculation of air through a HEPA filter before returning to circulation (MMWR 2005; 54 [RR-17]). Nosocomial infection. A term that is derived from two Greek words nosos (disease) and komeion (to take care of) and refers to any infection that develops during or as a result of an admission to an acute care facility (hospital) and was not incubating at the time of admission (signs and symptoms of infection develop after 48 hours of admission). Personal protective equipment (PPE). A variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with infectious agents. PPE includes gloves, masks, respirators, goggles, face shields, and gowns. Procedure Mask. A covering for the nose and mouth that is intended for use in general patient care situations. These masks generally attach to the face with ear loops rather than ties or elastic. Unlike surgical masks, procedure masks are not regulated by the Food and Drug Administration. Protective Environment. A specialized patient-care area or room (also known as a Positive Pressure Room), usually in a hospital, that has a positive air flow relative to the corridor (i.e., air flows from the room to the outside adjacent space). The combination of high-efficiency particulate air (HEPA) filtration, high numbers (more than 12) of air changes per hour (ACH), and minimal leakage of air into the room creates an environment that can safely accommodate patients/residents with a severely compromised immune system (e.g. those who have received allogeneic hemopoietic stem-cell transplant [HSCT]) and decrease the risk of exposure to spores produced by environmental fungi. Other components include use of scrubbable surfaces instead of materials such as upholstery or carpeting, cleaning to prevent dust accumulation, and prohibition of fresh flowers or potted plants. Residential care setting. A facility in which people live, minimal medical care is delivered, and the psychosocial needs of the residents are provided for. Respirator. A personal protective device or mask worn by healthcare personnel to protect them from inhalation exposure to airborne infectious agents that are more than 5 microns in size. These include infectious droplet nuclei from patients/residents with M. tuberculosis, variola virus [smallpox], SARS-CoV), and dust particles that contain infectious particles, such
Page 198
as spores of environmental fungi (e.g. Aspergillus sp.). The CDCs National Institute for Occupational Safety and Health (NIOSH) certifies respirators used in healthcare settings. The N95 disposable particulate, air purifying, respirator/mask is the type used most commonly by healthcare personnel. Other respirators used include N-99 and N-100 particulate respirators, powered air-purifying respirators (PAPRS) with high efficiency filters; and non-powered full-face piece elastomeric negative pressure respirators. A listing of NIOSH- approved respirators can be found at http://www.cdc.gov/niosh/npptl/topics/respirators. Respirators must be used in conjunction with a complete Respiratory Protection Program, as required by the Occupational Safety and Health Administration (OSHA), that includes fit testing, training, proper selection of respirators, medical clearance and respirator maintenance. Respiratory Hygiene/ Cough Etiquette. A combination of measures designed to minimize the transmission of respiratory pathogens via droplet or airborne routes in healthcare settings and should be practiced by patients/residents, healthcare workers, and visitors. The components of Respiratory Hygiene/Cough Etiquette are 1) covering the mouth and nose during coughing and sneezing, 2) using tissues to contain respiratory secretions with prompt disposal into a no-touch receptacle, 3) offering a surgical mask to persons who are coughing to decrease contamination of the surrounding environment, and 4) turning the head away from others and maintaining spatial separation, ideally more than 6 feet, when coughing. If a tissue is not available, the mouth and nose can be covered by a sleeve. These measures are targeted to all patients/residents with symptoms of respiratory infection and their accompanying family members or friends beginning at the point of initial encounter with a healthcare setting (e.g. reception/triage in emergency departments, ambulatory clinics, healthcare provider offices) (Srinivasin A ICHE 2004; 25: 1020 Routine Practices (previously known as Standard or Universal Precautions). A group of infection prevention practices that apply to all