INFECTION PREVENTION & CONTROL MANUAL Updated: March 2013
Disclaimer
The Interior Health Infection Prevention & Control Manual (the Manual) is intended as a reference document only. The Manual represents Interior Health’s guidelines and does not imply directly or indirectly that non Interior Health programs or facilities are bound by the guidelines. While non IH users are encouraged to develop their own infection prevention and control guidelines, these individual groups may choose to adopt the guidelines in the Manual as their own provided all references to Interior Health are removed. The most up-to-date version of the Manual is the electronic copy on the website. If a paper copy is being maintained it is the responsibility of the users to ensure they have the most current best practise information to guide their treatments and interventions. The Manual (paper or electronic version) and all the information it contains is provided “as is” without warranty of any kind, whether expressed or implied. All implied warranties, including, without limitation, implied warranties of merchantability, fitness for a particular purpose, and non-infringement, are hereby expressly disclaimed. Limitation of Liabilities Under no circumstances will the Interior Health Authority be liable to any person or business entity for any direct, indirect, special, incidental, consequential, or other damages based on any use of the Manual, including, without limitation, any lost profits, business interruption, or loss of programs or information, even if the Interior Health Authority has been specifically advised of the possibility of such damages.
Summary of Changes to Infection Prevention & Control Manual
March 2013
• The Revised IH Infection Prevention & Control Manual is now available and can be found on the
• • • •
InsideNet at Clinical Resources or Policies & Procedures or Quality & Patient Safety and on the Internet at http://www.interiorhealth.ca/AboutUs/QualityCare/Pages/InfectionControl.aspx All staff are expected to use the “on line” copy of the manual which contains the most up to date information. There will be one “hard copy” of the manual available at each Acute and Residential site in the event that the electronic copy cannot be accessed. Please refer to the table below for: “New” and “Revised” guidelines that have been added to the manual. The paper version of this manual will also be updated. Please note – highlighted sections have pending updates.
R= Revised N = New
Section(S) Revised
Throughout the manual: • •
The term “patient” is inclusive of patient, resident & client. There are links to signage and other tools on the insideNet – Infection Prevention & Control Home page.
Section 1B – Introduction – no revisions made Section 03F – Routine Practices Revisions include: IF0100: Routine Practices for all Care Areas
R/N
Revision: 4.1 Point of Care Risk Assessment - Healthcare providers need to assess the risk of exposure to blood, body fluids and non-intact skin before each interaction with a patient or their environment. Addition: 4.7 Administrative Control – added aseptic technique and aerosol-generating medical procedures. New visual aids for Putting on PPE and Taking off PPE.
IF0200: Hand Hygiene Guidelines
R/N
Addition: Reference to AH0700 Hand Hygiene Administrative Policy Purpose: Hand hygiene aslo referred to as ‘hand cleaning’ Guiding Principles: 3.4 Hand hygiene infrastructure information 3.6 Hand hygiene with the ABHR or soap and water can be used for patients with C. difficile. Procedure: 4.10 Education – on line education module for all staff – to be done upon orientation and when hand hygiene compliance rates fall below 59% on their specific unit
R= Revised N = New IF0300: Waste Management
R/N
Section(S) Revised
Addition: Guiding Principles: 3.3 Anatomical waste to be placed in Red container. Contents of drainable devices can be emptied into the sewer. Added ‘contaminated scissors, razors or contaminated glass’ to Sharps category. Procedure: 4.9 Added link to Biomedical Waste Disposal in Community Care.
Section 04H– Additional Precautions Revisions Include: IH0100: Additional Precautions for All Care Areas
R
- table removed – refer to each specific precaution for additional information Additional Precautions for all Care Areas Table 6: Transmission Characteristics and Empiric Precautions by Clinical Presentation: Recommendations for Acute Care Centres Table 7: Transmission Characteristics and Precautions by Specific Etiology: Recommendations for Acute Care Centres
H0200: Airborne Precautions IH0300: Droplet Precautions
IH0400: Contact Precautions
.
IH0500: Protective Precautions Section 08S – Specific Diseases Revisions Include: IS0200: Clostridium difficile
R/N
New –Hand Hygiene: - ABHR or soap and water are appropriate for hand hygiene New – Environmental Cleaning: - use sporicidal product (4.5% AHP - accelerated hydrogen peroxide) - double clean – clean once, then clean surfaces again to disinfect (contact time 10 minutes) - patient rooms cleaned twice per day using double clean – once in the morning and again in afternoon/evening New – Communication - provide daily line listings of current patients with CDI to Nursing, Housekeeping and Pharmacy
R= Revised N = New
Section(S) Revised
New – Discontinuing Contact Precautions for CDI - precautions may be discontinued when the patient has had no diarrhea for 72 hours - Housekeeping to do an Isolation Discharge Clean of patient room Revised: - Signage revised to reflect new hand hygiene guidelines - CDI Outbreak additional environmental cleaning IS0300: Antibiotic Resistant Organisms (ARO)
.
IS0500A: Tuberculosis IS0600: Chickenpox (Varicella-Zoster) and Herpes Zoster (Shingles) IS0900: Creutzfeldt-Jakob Disease IS1000: Respiratory Syncytial Virus (RSV)
R
Simplified the Procedure table
R
Removed ‘blood’ from infectious materials (2.2)
R
Revision: 1.0 Guideline applies to all patients, regardless of age 2.0 Definition less focused on infants/children
IS1200: Measles
N
Provides overview of measles, reporting and follow up of cases and contacts
IS1300: Mumps
N
Provides overview of mumps, reporting and follow up of cases and contacts
IS1400: Bed Bugs
N
Provides guidelines for identification and implications in acute, residential, home and community care
Section 09V – Surveillance and Outbreak Revisions include: IV0200: Definitions for Healthcare Associated Infections IV0400: Gastrointestinal Outbreak (GI) Guidelines
Revision: 4.1 Surgical Site Infections definitions revised to meet CDC/NHSN 2008 document
R
R
Revision/Additions: Title has been changed from IH GI Outbreak Guidelines to IH Health Care Facilities Gastrointestinal Outbreak Guidelines Added Table of Contents Case definition now includes: a bloody episode of diarrhea; and one episode each of vomiting and diarrhea in a 24 hours period Under Placement of patient/resident added Restriction of Units which provides clearer recommendations e.g. patient/residents transfers in ill and well wings Cleaning vomit and faeces, recommendation to disinfect the area in a 25 foot radius has been reduced to a 2 metre radius. Recommendations for cleaning solutions remain the same
R= Revised N = New
Section(S) Revised
Revised GI Outbreak Summary Report - used for initial reporting, daily reporting and summary reporting when outbreak is declared over IV0500: Respiratory Outbreak (RI) Guidelines
R
Addition: Includes 3 Scenarios of different types of RI Outbreaks and actions to take including: • Scenario A – More severe respiratory illness known or suspected to be due to influenza • Scenario B – More severe respiratory illness known or suspected to be due to non-influenza viral or bacterial infectious cause • Scenario C – Milder respiratory illness, known or suspected to be due to other non-influenza viral pathogens, most commonly rhinovirus and coronavirus Revisions: Revised RI Outbreak Summary Report form – used for initial reporting, daily reporting and summary reporting when outbreak is declared over A recent serum creatinine or creatinine clearance is not required before starting oseltamivir, unless there is reason to suspect significant renal impairment – preprinted orders have been changed to reflect this update
IV0600: Communicable Diseases in Employees
R/N
Addition: 3.1 Added Conjunctivitis to section “Employees must be evaluated by Employee Health or their private physician regarding their work area if they have certain signs or symptoms of the following conditions” New Communicable Disease Exposure Notification Tool
Section10X – Best Practices – IX0600 Recommendations for Rehabilitation Services removed and information incorporated into Routine Practices, Additional Precautions and ARO Guidelines New: IX0600 Cleaning Equipment Revisions include: IX0200: Prevention and Control of Catheter Associated Urinary Tract Infections (CAUTI) IX0300: Pneumococcal Vaccine for Residential Care
R
3.4 It is recommended that facilities carry out yearly audits to ensure the procedure for administering and documenting pneumococcal vaccination in Residential Care Facilities is being implemented appropriately with the target being at least a 90% vaccination coverage compliance rate.
IX0600: Cleaning Equipment
N
Summary of principles for cleaning and table of processes for cleaning equipment
IX0900: Construction Projects – previously called Construction and Renovation Guidelines IX1000: Construction and Renovation Guidelines –
R/N
Added foot care equipment and additional breast pump information Updated to reflect new CSA Z8000 standard
R/N
ICP must be given minimum 48 hours notice by anyone requesting a permit before the scope of work can be assessed and a permit issued. Updated to reflect new CSA Z8000 standard
R= Revised N = New previously IX0900
IX1100: Contractor Procedures and Information – previously part of IX0900 and now separated out
Section(S) Revised
ICP must be given minimum 48 hours notice by anyone requesting a permit before the scope of work can be assessed and a permit issued.
R
Added APPENDIX 4 Quick Reference Guide for CSA Z8000-11 Guidelines No changes made to content of guideline ICP must be given minimum 48 hours notice by anyone requesting a permit before the scope of work can be assessed and a permit issued.
TABLE OF CONTENTS MANUAL INTRODUCTION IB0100: Interior Health Infection Prevention & Control Program ROUTINE PRACTICES IF0100: Routine Practices for All Care Areas IF0200: Hand Hygiene Guidelines IF0300: Waste Management ADDITIONAL PRECAUTIONS IH0100: Additional Precautions for All Care Areas IH0200: Airborne Precautions IH0300: Droplet Precautions IH0400: Contact Precautions IH0500: Protective Precautions SPECIFIC DISEASES IS0100: Reportable Communicable Diseases IS0200: Clostridium difficile IS0300: Antibiotic Resistant Organisms (ARO) IS0400: Scabies/Lice IS0500A: Tuberculosis IS0500B Tuberculosis Risk Screening – Residential Facilities IS0600: Chickenpox (Varicella-Zoster) and Herpes Zoster (Shingles) IS0700: Invasive Group A Streptococcal Infections (IGAS) IS0800: Meningococcal Infection IS0900: Creutzfeldt-Jakob Disease IS1000: Respiratory Syncytial Virus (RSV) IS1100: Rabies IS1200: Measles IS1300: Mumps IS1400: Bed Bugs SURVEILLANCE AND OUTBREAKS IV0100: Surveillance for Healthcare Associated Infections IV0200: Definitions for Healthcare Associated Infections IV0300: Surgical Site Infections (SSIs) IV0400: Gastrointestinal Outbreak Guidelines IV0500: Respiratory Infection (RI) Outbreak Guidelines IV0600: Communicable Diseases in Employees BEST PRACTICES IX0100: Microbiology Specimen Collection IX0200: Prevention & Control of Catheter Associated Urinary Tract Infections (CAUTI) IX0300: Pneumococcal Vaccine for Residential Care IX0400: Pet Therapy and Visitation IX0500: Soiled Utility Rooms IX0600: Equipment Cleaning IX0700: Toy Management IX0800: Personal Care Supplies Best Practice Guidelines IX0900: Construction Projects IX1000: Construction & Renovation Guidelines IX1100: Contractor Procedures & Information
CROSS REFERENCE A Acute Care Plan for (ARO’s) Acute Care Plan for Clostridium difficile Additional Precautions for all Care Areas Table 6: Transmission Characteristics and Empiric Precautions by Clinical Presentation: Recommendations for Acute Care Centres
IS0300 IS0200 IH0100
Acute Care Admission Screening Form #807910
IH0200
• •
Table 7: Transmission Characteristics and Precautions by Specific Etiology: Recommendations for Acute Care Centres Airborne Precautions
• Antibiotic Resistant Organisms for Acute Care
IS0300
Antibiotic Resistant Organisms for Residential Care • Residential Care Plan Antimicrobial Resistant Organisms (ARO) Precautions for Community Care Antimicrobial Resistant Organisms (ARO) Antimicrobial Resistant Organisms (ARO) Residential Care
IS0300
Airborne Precautions Sign #807900 Airborne / Contact Precautions Sign #807901 Airborne Communicable Disease Algorithm #807907
IS0300 IS0300 IS0300
B C CCARO (Community Care Antibiotic Organisms) Care Plan – Resident with CDI Care Plan – Acute Care with CDI Care Plan – Acute for AROs
IS0300
Care Plan – Residential for AROs Care Plan – Community for AROs Chickenpox and Herpes Zoster (Shingles) Catheter Associated Urinary Tract Infections (CAUTI) Clostridium difficile
IS0300 IS0300 IS0600 IX0200
Clostridium difficile – Resident with CDI
IS0200 IV0400
Collection of Specimens in a
IS0200 IS0200 IS0300
IS0200
Clostridium difficile Contact Precautions Sign #807914
Gastroenteritis Outbreak Common Agents and Illness – Gastroenteritis (GI) Illness Community Care Plan for AROs Communicable Diseases in Employees Construction Projects
IV0400 IS0300 IV0600 IX0900
Construction & Renovation Guidelines Contractor Procedures & Information Contact Precautions
IX1000 IX1100 IH0400
Creutzfeldt-Jakob Disease
IS0900
Contact Precautions Sign #807902
D Definitions of Health Care Associated Infections Droplet Precautions for Acute Care
IV0200 IH0300
E Equipment Cleaning Exposure – Blood and Body Fluid (see IH Policy AV0300)
G Gastroenteritis Illness Outbreak guidelines
IV0400
H Hand Hygiene Guidelines Herpes Zoster
IF0200 IS0600
HIV Exposure (see IH Policy AV0300) I Interior Health Infection Prevention & Control Program Influenza Immunization Policy for Employees (See IH Policy AV1300) Influenza Like Illness Outbreak
IB0100
Invasive Group A Streptococcal Infections (IGAS)
IS0700
IV0500
L Lice/Scabies
IS0400
M Meningococcal Infection
IS0800
• •
Droplet Precautions Sign #807903 Droplet / Contact Precautions #807904
Microbiology Specimen Collection
IX0100
N Needlestick Exposure (see IH Policy AV0300) O Outbreak Facility Sign
IV0400
•
Form #807909
P Personal Care Supplies Best Practice Guideline Pet Therapy and Visitation Pneumococcal Vaccine for Residential Care Prevention & Control of Catheter Associated Urinary Tract Infections (CAUTI) Protective Precautions
IX0800 IX0400 IX0300 IX0200
IH0500
Protective/Reverse Isolation Precautions Private Room Sign #807095
Q Quick Reference Guide – Respiratory Illness Outbreak Quick Reference Guide for GI Outbreaks
IV0500 IV0400
R Rabies Reference guide – Respiratory Illness Outbreak Reference Guide for GI Outbreaks Renovation Guidelines, Construction and Reportable Communicable Diseases
IS1100 IV0500
Residential Care Plan ARO Residential Care Plan Clostridium difficile
IS0300 IS0200 IV0500 IS1000 IF0100
Respiratory Infection (RI) Outbreak Respiratory Syncitial Virus (RSV) Routine Practices for all Care Areas Routine Screening for Antibiotic Resistant Organisms (AROs) form
IV0400 IX0900 IS0100
IS0300
S Scabies/Lice
IS0400
Schedule A (Reportable Communicable Diseases) Shingles
IS0100 IS0600
Schedule A - List of Reportable Communicable Diseases in BC
Soiled Utility Rooms Specimen, Collection of Gastroenteritis Outbreak Specimen, Transport of Surgical Site Infections Surveillance of Health Care Associated Infections
IX0500 IV0400 IV0400 IV0300 IV0100
T Toy Management
IX0700
Transmission Characteristics and Empiric Precautions by Clinical Presentation: Recommendations for acute Care Centres (Table 6) Transmission Characteristics and Precautions by Specific Etiology: Recommendations for Acute Care Centres (Table 7) Transportation of Patients on Isolation or Additional Precautions Tuberculosis
IH0100
IH0100
IH0100 IS0500A IS0500B
U Urinary Tract Infections (Prevention of)
IX0200
W Waste Management
IF0300
MANUAL INTRODUCTION 1.0
PURPOSE The Manual has been prepared to assist healthcare providers in implementing infection prevention and control best practice strategies across the continuum of care. The principles and guidelines set out in the Manual are based on published best practices, national and international, which have been modified to reflect the specific needs of Interior Health (IH). The Manual will be updated as best practices evolve, and the most current edition will be posted on the web. I.H FACILITY
INFECTION PREVENTION & CONTROL WEBSITE.
NON I.H. FACILITY
INTERIOR HEALTH WEBSITE
This document covers acute, residential, and community care settings and programs. Note: In this document the term “patient” is inclusive of patient, resident & client. The implementation of routine infection control principles applies to all healthcare providers and patients in all healthcare settings all the time. The goal of infection control practices is to reduce the risk of transmission of infectious microorganisms in all healthcare settings by: • Understanding the concepts of the chain of transmission; • Understanding the concepts and application of Routine Practices (RP); • Knowing why and when to use Additional Precautions (AP); and • Appropriately using, applying and removing personal protective equipment (PPE) when indicated for the protection of the patient or the healthcare provider. 2.0
DEFINITIONS Aseptic Technique – refers to practices designed to render the patient’s skin, supplies and surfaces maximally free from microorganisms. Such practices are required when performing procedures that expose the patient’s normally sterile sites e.g., intravascular system, spinal canal, subdural space, and urinary tract, in such a manner to keep them free of microorganisms. Community- Acquired Infections – infections present or incubating at the time of admission to a healthcare facility or program with no association to a recent hospitalization. Health Care Associated Infection (HAI) – an infection that is not present or incubating at the time of admission to a healthcare facility or program but is associated with admission to or a procedure performed in a the facility or program. Infection – occurs when microorganisms invade a body site, multiply in tissue and cause clinical manifestations of local or systemic inflammation (e.g. fever, redness, heat, swelling, pain, etc.) PPE – personal protective equipment are barriers used by healthcare providers to protect mucous membranes, airways, skin and clothing from exposure to blood and body fluids.
Infection Prevention & Control Manual Note: In this document the term “patient” is inclusive of patient, resident & client.
Introduction -1
3.0
GUIDING PRINCIPLES
FIGURE 1 - The Chain of Infection – How Microorganisms are Spread
Disclaimer for Figure 1 and 2 This was developed by the Provincial Infectious Diseases Advisory Committee (PIDAC). PIDAC is a multidisciplinary scientific advisory body who provide to the Chief Medical Officer of Health evidence-based advice regarding multiple aspects of infectious disease identification, prevention and control. PIDAC’s work is guided by the best available evidence and updated as required. Best Practice documents and tools produced by PIDAC reflect consensus positions on what the committee deems prudent practice and are made available as a resource to the public health and health care providers.
FIGURE 2 - An infection can be prevented by breaking any link in the chain of infection. Infection control measures are designed to break the links and thereby prevent an infection from occurring. Infection Prevention & Control Manual Note: In this document the term “patient” is inclusive of patient, resident & client.
Introduction -2
Here are the six links in the chain of infection and how these links can be broken so an infection does not occur: 1. Causative (infectious) agent including bacteria, viruses, fungi, prions and parasites • Break the link by eliminating or inactivating the agent, preventing the agent from exiting the reservoir, sterilizing surgical instruments, safe food practices, safe drinking water, vaccinations, treating infectious individuals, practicing good hand hygiene. 2. Reservoir or “home” of the infectious agent including the human body, animals and the environment (water, food) • Break the link by treating infectious individuals, vaccination, handling and disposing of body fluids appropriately, safe food practices, monitoring water for contamination. 3. Portal of exit is the path by which an infectious agent leaves the reservoir or “home” including any break in the skin or any bodily fluid such as secretions, excretions and blood. • Break the link by implementing safe practices such as covering coughs and sneezes, handling body fluids with gloves, performing appropriate hand hygiene, and containing draining wounds. Healthcare providers should not work if they have exudative (wet) lesions or weeping dermatitis. 4. Mode of transmission – how the infectious agent travels from one place to another; the mechanism for transfer of an infectious agent from a reservoir to a susceptible host. “Vectorborne” diseases are spread by insects, rodents, birds and animals. Common vehicle transmission refers to a single contaminated source such as food, multi-dose vials, intravenous fluid or equipment which serves to transmit infection to multiple hosts. The primary modes of transmission in healthcare include: • Contact – direct contact which is person to person spread or indirect contact which is contact with a contaminated surface or inanimate object to person spread. • Droplet – where large particles are produced when an infected person sneezes, talks or coughs and settle out on horizontal surfaces leading to indirect contact transmission or direct contact onto another person’s mucous membranes; droplets can travel 1 - 2 metres. • Airborne – where organisms are contained within droplet nuclei (five microns or smaller in size) or dust particles in the air and the infectious agent is widely dispersed by air currents and inhaled by a susceptible host (e.g. Tuberculosis). • Break the link by ensuring transmission between objects or people does not occur; use appropriate barriers, safe practices, spatial separation, engineering controls, hand hygiene, environmental sanitation, and equipment disinfection/sterilization. 5. Portal of entry into a susceptible host via mucous membrane, GI, respiratory or broken skin. All portals of entry have natural protective barriers. These barriers are normally effective but may allow micro organisms to enter if the barriers are damaged or if they have been compromised by invasive medical devices (e.g. catheters). • Break the link by performing appropriate hand hygiene, using aseptic technique when required, applying best practice techniques with wound and catheter care, wearing appropriate PPE, eliminating invasive devices when safe to do so and providing safe food and water. 6. Susceptible Host occurs when the normal balance between microorganisms and their host may be disturbed by chronic diseases that cause an altered immune status e.g. diabetes , infancy, old age, invasive procedures, drug therapy, poor nutrition, radiation, chemotherapy, burns, etc • Break the link by ensuring hosts are not susceptible including measures such as immunizations, good nutrition, recognition and treatment of high risk patients
Infection Prevention & Control Manual Note: In this document the term “patient” is inclusive of patient, resident & client.