patients/residents, regardless of suspected or confirmed diagnosis or presumed infection status. Routine Practices are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. Routine Practices include hand hygiene, and depending on the anticipated exposure, use of gloves, gown, mask, eye protection, or face shield, as well as safe injection practices. Also, equipment or items in the patient environment likely to have been contaminated with infectious blood or body fluids must be handled in a manner to prevent transmission of infectious agents (e.g. wear gloves for handling, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient). The application of Routine Practices during patient care is determined by the nature of the HCW-patient interaction and the extent of anticipated blood, body fluid, or pathogen exposure. For some interactions (e.g. performing venipuncture), only gloves may be needed; during other interactions (e.g. intubation), use of gloves, gown, and face shield or mask and goggles is necessary. Education and training on the principles and rationale for recommended practices are critical elements of Routine Practices because they facilitate appropriate decision-making and promote adherence when HCWs are faced with new circumstances. An example of the importance of the use of Routine Practices is intubation,
Page 199
especially under emergency circumstances when infectious agents may not be suspected, but later are identified (e.g. SARS-CoV, Neisseria meningitides). Routine Practices are also intended to protect patients/residents by ensuring that healthcare personnel do not carry infectious agents to patients/residents on their hands or via equipment used during patient care. Safety culture/climate. The shared perceptions of workers and management regarding the expectations of safety in the work environment. A hospital safety climate includes the following six organizational components: 1) senior management support for safety programs; 2) absence of workplace barriers to safe work practices; 3) cleanliness and orderliness of the worksite; 4) minimal conflict and good communication among staff members; 5) frequent safety related feedback/training by supervisors; and 6) availability of PPE and engineering controls. Source Control. The process of containing an infectious agent either at the portal of exit from the body or within a confined space. The term is applied most frequently to containment of infectious agents transmitted by the respiratory route but could apply to other routes of transmission, (e.g. a draining wound, vesicular or bullous skin lesions). Respiratory Hygiene/Cough Etiquette that encourages individuals to cover your cough and/or wear a mask is a source control measure. The use of enclosing devices for local exhaust ventilation (e.g. booths for sputum induction or administration of aerosolized medication) is another example of source control. Sterilization. The only level of asepsis that kills all microbes, including spores, viruses and TB. It includes the use of gas, chemicals, steam under pressure and radiation. Sterilization is used on medical instruments and equipment, surgical dressing, gowns, etc Surgical mask. A device worn over the mouth and nose by operating room personnel during surgical procedures to protect both surgical patients/residents and operating room personnel from transfer of microorganisms and body fluids. Surgical masks also are used to protect healthcare personnel from contact with large infectious droplets (more than 5 microns in size). Surgical masks are evaluated by the FDA using standardized testing procedures for fluid resistance, bacterial filtration efficiency, differential pressure (air exchange), and flammability in order to mitigate the risks to health associated with the use of surgical masks. These specifications apply to any masks that are labelled surgical, laser, isolation, or dental or medical procedure (http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm072549.htm). Surgical masks do not protect against inhalation of smaller particles and should not be confused with particulate respirators/masks that are recommended for protection against selected airborne infectious agents, (e.g. Mycobacterium tuberculosis). Unit closure a unit or area is closed to admissions and transfers in
References:
Page 200
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: preventing Transmission of Infectious Agents in Healthcare Settings, June 2007
Page 201
APPENDIX C: Specific Cleaning Instructions