Introduction -3
BY UNDERSTANDING THE CHAIN OF INFECTION, THE PROCEDURES DESCRIBED IN THIS MANUAL CAN BE APPLIED TO INTERRUPT MICROBIAL TRANSMISSION BETWEEN PATIENTS/RESIDENTS, VISITORS, AND HEALTHCARE PROVIDERS.
2.0
REFERENCE 2.1
Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care, Health Canada Infection Control Guidelines; 1999. http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/99vol25/25s4/index.html
2.2
Routine Practices and Additional Precautions In all Health Care Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; August 2009. http://www.health.gov.on.ca/english/providers/program/infectious/diseases/best_prac/bp_rou tine.pdf
2.3
Infection Prevention and Control Manual. Vancouver Island Health Authority (VIHA); 2009 http://www.viha.ca/NR/rdonlyres/18AA28E4-E3F1-4AE7-8A3FE4EC3A18D5E5/0/ipcp_manual.pdf
2.4
APIC Text 2009. http://text.apic.org/item-3/chapter-2-general-principles-epidemiology/usesof-epidemiology-in-healthcare
Infection Prevention & Control Manual Note: In this document the term “patient” is inclusive of patient, resident & client.
Introduction -4
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IB0100:
Interior Health Infection Prevention & Control Program
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010 REVIEWED DATE:
1.0
PURPOSE To protect patients, staff and visitors from infectious organisms within the healthcare environment the Interior Health Infection Prevention & Control (IPAC) Program has three principle goals: • Protect the patient. • Protect the healthcare provider, visitors and others in the healthcare environment. • Accomplish the previous two goals in a cost-effective manner whenever possible.
2.0
DEFINITIONS Healthcare Associated Infections (HAIs) – infections that are not present or incubating at the time of admission to the facility or program but are associated with admission to or a procedure performed in a healthcare facility or program.
3.0
GUIDING PRINCIPLES 3.1
The IPAC Program functions in accordance with international, national and provincial guidelines and best practices across the continuum of care.
3.2
The IPAC Program influences practice through direct actions including the following: • Manages critical data including surveillance for infections and disseminates data to appropriate stakeholders. • Develops and recommends policies, procedures and best practices in IPAC including but not limited to Routine Practices, Additional Precautions, asepsis, equipment cleaning, disinfection and sterilization, product selection and evaluation, and construction consultation as it pertains to IPAC. • Intervenes directly to prevent infections and includes liaison and consultation with community agencies and programs. • Educates and trains healthcare providers, patients and nonmedical caregivers.
3.3
A multidisciplinary IPAC Committee with representation from across the continuum of care including administration, clinical and ancillary staff acts as an advocate for the prevention and control of HAIs, to promote patient safety and provide support that empowers the implementation of best practices both at the local and corporate level of the organization.
3.4
Each multidisciplinary committee requires its own Terms of Reference that identifies its purpose, responsibilities, membership and reporting expectations to ensure appropriate dissemination of information and facilitates medical and administrative support for the IPAC Program.
Infection Prevention & Control - IB0100 Note: In this document the term “patient” is inclusive of patient, resident & client.
1
3.5
The IPAC Program provides an Annual Report which clearly identifies the goals and priority objectives of the program and the key improvements for monitoring infection prevention & control practices that have influenced practices aimed at improving safety for patients and staff and allocating IPAC resources appropriately.
Infection Prevention & Control - IB0100 Note: In this document the term “patient” is inclusive of patient, resident & client.
2
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IF0100: Routine Practices for All Care Areas
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010, December 2012 REVIEWED DATE:
1.0
PURPOSE Routine Practices are infection prevention and control practices designed to reduce the risk of blood and body fluid exposures to healthcare workers AND to prevent and control contamination and transmission of microorganisms in all healthcare settings.
2.0
DEFINITIONS
3.0
See the glossary in Appendix A for definitions. . GUIDING PRINCIPLES
Routine Practices Routine Practices are used by ALL healthcare providers for ALL patients/residents/clients in ALL settings ALL of the time
3.1
Routine Practices must be incorporated into the culture of each healthcare setting and into the daily practice of each healthcare provider.
3.2
Routine Practices apply to all BODY FLUIDS, NON-INTACT SKIN, MUCOUS MEMBRANES OR EQUIPMENT CONTAMINATED WITH BLOOD, BODY FLUIDS OR TISSUES.
3.3
A Point of Care Risk Assessment must be done by healthcare providers before each interaction with the patient or their environment to determine which interventions are required to prevent transmission of microorganisms during that interaction. • Choose patient placement or accommodation based on the risk assessment. • Choose personal protective equipment (PPE) based on the risk assessment.
3.4
PPE is used to prevent transmission of infectious agents both from patient-to-patient and from patient-to-healthcare provider. Healthcare settings must ensure sufficient supplies of, and quick, easy access to PPE is provided.
Infection Prevention & Control-IF0100 Note: in this document the term “patient” is inclusive of patient, resident or client.
Page 1
3.5
Preventing transmission of microorganisms to other patients is a patient safety issue, and preventing transmission to staff is an occupational health and safety issue. Healthcare providers are accountable to practice safely to protect patients and themselves by following organizational infection prevention and control guidelines. Just because it ‘looks’ clean doesn’t mean it isn’t contaminated by bacteria or viruses
4.0
PROCEDURE 4.1
Point of Care Risk Assessment - to be done before each interaction with a patient or their environment. Assess the patient for high risk of contaminating environment: • Uncontrolled diarrhea. • Uncontained draining wounds or skin lesions. • Uncontrolled respiratory symptoms. • Symptoms – vomiting, fever, skin rash. • Inability to clean hands or cover cough. What type of environment is high risk for patient? • Shared space (i.e.) multi-bed room, shared bathrooms. • Crowded areas such as waiting rooms, hallways. • Shared equipment.
4.2
Use avoidance procedures that minimize contact with droplets (e.g., sitting next to, rather than in front of, a coughing patient when taking a history or conducting an examination).
4.3
Hand Hygiene I.H FACILITY
REFER TO IF0200 HAND HYGIENE GUIDELINE
NON I.H. FACILITY
REFER TO IF0200 H AND HYGIENE GUIDELINE
Activity
Best Practice
Hand Hygiene
▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪
Before and after every patient/patient environment contact. After contact with blood or body fluids, soiled linen, equipment or garbage. Before and after glove use. Before performing aseptic procedures. Before handling food or medication. Before handling clean linen or supplies. After using the toilet or after toileting others. After changing an incontinence product or a child’s diaper. Prior to using computers and other electronic devices. Alcohol-based hand rub (ABHR) used routinely when hands are not visibly soiled. Soap and water used when hands are visibly soiled. Assist patients with hand hygiene before eating, after toileting and when hands are soiled. Educate visitors about hand hygiene.
Infection Prevention & Control-IF0100 Note: in this document the term “patient” is inclusive of patient, resident or client.
Page 2
4.4
Personal Protective Equipment (PPE) Determine the appropriate PPE to use that will decrease exposure risk and prevent transmission of infectious agents: includes gloves, masks, N95 respirators, eye protection, and gowns/aprons.
Activity
Best Practice
Gloves – non sterile, single use, latex free
▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪
Masks and eye protection
▪ ▪ ▪ ▪ ▪
N95 Respirators
Gowns/aprons – single use
▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪
Wear for contact with blood or body fluids, mucous membranes, draining wounds or non-intact skin (open skin lesions or rash). Wear for handling items or surfaces potentially contaminated with blood or body fluids. Gloves should be put on directly before the task for which gloves are required. Gloves must be removed and discarded immediately after the activity for which they were used. Hand hygiene must be done immediately prior to putting on gloves and after removing gloves. Gloves are not required for routine care when in contact with intact skin (e.g. bathing, dressing the patient, taking blood pressure). Gloves are not required to handle food trays and dishes. Change gloves after touching a contaminated body site and before touching a clean body site or the environment. Do not wash or re-use single use gloves. Sterile gloves are worn to protect the patient during aseptic procedures. Non-disposable household gloves are worn for tasks other than direct patient care (e.g. laundry, working with chemicals, cleaners and disinfectants). I.H. Facilities refer to the GLOVE USE FACTS & MYTHS PAMPHLET (NOT AVAILABLE TO NON IH FACILITIES). Wear to protect the mucous membranes of the nose, mouth and eyes during procedures/activities likely to generate splashes of blood, body fluids, secretions or excretions or within two metres of a coughing patient. Change mask if it becomes wet. Do not allow mask to hang or dangle around the neck. Remove mask by using ties or elastic and discard mask promptly after use. Remove and discard the eye protection after use if disposable; if re-usable, clean with a disinfectant after each use. The outside of the mask and eye protection are considered contaminated. Clean hands after removing the mask and eye protection. Do not re-use disposable masks. Prescription eye glasses are not acceptable as eye protection. Must be fit tested prior to wearing N95 respirator. Wear when caring for patients on Airborne Precautions. A single-use N95 mask must only be worn once. Wear impermeable long sleeve gown to protect uncovered skin and prevent soiling of clothing during activities likely to generate aerosolization of blood or body fluids. The gown/apron should be put on immediately before the task and must be worn properly, i.e., tied at top and around the waist. Gowns/aprons are SINGLE USE - remove promptly after use and discard in appropriate receptacle. The outside of the gown/apron is considered contaminated so hand hygiene must be done following removal.
Infection Prevention & Control-IF0100 Note: in this document the term “patient” is inclusive of patient, resident or client.
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4.6
Environmental Controls Measures implemented to reduce the risk transmission of infectious agents to patients and healthcare providers; includes patient placement and transport, patient care equipment, cleaning practices including laundry and dishes and engineering controls such as point-ofcare sharps containers and waste management.
Activity
Best Practice
Patient Placement
▪ ▪ ▪ ▪
Patient transport
Patient care equipment
▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪
Options include single patient rooms, two patient rooms and multi-bed rooms/bays. Single room with dedicated bathroom and sink preferred when there is a potential for transmission of an infectious agent (i.e.) patients with uncontrolled diarrhea Maintain a spatial separation of at least 2 meters between coughing patients and others in the room – draw the privacy curtain between beds. Cohorting a group of patients (with same disease/organism) in the same area is an option if single rooms are not available. Patient’s gown/clothing is clean. Patient has clean hands prior to going to another department. Wounds are covered with clean, intact dressings. Incontinence products are in place and intact when required. Patients who are coughing need to wear a surgical/procedure mask. ALL patient care equipment including transport equipment requires cleaning and disinfection after each use. Storage of contaminated equipment is to be in a designated area/container – usually in a Soiled Utility Room. Gross soil must be removed before the item can be cleaned and disinfected. Once items are cleaned and disinfected, they should be labeled as such, and moved to a clean storage area. Dedicate bedpans and commodes for single patient use. Clean and disinfect before use by another patient. Single use items are to be discarded, not reused. Procedures should be established for assigning responsibility for routine cleaning of all healthcare equipment. Wear appropriate PPE when handling, cleaning and disinfecting soiled equipment. Personal care supplies are single patient use items and are NOT to be shared (i.e.) soap, lotions and creams.
I.H FACILITY
•
REFER TO IX0800 PERSON CARE SUPPLIES GUIDELINE
NON I.H FACILITY
▪
REFER TO IX0800 PERSONAL CARE SUPPLIES GUIDELINE
▪
When using nursing bags in the Community settings, place soiled equipment in impervious container and do not return it to the nursing bag.
Infection Prevention & Control-IF0100 Note: in this document the term “patient” is inclusive of patient, resident or client.
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Activity
Best Practice
Environmental cleaning
▪
▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Dishes
▪ ▪ ▪ ▪ ▪
Laundry
▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪
Sharps
▪ ▪ ▪ ▪ ▪ ▪
High touch surfaces in patient care areas are cleaned and disinfected with a hospital-grade disinfectant (quaternary ammonium compound or hydrogen peroxide product) daily and more frequently if the risk of environmental contamination is higher. Floors are cleaned with a detergent product. No “re-dipping” (double dipping) of cleaning cloths in the cleaning solutions. Household utility gloves should be worn during cleaning and disinfecting procedures. Containers for liquid soap and ABHR are disposable and should not be ‘topped up’. When a patient is discharged or transferred the room or bed space must be cleaned and disinfected thoroughly before the next patient occupies the space. Do not apply cleaning chemicals by aerosol or trigger sprays. Tubs should be cleaned and disinfected after each use. Use cold water when using the disinfectant and ensure contact time of the disinfectant with all surfaces is for 10 minutes or as recommended by the manufacturer. Use gloves when handling waste/garbage. Place biohazardous waste (items saturated, dripping with blood) in appropriate biomedical waste container in the soiled utility room. Items that are broken, torn, cracked or malfunctioning need to be replaced. Use commercial dishwashers or wash with hot water and detergent for ALL dishes, including those used by patients on Additional Precautions. Disposable dishes are not required. Gloves are not required when transporting dirty dishes. If Food Service Workers identify trays that contain bodily fluids or sharps, they will bring this to the attention of the nursing staff. ALL laundry is handled the same way, including those patients on Additional Precautions. Wear appropriate PPE when handling soiled laundry (i.e. gloves and if necessary disposable gown or apron). Position hamper/tote/laundry bag in room or as close to the room entrance as possible. Ensure that laundry is free of sharps, instruments, and patient‘s personal belongings. Excrement should removed manually, not by spraying with water. Roll laundry carefully into itself. Avoid shaking or fluffing. Dirty laundry is not to be placed on the bedside tables, floor or in the sink. Place soiled laundry into leak proof bags. Laundry bags should be tied securely and not over-filled. Remove PPE after handling soiled linen and perform hand hygiene before handling clean laundry. 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. Do not recap needles. Scalpel blades must be removed using forceps. Never fill a sharps disposal container more that ¾ full. Never leave a sharp protruding from the sharps disposal container.
Infection Prevention & Control-IF0100 Note: in this document the term “patient” is inclusive of patient, resident or client.
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Activity
BEST PRACTICE
Waste Management
I.H FACILITY
Blood/body fluid spills
▪ ▪
REFER TO IF0300 WASTE MANAGEMENT GUIDELINE
NON I.H. FACILITY
▪ ▪
4.7
REFER TO IF0300 WASTE MANAGEMENT GUIDELINE Wear appropriate PPE. Absorb excess fluid with paper towels and discard in biohazardous waste container. Clean area first, and then disinfect the area with an approved hospital disinfectant. Notify Housekeeping of large spills.
Administrative/Source Controls
Activity
BEST PRACTICE
Healthcare Provider Education Patient Education
▪
Respiratory Hygiene
▪
▪
▪ ▪ ▪ Visitors
▪ ▪ ▪ ▪
Healthy Workplace Practices
▪
Aseptic Technique AerosolGenerating Medical Procedures
▪
▪
▪ ▪ ▪
Ongoing education includes hand hygiene, Point of Care Risk Assessment, Routine Practices & Additional Precautions, cleaning & disinfection of the environment and equipment and staff safety. Includes hand hygiene, respiratory hygiene and not sharing personal care items. Post signs with instructions to patients and visitors on how to ‘cough/sneeze into your sleeve’, ‘cover your cough’ with a tissue and promptly dispose of used tissue, or put on a mask if the symptoms are uncontrollable or person cannot comply with instructions. Hand hygiene must be done following contact with respiratory secretions including disposal of used tissues. Maintain spatial separation, ideally more than 2 meters (6 feet) between persons with respiratory symptoms in common areas, such as waiting rooms. Healthcare providers to use and teach patients avoidance measures that minimize contact with droplets when coughing or sneezing, such as: turning the head away from others; covering the nose and mouth with tissue. Should not enter the healthcare setting if they are sick or unable to comply with hand hygiene and other precautions that might be required. Should be instructed to do hand hygiene when entering and exiting the patient’s room. Encourage visitors to have annual influenza vaccine. Provide visitor with information pamphlets located on the INFECTION PREVENTION & CONTROL WEBSITE. (NOT AVAILABLE TO NON IH FACILITIES). Staff not to come into work when ill with symptoms that are of an infectious origin. Provide appropriate immunizations to patients and healthcare providers including annual influenza vaccine. Use for handling medications and for procedures such as intravenous catheterization, urinary catheterization, wound care, etc. Only those needed to perform the procedure should be present in room. Use Routine Practices including hand hygiene and appropriate PPE based on the Point of Care Risk Assessment Use Additional Precautions based on the Point of Care Risk Assessment and potential for infectious disease diagnosis.
Infection Prevention & Control-IF0100 Note: in this document the term “patient” is inclusive of patient, resident or client.
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Infection Prevention & Control-IF0100 Note: in this document the term “patient” is inclusive of patient, resident or client.
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Infection Prevention & Control-IF0100 Note: in this document the term “patient” is inclusive of patient, resident or client.
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Infection Prevention & Control-IF0100 Note: in this document the term “patient” is inclusive of patient, resident or client.
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5.0
REFERENCES 5.1.
Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care; Public Health Agency of Canada; Sept 1, 2010 – Final Version.
5.2.
Routine Practices and Additional Precautions In all Healthcare Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; July 2011. http://www.oahpp.ca/resources/documents/pidac/RPAP%20-%20PHO%20template%20%20FINAL%20-%202011-07-26.pdf
5.3.
Best Practice for Environmental Cleaning for Prevention and Control of Infections in nd all Healthcare Settings. 2 Edition. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; May 2012. http://www.oahpp.ca/resources/documents/pidac/Environmental%20Cleaning%20BP_ENGLI SH_FINAL_2012-07-15.pdf
APPENDIX A Aerosol-generating medical procedures (AGMPS) - procedures that stimulate coughing and promote generation of aerosols; examples include intubation and related procedures, manual ventilation, open endotracheal suctioning, CPR, bronchoscopy, sputum induction, surgery, autopsy, and non-invasive positive pressure ventilation (CPAP, BiPAP), high concentration oxygen therapy (50% or higher). For diagnostic (but not therapeutic) bronchoscopy or sputum induction, use an N95 respirator, due to risk from undiagnosed TB. Aseptic Technique – preventative measures to reduce the risk of introduction of microorganisms through a portal of entry including mucous membranes, intravenous catheterization, breaks in the skin, urinary catheterization; methods of introduction include inhalation, injection, and puncture. Cleaning – the physical removal of dirt, dust or foreign material. Cleaning usually involves soap and water, detergents or enzymatic cleaners. Thorough cleaning is required before disinfection or sterilization may take place. Cohorting – the placement and care of patients in the same room, who are infected or colonized with the same microorganism; or placing those who have been exposed together to limit risk of further transmission. Disinfection – removal and destruction of most pathogens (or disease-causing organisms) except bacterial spores; requires friction (cleaning) and the use of a disinfectant product. High touch areas/surfaces – are those that have frequent contact with hands and require more frequent cleaning, particularly during outbreaks. Examples include doorknobs, elevator buttons, telephones, call bells, bedrails, light switches, monitoring equipment, chair arms, faucet handles, over bed tables, hand rails, flusher handle, soap and ABHR dispensers, paper towel holder and edges of privacy curtains.