A. Procedure for Cleaning Agitator Tubs/Hydrotherapy Tanks
Prior to cleaning an agitator tub it is important to don PPE (Personal Protective Equipment). Nursing Responsibilities (between patient use): drain dirty water close drain and start filling tub when water level, covers half of whirlpool intake, turn on whirlpool pump motor turn water off when water starts to surge out the whirlpool outlet add manufacturer approved disinfectant (MAP) to water in the bottom of tub (follow manufacturers directions on concentration and amount) and let the whirlpool run for one minute wash/scrub the interior of tub with brush/mop and the disinfectant in tub swing chair over tub and clean with disinfectant drain the system shower down interior of tub and chair with clean water and back flush the pump wipe down chair with clean cloth. End of the Day Cleaning (Housekeeping Staff) fill tub with water to point midway between chair and overflow add manufacturers approved cleaning agent at appropriate strength to the water lower chair into water activate whirlpool for 3 5 minutes scrub and clean all surfaces of chair(s) rinse the chair thoroughly and drain the tub drain the system shower down interior of tub and chair with clean water and back flush the pump wipe down chair with clean cloth
B.
Procedure for Cleaning Fans
Fans must not be used in Acute Patient Care settings. When fans are used in other settings, they must have a removable fan blade grill cover. When the fan is no longer required, or at a minimum once per month, the grill cover must be removed and the fan blades cleaned with the approved disinfectant wipes. When the grill is replaced, all surfaces of the fan including the base and electrical cord are cleaned and sanitized. A dust cover is placed over the fan head. The fan must be sent to Facilities Maintenance and Operations annually for inspection and maintenance.
Page 202
C.
Procedure for Cleaning Commodes
Nursing Responsibilities Contact surfaces of the commode (seat, armrests, and basin) must be cleaned and sanitized following each patient use. The approved disinfectant ready to use wipes must be readily available for this purpose. When a commode dedicated for patient use is no longer required by the patient, housekeeping is notified and a completed Housekeeping: cleaning and disinfection required sign is placed on the chair to prevent use by another patient. (A sign is being developed.) Housekeeping Responsibilities Upon notification by nursing staff, the commode will be removed from circulation and taken for cleaning and disinfection. Chairs that are constructed to withstand power washing or automated washing in a machine designed for this purpose may be processed in this manner, where such equipment is available. When manual cleaning is done, all surfaces must be cleaned and then disinfected.
NOTE: If the chair is found to be in a state of disrepair or surfaces are cracked, the chair cannot be adequately cleaned. This must be brought to the attention of the nursing manager or leader so that repair or replacement can be facilitated.
D.
Procedure for Cleaning Suction Regulators
Procedure for ensuring safe Infection Prevention and Control practices to ensure appropriate use of wall mounted suction equipment: Hard Plastic Reusable Suction Canisters with fixed red tubing and fixed wall attachment along with the single-use inner liners, red lids, and sealed suction tubing packages are placed in all patient rooms. If used during the patients admission, the Hard Plastic Reusable Suction Canister with fixed red tubing and wall attachment is taken to the Dirty Utility Room cleaned and returned to the patient bedside. The single-use inner liners, red lids, and suction tubing are removed and discarded upon discharge. A new single-use liner and red lid is placed within the clean hard outer canister and a new sealed suction tubing package is placed at the bedside. Hard Plastic Reusable Suction Canister with fixed red tubing and fixed wall attachment with single-use inner liners and red lids within patient rooms that are not used are surface wiped at discharge. The outside of the sealed suction tubing packaging is surface wiped upon patient discharge. The sealed suction tubing packaging is an indicator that the suction bottle was NOT used. If the Hard Plastic Reusable Suction Canister with fixed red tubing and wall
Page 203
attachment and the single-use inner liners and red lids are clean and the suction tubing package is open, discard the suction tubing Within the Endoscopy suite, staff will cleans the Hard Plastic Reusable Suction Canisters with fixed red tubing and fixed wall attachment and discard the single-use inner liners, red lids, and the suction tubing between every patient case. N.B. The Hard Plastic Reusable Suction Canisters with fixed red tubing and fixed wall attachment are manufactured and sold as a reusable item. The Suction Canister inner liners and sealed suction tubing packages are manufactured, sold, and labeled as single-use items (i.e. one patient only).
E.
Ice Bag
Procedure for Cleaning and Use of Hot/Cold Pack and Ice Bags
Disposable bags designed to accommodate ice cubes and then secured, for use within the health care setting. These bags, from an IC perspective, are recommended for use when there is potential for exposure to blood, body fluids and/or mucus membranes. These are single patient use items. Hot/Cold pack A re-usable, gel-filled pack which is marketed for use on any part of the body. Manufactures advocate storage within a freezer until use. These packs, from an IC perspective, are recommended for use when there is no risk of exposure to blood, body fluids and/or mucus membranes. Decontamination of these products will be in conjunction with the manufacturers instructions and IC recommendations. Infection Control Recommendations: Having contacted the companies of products currently purchased through VIHA, it was established that written manufacturers cleaning instructions for the re-useable products are not currently available. As some of these products, according to the MSDS sheets are incompatible with strong oxidizers (e.g. Chlorine, Peroxides, etc.) the products will be cleaned with an alcohol surface disinfectant wipe which has a cleaning element included (e.g. Cavi Wipe). It is not known whether using these decontamination guidelines will, in time, compromise the integrity of the product. It is cautioned that the product shall be inspected prior to each use to ensure that there are no breaches in the product fabrication which may result in leakage of the internal material or make the pack difficult to decontaminate appropriately.
Page 204
Table 29 - Products currently acquired through VIHA purchasing department:

CI/NI MEDITECH # 0042414 0052916 South Island AMS # Current Item Description Normalized Vendor Current Product Code 66018 88016 Cleaning
PACK INSTANT COLD DISP 20/CS 6X9IN ICE PACK RIGID 4 X 6.8" 24/CA ICE PACK RIGID 8 X 8" 24/CS PACK,ICE,LGE,TECNOL PACK HOT/COLD REUSABLE 24/C 2498610 6X10IN ICEPACK
STEVENS STEVENS
Single use only Decontaminate following above recommendations Decontaminate following above recommendations Single patient use Decontaminate following above recommendations
0052917
STEVENS CARDINAL HEALTH CARDINAL HEALTH
88046
0001652
KC33500
0007872
6E+09
RAP12259
F.
Recommendations for Bath Mats Prior to Purchase
Products Reviewed AMG Medical Inc. Small Bath Mat containing dry natural rubber. This product has suction cups on the underside of the mat to secure it to the bath/floor, these will make cleaning difficult. The manufacturer provides the option of machine washing. Stevens Sure-Step Bath Mat made from poly-vinyl chloride (PVC). This product is a tubular construction which does not provide easy access to all surfaces ensuring an appropriate clean/decontamination of the product has occurred. IPC Product Recommendation Of the two products reviewed, the Aquasense product was the preferred option as there were concerns with the tubular construction of the Stevens Sure-Step Bath Mat and its ability to be cleaned/decontaminated appropriately. Cleaning/Decontamination Recommendations Ensure a written cleaning regime for these products is in place prior to purchase and instillation Follow manufacturers guidelines for cleaning product in a washing machine and hanging to dry If product cannot be cleaned using a washing machine: o Thoroughly clean all surfaces using detergent and water o Hang to dry after each use
Page 205
RECENT CHANGES/ADDITIONS
February 7, 2013 minor word updates to Table 12 and Table 15 January 7, 2013 Table 17 has been updated for content and structure November 9, 2012 update to the Soiled Linen section (bullet #4 used to say Roll linen carefully into itself. Avoid shaking or fluffing October 12, 2012 Addition of procedures for negative pressure rooms after patient discharge or transfer Update to Table 16 to keep in line with the MRSA Policy for patients in Residential Care Update to Vanity Top fixture section Addition of fixture section on Hand Wash Facilities Update to Table 21 to keep in line with the ILI algorithms September 17, 2012 Update to Table 15 - ARO Screening and Collecting Swabs July 31, 2012 Update to the information surrounding negative pressure rooms July 13, 2012 Cleaning of Isolation Carts Specific nursing responsibilities in the Housekeeping processes Discontinuation of additional precautions June 15, 2012 Clarification on the use of non-disposable household utility gloves Hot/Cold Pack and Ice Bags May 11, 2012 Addition of Recommendations for Bath Mats Prior to Purchase Addition of Play Equipment and Toys section April 13, 2012 Table 10 indicates Precaution Clean is to be used for all types of precautions Type 4 has been added to the parainfluenza row in Table 18 Respiratory Infections Precaution Clean and Precaution Plus Clean replaces 2-Step and Routine Plus Clean March 13, 2012 Part 4 - Housekeeping has been completely revised January 4, 2012 updated hyperlinks to Policy 15.3 Management of Patients with VRE (Acute and Residential)
Page 206