Infection Prevention & Control-IF0100 Note: in this document the term “patient” is inclusive of patient, resident or client.
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Housekeeping Clean • Terminal/Discharge Clean – refers to the process of cleaning and disinfection which is undertaken upon discharge of a patient from a room. The patient room, cubicle, or bed space, bed, bedside equipment, environmental surfaces, hand washing sink and bathroom should be thoroughly cleaned before another patient is allowed to occupy the space. • Isolation Terminal Clean – refers to the process of cleaning and disinfection which is undertaken upon discharge of a patient from or discontinuation of any ‘Isolation Precautions’ (Additional Precautions). In addition to the Terminal/Discharge clean, privacy and shower curtains are changed, toilet paper, paper towel, glove box and toilet brush should all be discarded and replaced. Non-critical Medical Equipment – equipment in the patient care environment that is used between patients (e.g. imaging equipment, electronic monitoring equipment, commode chairs); items that touch only intact skin but not mucous membranes. N95 Respirator – type of mask used to prevent inhalation of small particles that may contain infectious agents transmitted via the airborne route. Personal Protective Equipment (PPE) – barriers placed between the infectious source and one’s own mucous membranes, airways, skin and clothing to prevent exposure to blood and body fluids. Point of Care Risk Assessment – a dynamic process done before each interaction with a patient or their environment in order to determine which interventions are required to prevent transmission of microorganisms during the interaction considering the patient’s status can change. Respiratory Hygiene – personal practices that help prevent the spread of microorganisms that cause respiratory infections; applies to any person entering a healthcare facility who has signs of illness, including cough, congestion, runny nose or increased production of respiratory secretions. Routine Practices – based on the assumption that all blood and body fluids contain potentially infectious organisms, the same safe standards of practice should be used routinely with all patients to prevent exposure to blood, body fluids, secretions, excretions, mucous membranes, non-intact skin or soiled items and to prevent the spread of microorganisms. Sharps – are devices that can cause occupational injury to healthcare providers (e.g. laceration or puncture the skin). Some examples of sharps include needles, lancets, blades and clinical glass.
Infection Prevention & Control-IF0100 Note: in this document the term “patient” is inclusive of patient, resident or client.
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IF0200:
Hand Hygiene Guidelines
EFFECTIVE DATE: September 2006 REVISED DATE: December 2012 REVIEWED DATE:
1.0
PURPOSE Hand hygiene (hand cleaning) is the single most important procedure for preventing the spread of healthcare associated infections.
2.0
DEFINITIONS See the glossary in Appendix A for hand hygiene definitions.
3.0
GUIDING PRINCIPLES 3.1
Hand hygiene is known to reduce patient morbidity and mortality from healthcare associated infections. It causes a significant decrease in the carriage of potential pathogens on the hands. Hand hygiene is the responsibility of ALL individuals involved in health care.
3.2
Hand sanitizing with an alcohol-based hand rub (ABHR) is the preferred method (when hands are not visibly soiled) for cleaning hands.
3.3
There is standardized ABHR product placement throughout IH : • • • • • • •
•
At entrances to facilities. In waiting rooms. At entrances to units. In dining rooms. At entrance to each patient room. At point-of-care, within 3 feet of the patient bed. Affixed to the mobile work carts such as vital sign cart, med cart, dressing cart, clean linen carts, and others. ABHR that is attached to the wall must not be installed directly over a source of ignition (i.e. electrical outlets). The risk of fire related to the use of ABHR is very small.
Infection Prevention & Control-IF0200 Note: in this document the term “patient” is inclusive of patient, resident or client.
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3.4
Hand hygiene infrastructure • Sinks should be in adequate numbers and accessible to facilitate staff, patient and visitor hand washing (CSA Z8000). • Bar soaps are not recommended for use by healthcare providers. • Disposable paper towels are readily available for drying hands. • Healthcare workers will inform housekeeping if they see that the ABHR is empty. • Hand hygiene products must be dispensed in single-use dispensers and discarded when empty; containers must not be “topped-up” or refilled - this practice is not acceptable since it can result in contamination of the container and product. • ABHR’s should not be placed at, or adjacent to, hand washing sinks. • Plain soap is used in all care settings for routine hand washing.
3.5
The use of gloves is not a substitute for performing hand hygiene. Hand hygiene must be performed before putting on gloves and after removing gloves.
3.6
When Clostridium difficile infection is suspected or diagnosed, hand hygiene with either ABHR or soap and water is an important part of controlling the spread of this infection in healthcare settings. Currently there is a lack of evidence regarding the efficacy of ABHR versus hand washing with soap and water for removal of spores from hands. However, if hands are visibly soiled, soap and water is recommended as ABHR has limited efficacy in the presence of gross soilage.
3.7
The fingernails are the area of greatest contamination. Short nails are easier to clean and are less likely to tear gloves. Artificial nails and nail enhancements have been implicated in the transfer of microorganisms. • The areas of the hands that are often missed when performing hand hygiene are the wrist creases, thumbs, fingertips, under the fingernails and under jewelry. • Dry or damaged skin conditions of the hands show a higher bacterial load, which is more difficult to remove than with healthy, intact skin.
3.8
Compatibility between lotions and hand hygiene products, and lotion‘s potential effect on glove integrity should be considered (i.e. lotions should not be petroleum based).
Infection Prevention & Control-IF0200 Note: in this document the term “patient” is inclusive of patient, resident or client.
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4.0
PROCEDURE 4.1
4 Moments for Hand Hygiene
Reference: Government of Ontario (2006)
THE 4 MOMENTS FOR HAND HYGIENE IN HEALTHCARE:
1. 2. 3. 4.
4.2
BEFORE initial patient/patient environment contact BEFORE aseptic procedure AFTER body fluid exposure risk AFTER patient/patient environment contact
Additional Moments for Hand Hygiene • Before initial contact with a patient or items in their environment; this should be done on entry to the room or bed space, even if the patient has not been touched. • Before putting on gloves. • Before preparing, handling or serving food or medications to a patient. • After care involving contact with blood, body fluids, secretions and excretions of a patient, even if gloves are worn. • Immediately after removing gloves and before moving to another activity. • When moving from a contaminated body site to a clean body site during healthcare activities. • After contact with a patient or items in their immediate surroundings when leaving the area, even if the patient has not been touched. • After using the toilet or after toileting others. • After changing an incontinence product or a child’s diaper. • Prior to using computers and other electronic devices. • And… whenever in doubt.
Infection Prevention & Control-IF0200 Note: in this document the term “patient” is inclusive of patient, resident or client.
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4.3
Hand Hygiene Using Alcohol Based Hand Rub (ABHR) • Use routinely when hands are not visibly soiled. • Three steps for hand rub: 1. Apply product liberally to palms of hands. 2. Spread thoroughly over hands. 3. Rub until dry.
4.4
Hand Hygiene Using Soap and Water • Use when hands are visibly soiled. • Steps for hand washing with soap and water: 1. Wet your hands with warm running water. 2. Apply soap. 3. Lather for 15 seconds. 4. Rinse well with warm running water. 5. Pat hands dry with a paper towel. 6. Use the paper towel to turn off the taps. • If hands are visibly soiled and running water is not available, perform hand hygiene using ABHR then immediately find a sink to wash with soap and water.
4.5
Hand Hygiene for Patients • Staff should encourage and assist patients to perform hand hygiene prior to eating, when their hands are soiled, after toileting and before leaving their room or clinic area. • ABHR is available for patients to use at point of care. • It is okay for patients to ask their healthcare providers if they have performed hand hygiene prior to providing direct care.
4.6
Surgical hand scrubs are performed in the operative setting (http://inet.interiorhealth.ca/infoResources/clinresources/Documents/Surgical%20Scrub.pdf)
4.7
Hand Care • Hand care for staff is a key component of improving effective and safe hand hygiene practices. • Provide staff education on the benefits of using ABHRs and appropriate hand hygiene technique. • Refer staff to Occupational Health for an assessment if skin integrity is an issue. • Provide staff with appropriate hand moisturizing skin care products. • To prevent skin damage from frequent hand hygiene, staff to moisturize hands regularly by applying hand lotion from a pump dispenser
4.8
Nails, Jewelry and Clothing: • Nails must be kept clean and short (less than 3 mm) at all times - the nail should not show past the end of the finger. • Nail polish should not be worn. • Artificial nails or nail enhancements must not be worn by healthcare providers who provide direct patient care. • Hand/wrist jewelry should not be worn by healthcare providers who provide direct patient care. • Watches must be removed or pushed up above the wrist by healthcare providers who provide direct patient care before performing hand hygiene. • Long sleeves should not interfere with, or become wet when performing hand hygiene. If long sleeves are worn, push sleeves back prior to doing hand hygiene.
Infection Prevention & Control-IF0200 Note: in this document the term “patient” is inclusive of patient, resident or client.
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5.0
4.9
Other Impediments to Effective hand Hygiene • Upper extremity support devices such as casts and splints, or complex bandages on hands and forearms of healthcare workers may impede effective hand hygiene, HCW’s; who wear such devices should be assessed by occupational health and infection control to investigate whether they: 1. Are able to perform adequate hand hygiene. 2. Can continue to provide direct patient care. 3. Require an alternate work placement.
4.10
Education • IH will provide staff hand hygiene education, training, and competency assessment and inform all healthcare providers of the hand hygiene policy at the time of hiring and during orientation (AH0700 Hand Hygiene Administrative Policy). • The requirements to complete education/training are as follows: 1. Physicians – At the time of initial credentialing and every 3 years. 2. Direct Patient Care Staff – Education will be linked to hand hygiene performance rates of the unit. Staff working on units with hand hygiene compliance less than 59% over a one year period will be required to complete the provincial hand hygiene education module (http://www.picnet.ca/pages/128/folder/ or IH I-Learn site). 3. New Hires – At the time of their orientation. 4. Students – At the time of their orientation. • Provide education for patients, families and visitors including instructions regarding when and how to perform hand hygiene – use information brochures, posters. • The hand hygiene pamphlet for patients, visitors, and families shall be at the bedside for each new admission. • Routinely monitor healthcare provider hand hygiene compliance and provide timely feedback using an action plan with the goal of improving patient safety by increasing hand hygiene compliance rates.
REFERENCES 5.1
AH0700 – Interior Health Administrative Hand Hygiene Policy.
5.2
Best Practices for Hand Hygiene In All Healthcare Settings and Programs. British Columbia Ministry of Health; July 2012. http://www.picnet.ca/download.php?filepath=%2Fpracticeguidelines%2F38%2Fattachment.p df&filetitle=BC_Best_Practices_for_Hand_Hygiene_2012_pdf&extension=pdf
5.3
Best Practices for Hand Hygiene In all Healthcare Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; December 2010. http://www.oahpp.ca/resources/documents/pidac/2010-12%20BP%20Hand%20Hygiene.pdf
5.4
APIC Text 2009. http://text.apic.org/item-53/chapter-49-ambulatory-care/guidelines
5.5
World Health Organization (WHO) World Alliance for Patient Safety. WHO Guidelines on Hand Hygiene in Health Care http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf
Infection Prevention & Control-IF0200 Note: in this document the term “patient” is inclusive of patient, resident or client.
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APPENDIX A Glossary Alcohol-based Hand Rub (ABHR) – can be a liquid, gel, or foam formulation. ABHR’s are the preferred method to routinely decontaminate hands in clinical situations when hands are not visibly soiled as they provide for a rapid kill of most transient microorganisms, are less time-consuming than washing with soap and water and are easier on skin. ABHR must contain between 70 - 90% alcohol. Can be used as a surgical scrub. Contamination: The presence of an infectious agent on hands or on a surface, such as clothing, gowns, gloves, bedding, toys, surgical instruments, patient care equipment, dressings or other inanimate objects. Direct Care: Provision of hands-on care (e.g. bathing, washing, turning patient, changing clothes, continence care, dressing changes, care of open wounds/lesions, toileting). Environment of the Patient: The immediate space around a patient that may be touched by the patient and may also be touched by the healthcare provider when providing care. For example: • In a single room, the patient environment is the room • In a multi-bed room, the patient environment is the area inside the individual’s curtain and including the curtain • In an ambulatory setting, the patient environment is the area that may come into contact with the patient within their cubicle • In a nursery/neonatal setting, the patient environment includes the inside of the bassinette or isolette, as well as the equipment outside the bassinette or isolette used for that infant (e.g. ventilator, monitor) Hand Care: Actions and products that reduce the risk of skin irritation. A hand care program for staff is a key component of hand hygiene and includes hand care assessment, staff education and an occupational health assessment. Hand Hygiene: A general term referring to any action of hand cleaning. Hand hygiene relates to the removal of visible soil and removal or killing of transient microorganisms from the hands. Hand hygiene for patient care may be accomplished using an alcohol-based hand rub or soap and running water. Hand hygiene includes surgical hand preparation. Hand Hygiene Moment - points to a patient care activity during which hand hygiene is essential because the risk of transmission of microorganisms is greatest. There may be several hand hygiene moments in a single care sequence or activity. Hand Washing: The physical removal of microorganisms from the hands using soap and running water. Healthcare Provider (HCP): Any person working in the healthcare system. This includes, but is not limited to, the following: emergency service workers, physicians, dentists, nurses, respiratory therapists and other health professionals, personal support workers, clinical instructors, students, environmental and food services, facility maintenance, contracted providers and home healthcare workers. In some settings, volunteers might provide care and would be included as a healthcare provider. Nail Enhancement: Nail enhancements refer to artificial nails, resin wraps, tips, acrylics, gems, sticker, piercings or gels. Occupational Health and Safety (OHS)/Workplace Health: Preventive and therapeutic health services in the workplace provided by trained occupational health professionals, e.g. nurses, hygienists, and physicians. Patient: The term ‘patient’ in this document refers to any patient, clients and residents receiving care within a healthcare setting. Infection Prevention & Control-IF0200 Note: in this document the term “patient” is inclusive of patient, resident or client.
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Plain Soap: Detergents that do not contain antimicrobial agents or that contain very low concentrations of antimicrobial agents that are present only as preservatives. Point-of-Care: The place where three elements occur together: the patient, the healthcare provider and care or treatment involving patient contact. Point-of-care products should be accessible to the healthcare provider, within arm’s reach, without the provider leaving the zone of care. Surgical hand preparation: The preparation of hands for surgery, using either antimicrobial soap and water or an alcohol-based hand rub, preferably one with sustained antimicrobial activity. Visibly Soiled Hands: hands on which dirt or body fluids can be seen.
Infection Prevention & Control-IF0200 Note: in this document the term “patient” is inclusive of patient, resident or client.
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IF0300:
Waste Management
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010, December 2012, March 2013 REVIEWED DATE:
1.0
PURPOSE To prevent the spread of infection, reduce the risk associated with waste disposal and ensure the safety of the general public, patients and healthcare providers in regards to waste disposal processes.
2.0
DEFINITION See the glossary in Appendix A for hand hygiene definitions.
3.0
GUIDING PRINCIPLES 3.1.
Written procedures for the management of biomedical waste from healthcare settings should be developed based on provincial and municipal regulations and legislation.
3.2.
All staff handling waste or garbage will wear personal protective equipment including protective gloves.
3.3.
Waste should be segregated according to the categories listed in the table below. Waste from several different categories should not be mixed in one bag. NOTE: Placing regular waste that does not require special disposal will result in increased cost and may incur penalties from collection agencies. WASTE TYPE Anatomical waste – placentas, human tissue, organs and body parts Microbiology Laboratory waste autoclaved waste Fluid waste pleurevacs, hemovacs, blood bags, suction liners/containers with visible blood, etc.
COLOUR-CODING Red
STORAGE/DISPOSAL Commercial BioMedical Waste Disposal - incinerated
White Bucket
Landfill
Yellow
Commercial BioMedical Waste Disposal
Infection Prevention & Control-IF0300 Note: in this document the term “patient” is inclusive of patient, resident or client.
*Contents of drainable devices can be emptied into the sewer.
Page 1
Sharps – needles, sutures, lancets, blades, trocars, contaminated scissors, razors or clinical glass General waste disposable suction containers with no visible blood, dressings, sponges, diapers, incontinent pads, PPE, disposable drapes, dialysis tubing and filters, empty IV bags and tubing, catheters, empty specimen containers, disposable lab coats and aprons and pads that will not release liquid or semi-liquid blood if compressed, etc.
Yellow Commercial Sharps Containers
Commercial BioMedical Waste Disposal
Black bag **
Landfill – Regular Garbage Disposal **
** FOLLOW LOCAL LANDFILL REGULATIONS.
3.4.
Plastic waste holding bags are color coded and sturdy enough to resist puncture under conditions of use and to the point of disposal. Use the Soiled Utility Room to gather together disposable biomedical waste.
Safe Sharps Handling Use safety engineered medical devices, such as needleless devices. NEVER re-cap a used needle. NEVER reach into waste or sharps containers. Provision of rigid, puncture-resistant sharps containers at or near the point-of-use to permit safe one-handed disposal required. Handle laundry with care. Educate staff about the risks associated with sharps, including safe disposal of sharps in puncture-resistant containers if found in the environment (e.g. sharps in laundry, waste, bedside, floor).
Infection Prevention & Control-IF0300 Note: in this document the term “patient” is inclusive of patient, resident or client.
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4.0
PROCEDURE 4.1.
Use appropriate PPE when handling waste/garbage including puncture resistant gloves.
4.2.
Ensure bags are not torn, are securely closed and no sharp objects are protruding through.
4.3.
It is not necessary to double bag garbage unless the first bag is leaking.
4.4.
Human blood & body fluid waste can be disposed of from drainable devices into a sanitary sewer and does not require special treatment before disposal. When handling these fluids care must be taken to eliminate spills and the formation of aerosols.
4.5.
Place all general waste into the regular garbage containers.
4.6.
Place Biomedical waste into appropriate containers.
4.7.
SHARPS • Choose the correct size/shape of sharps container for the situation (e.g.) small closable container for Home/Community care. • Staff responsible for collecting and replacing sharps containers should be trained in proper handling methods. • All SHARPS containers must have an approved biohazard waste label. • Place all sharp items in an approved sharps container. • DO NOT over fill sharps containers.
4.8.
BLOOD & BLOODY BODY FLUID SPILLS • •
• • •
4.9.
Wear appropriate personal protective equipment to clean up spills (e.g.) gloves, gown and face shield if there is a danger of splashing. Clean the area - gross soil must be removed prior to cleaning and disinfecting o Use paper towels for small spills, mop for large spills. o Used paper towels should be placed in biohazardous waste container. o Mop heads should be placed in laundry bags. Disinfect area with approved hospital disinfectant. Cleaning equipment/reusable gloves are to be cleaned/discarded appropriately. Hands must be washed at the end of the procedure.
BIOMEDICAL WASTE DISPOSAL IN COMMUNITY CARE • Follow Biomedical Waste Disposal – Community Care guidelines http://inet.interiorhealth.ca/infoResources/clinresources/Documents/Biomedical%20Wast e%20in%20Community%20Care.pdf
Infection Prevention & Control-IF0300 Note: in this document the term “patient” is inclusive of patient, resident or client.
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APPENDIX A Glossary Anatomical Waste – placentas, human tissues, organs and body parts; does not include teeth, hair and nails. Biomedical waste – waste that requires additional precautions due to potential infectious nature; includes anatomical waste, fluid waste, sharps, microbiology laboratory waste and sharps as defined in APPENDIX A. Drainable devices – any device that can have its liquid contents evacuated or drained out. Fluid Waste – human fluid blood and blood products, items saturated or dripping with blood, body fluids contaminated with blood and body fluids removed for diagnosis during surgery, treatment or autopsy; does not include urine or feces. General Waste – includes items such as dressings, sponges, diapers, incontinent pads, PPE, disposable drapes, dialysis tubing and filters, empty IV bags and tubing, catheters, empty specimen containers, disposable lab coats and aprons and pads that will not release liquid or semi-liquid blood if compressed. • Includes waste from Contact, Droplet and Airborne Precautions rooms. • Includes waste from offices, kitchens, washrooms, public areas. Microbiology Laboratory Waste - laboratory cultures, stocks or specimens of microorganisms, live or attenuated vaccines, human or animal cell cultures used in research including laboratory material that has come into contact with any of these. Non drainable and/or Single Use devices – any device that is not able to have its liquid contents drained out or are meant to be used once and then the device discarded. Personal Protective Equipment (PPE) – barriers used by healthcare providers to protect mucous membranes, airways, skin, and clothing from exposure to blood and body fluids. Can include gloves, mask, eye protection or gown, as needed. Sharps – items capable of cutting or puncturing the skin and that have come into contact with blood, body fluids or microorganisms – items include all needles and devices containing needles or spikes, broken medical glassware, contaminated scalpel blades, scissors, razors, lancets.