Infection Control Manual

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Infection Control Manual

Uploaded by

Copyright:

Available Formats

INFECTION PREVENTION AND CONTROL MANUAL

VIHA Infection Prevention and Control Manual, February 7, 2013

PART 2: UNDERSTANDING HOW INFECTIONS ARE SPREAD ...................... 9

Causative Agents ............................................................................................... 10 Reservoirs .......................................................................................................... 11

Portal of Exit ....................................................................................................... 12 Transmission ...................................................................................................... 13

Portal of Entry ..................................................................................................... 14 Susceptible Host................................................................................................. 15

PART 3: INFECTION PREVENTION AND CONTROL PRACTICES AND PRECAUTIONS................................................................................................. 18

VIHA Infection Prevention and Control Manual, February 7, 2013

Risk Reduction ................................................................................................... 22

VIHA Infection Prevention and Control Manual, February 7, 2013

6. Safe Handling of Sharps ......................................................................................... 36 7. Decontamination ..................................................................................................... 37

SUMMARY OF PRECAUTIONS ........................................................................ 64

Discontinuing Additional Precautions ................................................................. 68

VIHA Infection Prevention and Control Manual, February 7, 2013

EVALUATING PRODUCTS ................................................................................ 77

PART 5: ANTIBIOTIC RESISTANT ORGANISMS............................................ 78

4. ARO Screening and Collecting Swabs ....................................................................... 80

6. ARO Room Placement ............................................................................................... 83

7. Key Management Issues ............................................................................................ 85

PART 6: OUTBREAK MANAGEMENT ............................................................. 91

VIHA Infection Prevention and Control Manual, February 7, 2013

Reporting a Suspected Outbreak ....................................................................... 92

Influenza-Like Illness (ILI) Outbreaks ................................................................. 95

Gastrointestinal Illness (GI) Outbreaks ............................................................. 106

Outbreaks Caused by Other Organisms ........................................................... 115

PART 7: DEPARTMENTAL GUIDELINES ...................................................... 120

VIHA Infection Prevention and Control Manual, February 7, 2013

7. Respiratory Department Guidelines .......................................................................... 159

PART 8: Specific Procedural Recommendations ............................................ 162

APPENDICES ................................................................................................. 170

Recommendations for Bath Mats Prior to Purchase ......................................... 205

VIHA Infection Prevention and Control Manual, February 7, 2013

Scope of the Document

VIHA Infection Prevention and Control Manual, February 7, 2013

PART 2: UNDERSTANDING HOW INFECTIONS ARE SPREAD

Figure 1: Chain of Infection

Infectious Agents Susceptible Host

VIHA Infection Prevention and Control Manual, February 7, 2013

Causative organisms can be eliminated by several methods, including:

VIHA Infection Prevention and Control Manual, February 7, 2013

VIHA Infection Prevention and Control Manual, February 7, 2013

Table 1: Human Reservoirs and Transmission of Infectious Agents

Skin and Soft Tissue

Drainage from a wound or incision

Reproductive tract and genitalia

Urine, semen, vaginal secretions

Droplets from sneezing or coughing

Vomitus, feces, bile, saliva

VIHA Infection Prevention and Control Manual, February 7, 2013

VIHA Infection Prevention and Control Manual, February 7, 2013

4. Common Vehicle Transmission

5. Vector Borne Transmission

VIHA Infection Prevention and Control Manual, February 7, 2013

VIHA Infection Prevention and Control Manual, February 7, 2013

VIHA Infection Prevention and Control Manual, February 7, 2013

Routine Practices are to be applied at ALL times by ALL staff.

VIHA Infection Prevention and Control Manual, February 7, 2013

PART 3: INFECTION PREVENTION AND CONTROL PRACTICES AND PRECAUTIONS

VIHA Infection Prevention and Control Manual, February 7, 2013

VIHA Infection Prevention and Control Manual, February 7, 2013

Figure 2: Risk Assessment Decision Tree - Acute Care

VIHA Infection Prevention and Control Manual, February 7, 2013

Table 2: Risk Assessment

Diarrhea NYD Draining infected wounds