5.0
REFERENCES 5.1
Canadian Council of Ministers of the Environment (CCME) Guidelines for the Management of Biomedical Waste in Canada. CCME-EPC-WM-42E. February 1992. http://www.ccme.ca/assets/pdf/pn_1060_e.pdf
5.2
Best Practices for Environmental Cleaning for Prevention and Control of Infections In All Health Care Settings - 2nd edition. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; May 2012. http://www.oahpp.ca/resources/documents/pidac/Environmental%20Cleaning%20BP_ENGLISH_FIN AL_2012-07-15.pdf
5.3
City of Kelowna. (2012). Solid Waste Management Regulation Bylaw Number 10106. February 13, 2012. Retrieved from the City of Kelowna web site
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IH0100:
Additional Precautions for All Care
Areas
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010, December 12, 2012 REVIEWED DATE:
1.0
PURPOSE Additional Precautions are interventions used in addition to Routine Practices to prevent transmission of certain microorganisms to patients and healthcare providers by interrupting transmission of infectious agents that are suspected or identified in a patient.
2.0
DEFINITION Additional Precautions – interventions used in addition to Routine Practices for certain pathogens or clinical presentations. These precautions are based on the method of transmission (e.g., contact, droplet, airborne) and for certain highly transmissible or epidemiologically important microorganisms transmitted by direct or indirect contact. Airborne Precautions – used for patients known or suspected of having an illness transmitted by the airborne route (i.e., by small droplet nuclei that remain suspended in the air and may be inhaled by others). Cohorting - the placement and care of patients in the same room, who are infected or colonized with the same microorganism; or placing those who have been exposed together to limit risk of further transmission. Contact Precautions – used for patients known or suspected of having an illness that can be transmitted via contact with the patient or contaminated environmental surfaces. Droplet Precautions – used for patients known or suspected of having an infection that can be transmitted by large infectious droplets. Engineering controls - removal or isolation of a workplace hazard through technology. Negative pressure rooms, sharps injury prevention devices and sharps containers are examples of engineering controls. Isolation Discharge Clean – refers to the process of cleaning and disinfection which is undertaken upon discharge of a patient from a room. The patient room, cubicle, or bed space, bed, bedside equipment, environmental surfaces, hand washing sink and bathroom should be thoroughly cleaned before another patient is allowed to occupy the space.
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3.0
GUIDING PRINCIPLES 3.1
Additional precautions are required for: • Patients infected with certain organisms that may be transmitted easily by direct or indirect contact with the patient or with their environment. • Situations in which contamination of the patient‘s environment is likely (e.g. a patient with diarrhea that cannot be contained).
3.2
Initiating Addition Precautions: • Based on point of care risk assessment of patient • As soon as symptoms suggestive of an infection are noted and/or contamination of the patient environment Is likely
3.3
Additional Precautions should remain in place until there is no longer a risk of transmission of the microorganism or illness. REFER TO THE TRANSMISSION SUMMARY TABLES 6 & 7. These tables summarize information about transmission of most infectious diseases and are designed for use in acute care settings. • Table 6 lists precautions to be taken for specific clinical presentations when the microorganism involved is not known. • Table 7 lists precautions to be taken for infections due to specifically identified micro organisms.
Additional Precautions do not require a physicians order initiated by nursing staff based on point of care risk assessment of patient (i.e.) diarrhea & uncontained draining wounds = Additional Precautions
Clinical Syndromes Requiring the Use of Controls (Including PPE) Pending Diagnosis •
•
• • • • •
Acute diarrhea and / or vomiting of suspected infectious etiology: o GLOVES, SINGLE ROOM o GOWN if skin or clothing will come into direct contact with the patient or the patient’s environment and for paediatrics and incontinent/noncompliant adults Acute respiratory infection, undiagnosed: o SINGLE ROOM/SPATIAL SEPARATION preferred, FACIAL PROTECTION, GLOVES o GOWN if skin or clothing will come into direct contact with the patient or the patient’s environment Respiratory infection with risk factors and symptoms suggestive of Tuberculosis: o FIT-TESTED N95 RESPIRATOR, NEGATIVE PRESSURE ROOM Suspected meningitis and/or sepsis with petechial rash: o SINGLE ROOM, FACIAL PROTECTION Undiagnosed rash without fever: o GLOVES Rash suggestive of varicella or measles: o NEGATIVE PRESSURE ROOM -= only immune staff to enter Abscess or draining wound that cannot be contained: o GLOVES o GOWN if skin or clothing will come into direct contact with the patient
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3.4
Accommodation and signage for patients on Additional Precautions includes: • Spatial separation, such as single room and private toileting facilities for patients on Additional Precautions. • Signage specific to the type(s) of Additional Precautions that lists the required precautions is posted at the entrance to the patient’s room or bed space (in Emergency, place on cubicle curtain). • A residential care facility is the “resident’s home” and infection prevention control precautions must be balanced with promoting optimal healthy lifestyles for the residents. Most importantly ALL healthcare workers must consistently use Routine Practices when providing ALL care in these settings. Hence Additional Precautions signs may not be required.
3.5
PPE must be readily available outside the room/area where Additional Precautions are being implemented • It is never appropriate for patients to wear gloves or isolation gowns while outside their room.
3.6
Equipment must be dedicated to the patient whenever possible • No more than one day’s supplies stocked inside the room • Additional cleaning measures may be required for the patient environment.
3.7
Limited Transport : • Patients who leave their room must be assessed to determine their risk of transmission to others and risk reduction strategies must be used • Clean and disinfect equipment used for transport after each use.
3.8
Communication regarding Additional Precautions is essential when a patient goes to another department for testing, to another unit or to other healthcare settings/facilities. This communication must include Emergency Medical Services (EMS) staff and other transport staff.
Elements of Additional Precautions
Routine Practices + Specialized Accommodation and Signage + Barrier Equipment + Dedicated Equipment and Additional Cleaning Measures + Limited Transport +
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3.9
Cohorting: • Cohorting practices can be utilized when single rooms are not available or during outbreak situations. • Cohorting should never compromise infection control practices and Additional Precautions must be applied individually for each patient within the cohort.
3.10
Visitors: • Must receive education regarding hand hygiene and the appropriate use of PPE. • Must wear the same PPE as healthcare providers if providing direct patient care.
It is important to be sensitive to the effect that Additional Precautions have on patients and others. Patients can feel stigmatized by all the PPE (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, healthcare providers and the public alike.
4.0
PROCEDURE •
•
•
Follow the guidelines under Airborne Precautions I.H FACILITY
REFER TO IH0200 FOR AIRBORNE PRECAUTIONS
NON I.H. FACILITY
REFER TO IH0200 FOR AIRBORNE PRECAUTIONS
Follow the guidelines under Droplet Precautions I.H FACILITY
REFER TO IH0300 FOR DROPLET PRECAUTIONS
NON I.H. FACILITY
REFER TO IH0300 FOR DROPLET PRECAUTIONS
Follow the guidelines under IH0400 for CONTACT PRECAUTIONS. I.H FACILITY
REFER TO IH0400 FOR CONTACT PRECAUTIONS
NON I.H. FACILITY
REFER TO IH0400 FOR CONTACT PRECAUTIONS
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5.0
REFERENCES 5.1
Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare, Public Health Agency of Canada; Sept 1, 2010 – Final Version.
5.2
Routine Practices and Additional Precautions In all Healthcare Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; July 2011. http://www.oahpp.ca/resources/documents/pidac/RPAP%20-%20PHO%20template%20%20FINAL%20-%202011-07-26.pdf
5.3
Best Practice for Environmental Cleaning for Prevention and Control of Infections in nd all Healthcare Settings. 2 Edition. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; May 2012. http://www.oahpp.ca/resources/documents/pidac/Environmental%20Cleaning%20BP_ENGLI SH_FINAL_2012-07-15.pdf
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4.0
References Health Canada Infection Control Guidelines. Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care, 1999.
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IH0200:
EFFECTIVE DATE: September 2006
Airborne Precautions
REVISED DATE: April 2011 REVIEWED DATE:
1.0
PURPOSE Airborne Precautions refer to infection prevention and control interventions to be used in addition to Routine Practices to prevent transmission of airborne particles that remain suspended in the air, travel on air currents and are then inhaled by others who are nearby or who may be some distance away from the source patient, in a different room or ward (depending on air currents) or in the same room that a patient has left, if there have been insufficient air exchanges. Common microorganisms transmitted by the airborne route are Mycobacterium tuberculosis (TB), varicella virus (chickenpox virus) and measles virus.
2.0
DEFINITIONS Airborne Precautions - used for diseases that are spread by airborne transmission. This primarily occurs through dissemination of microorganisms by aerosolization. Organisms are contained in droplet nuclei which are small airborne particles, less than 5 microns in size that result from evaporation of large droplets. Organisms can also be contained in debris in dust particles that remain suspended in the air for long periods of time. These microorganisms are then widely dispersed by air currents and can be inhaled by susceptible hosts who may be some distance away from the source patient. Control of airborne transmission is the most difficult, as it requires control of air flow through special ventilation systems and use of respirators. Clinical Presentation Requiring Airborne Precautions: Refer to:
• •
•
•
I.H FACILITY
AIRBORNE ALGORITHM
NON I.H. FACILITY
AIRBORNE ALGORITHM
Suspected infectious pulmonary or laryngeal tuberculosis (cough, fever, pulmonary infiltrations in a patient at risk for tuberculosis). Maculopapular rash with coryza and fever until measles (rubeola) ruled out. Vesicular rash compatible with varicella or disseminated zoster until these are ruled out (Contact Precautions also). I.H FACILITY
AIRBORNE / CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY
AIRBORNE /CONTACT PRECAUTIONS SIGN
Hemorrhagic fever with pneumonia, acquired in appropriate endemic area (Contact Precautions as well). I.H FACILITY
AIRBORNE / CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY AIRBORNE /CONTACT PRECAUTIONS SIGN Specific Etiology Requiring Airborne Precautions: • Tuberculosis, pulmonary or laryngeal. I.H FACILITY
REFER TO IS0500 SPECIFIC DISEASES TUBERCULOSIS
NON I.H. FACILITY
REFER TO IS0500 SPECIFIC DISEASES TUBERCULOSIS
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• • • • •
• •
Measles (rubeola). Monkeypox. Smallpox. Nonimmune measles contact in infectious stage of incubation period (from 5 to 21 days after the last day of exposure). Varicella primary and disseminated Herpes Zoster (Contact Precautions as well). I.H FACILITY
AIRBORNE / CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY
AIRBORNE /CONTACT PRECAUTIONS SIGN
Zoster: extensive, localized zoster that cannot be covered, in pediatric setting where there are susceptible immunocompromised patients. Zoster: localized, in immunocompromised patient (even if covered) until the patient has received 24 hours of antiviral treatment (Contact Precautions as well); after this, as for zoster in an immunocompetent host. I.H FACILITY
• •
AIRBORNE / CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY AIRBORNE /CONTACT PRECAUTIONS SIGN Nonimmune varicella or zoster contact in infectious stage of incubation period (from 10 days after the first day of exposure to 21 days after the last day of exposure; 28 days if given varicellazoster immune globulin). Lassa, Ebola, Marburg and other hemorrhagic fevers with pneumonia (Contact Precautions as well). I.H FACILITY
AIRBORNE / CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY
AIRBORNE /CONTACT PRECAUTIONS SIGN
Aerosol-generating medical procedures (AGMPS) - are medical procedures that can generate aerosols as a result of artificial manipulation of a patient’s airway. Examples include intubation, manual ventilation, open endotracheal suctioning, CPR, bronchoscopy, sputum induction, nebulized therapy, surgery, autopsy, and non-invasive positive pressure ventilation (CPAP, BiPAP) Airborne Isolation Room – a single patient room that is equipped with special air handling and ventilation capacity. Anteroom – is considered a clean area and is used to transition people in and out of the airborne isolation room when it is under negative pressure. An anteroom is used as a transitional space between the hallway and the airborne isolation room. This transition area is where the Healthcare Worker puts on their PPE when entering the Airborne isolation room. The HCW also will store all clean PPE in this area. See Anteroom Protocol Negative Pressure Room – also known as an Airborne Isolation Room; a negative pressure room that is a single-occupancy patient-care room used to isolate persons with a suspected or confirmed airborne infectious disease. N95 Respirators – specific masks that filter particles one micron in size, have a 95% filter efficiency and provide a tight facial seal with less than 10% leak.
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3.0
GUIDING PRINCIPLES 3.1.
Effective control of airborne microorganisms hinges on maintaining a high degree of suspicion for those who present with compatible symptoms of an airborne infection, prompt implementation of airborne precautions and rapid diagnosis.
3.2.
For the purpose of this guideline, the term Airborne Isolation Room will be used to refer to a “negative pressure room”. An Airborne Isolation Room must have: • Ventilation creating inward directional airflow from adjacent spaces to the room (‘negative pressure’) that is regularly monitored. • 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. • Twelve (12) air changes per hour. • The door into the room kept closed to maintain negative pressure, even if the patient is not in the room. • Windows closed at all times; opening the window may cause reversal of air flow, an effect that can vary according to wind direction and indoor/outdoor temperature differentials.
3.3.
In settings where Airborne Precautions cannot be implemented due to limited engineering resources (e.g. Residential Facilities): • Place the patient in a private room. • Keep the door to the room closed. • Have the patient wear a surgical/procedure mask (if possible). • Healthcare providers and visitors must wear an N95 respirator when in patient room. • Arrange for transfer of patient to a facility with an Airborne Isolation Room. Contact Infection Prevention and Control.
3.4.
All healthcare providers entering the patient‘s room, treating or examining the patient must wear an N95 respirator and must wear the type and size for which they were fit-tested. All healthcare providers in high risk areas must be fit tested. REFER TO AV 1900 RESPIRATORY PROTECTION PROGRAM POLICY (NOT AVAILABLE TO NON IH FACILITIES)
3.5.
Only immune healthcare providers should enter a room where airborne precautions are in place for measles or varicella; an N95 respirator is not required.
3.6.
An N95 respirator must be worn if non-immune health care providers are required to enter the room of a patient with measles or varicella when there are no qualified immune health care providers available and patient safety would be compromised if they did not provide care.
3.7.
Patients suspected or confirmed to have an airborne infection are to wear a surgical/procedure mask at all times, if tolerated, when they must leave the Airborne isolation room. If the patient is ventilated, a filter must be present on the expiratory circuit.
3.8.
Strategies to reduce aerosol-generation are required when performing AGMPs on patients with signs and symptoms of suspected and confirmed airborne diseases such as tuberculosis. Limit aerosol-generating medical procedures to those that are medically necessary.
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4.0
PROCEDURE As well as Routine Practice, Airborne Precautions includes the following: 4.1
Accommodation • An Airborne Isolation Room – each facility will have a specific list of these rooms. • If a facility does not have an Airborne Isolation Room, follow the instructions under Guiding Principles (3.3). • Set controller in designated room to “negative pressure”. • Door of patient's room must be kept closed at all times. • Place Airborne Precautions signage on the door. Refer to: I.H FACILITY
AIRBORNE PRECAUTIONS SIGN
NON I.H. FACILITY
AIRBORNE PRECAUTIONS SIGN
4.2
PPE • Healthcare provider to wear appropriately fit-tested N95 respirator upon entering room. • Remove N95 respirator only after leaving room and door has been closed. • For measles and varicella only, immune healthcare providers may enter the Airborne Isolation Room and do not require an N95 respirator; for non-immune healthcare providers an N95 respirator must be worn. • Follow instructions on chart below for performing seal checks when using an N95 respirator.
4.3
Environment • Dietary staff do not deliver or remove food trays of patients in Airborne Isolation Rooms. • After patient is transferred or discharged, room door must remain closed and negative airflow maintained until all air in the room has been replaced – requires 45 minutes.
4.4
Patient Transport • Patient must wear a surgical/procedure mask during transport. • Transport staff to wear N95 respirator if patient is not able to comply with/tolerate wearing a surgical/procedure mask.
4.5
Visitors • Should be counseled and wear an N95 respirator.
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IHA DOES NOT RECOMMEND THE REUSE OF THESE MASKS
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5.0
REFERENCES 5.1
Routine Practices and Additional Precautions In all Healthcare Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; August 2009. http://www.oahpp.ca/resources/documents/pidac/RPAP%20-%20PHO%20template%20%20FINAL%20-%202011-07-26.pdf
5.2
Environmental Cleaning for the Prevention and Control of Infections in all Healthcare Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; December 2009. http://www.oahpp.ca/resources/documents/pidac/Environmental%20Cleaning%20BP_ENGLI SH_FINAL_2012-07-15.pdf
5.3
Infection Prevention and Control Manual. Vancouver Island Health Authority (VIHA); 2009.
5.4
Canadian Tuberculosis Standards 6th Edition by The Public Health Agency of Canada and The Lung Association, 2007; Chapter 16. Page 335.
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Airborne Precautions Sign - Form #807900
EFFECTIVE DATE: September 2006 REVISED DATE: July 2007
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Airborne / Contact Precautions Sign - Form #807901
Infection Prevention & Control-IH0200 Note: in this document the term “patient” is inclusive of patient, resident or client.
EFFECTIVE DATE: September 2006 REVISED DATE: July 2007
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Airborne Communicable Disease Algorithm Form #807907
Infection Prevention & Control-IH0200 Note: in this document the term “patient” is inclusive of patient, resident or client.
EFFECTIVE DATE: January 2008 REVISED DATE: March 2011
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Airborne Isolation Room – Anteroom Protocol
EFFECTIVE DATE: February 2011 REVISED DATE:
1.0
PURPOSE An anteroom is used as a transitional space between the hallway and the airborne isolation room. This transition area is where the Health Care Worker puts on their PPE when entering the Airborne isolation room. The HCW also will store all clean PPE in this area.
2.0
DEFINITIONS Anteroom - anteroom is considered a clean area and is used to transition people in and out of the airborne isolation room when it is under negative pressure.
3.0
GUIDING PRINCIPLES 3.1
During Airborne Precautions. • • •
• 3.2
The anteroom is to be used for anyone entering or exiting the patient room when the room is used for airborne precautions. The laundry hamper shall be situated just inside the patient room when additional precautions are in place. The only items that should be stored in this room include: o PPE ( N95 respirators, procedure masks, gowns, eye protection, gloves). o Garbage container. o Alcohol based hand rub (ABHR) in a holder. o Sanicloths in a holder. o Precaution signs. o Hand soap in a holder. o Paper towels in a holder. Posters could include – hand hygiene, donning and doffing, instructions for families.
No Additional Precautions in use. o o o o
4.0
DO NOT USE the room for storage. May be used to go in and out of patient room. Use for hand hygiene prior to entering and on exit from room. May be used to don PPE as necessary for routine practices.
PROCEDURE 4.1
During Airborne Precautions: • Doors to and from the anteroom and the patient room shall remain closed when the room is used for airborne precautions. • Perform hand hygiene in the anteroom on entrance and exit from room. • Put personal protective equipment (PPE) on before entering the patient room. • Remove the N95 respirator in the anteroom after you have closed the door to the patient room. • For airborne/contact precautions remove the gown and gloves just inside the patient room, and then remove the N95 respirator in the anteroom after you have closed the door to the patient room.
Infection Prevention & Control-IH0200 Note: in this document the term “patient” is inclusive of patient, resident or client.
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IH0300:
EFFECTIVE DATE: September 2006
Droplet Precautions
REVISED DATE: April 2011 REVIEWED DATE:
1.0
PURPOSE Droplet Precautions refer to infection prevention and control interventions to be used in addition to Routine Practices and are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions.
2.0
DEFINITIONS Droplet Precautions - used for diseases that are spread by direct contact through droplet transmission. Droplet transmission refers to large droplets, greater that 5 microns in diametre, generated from the respiratory tract of the source patient during coughing or sneezing, or during procedures such as suctioning or bronchoscopy. These droplets are propelled a short distance of less than two metres (6 feet) through the air and deposited on the nasal, oral or conjunctival mucosa of the new host or fall onto surfaces. Large droplets do not remain suspended in the air. Special ventilation is not required since true aerosolization does not occur. Clinical Presentation Requiring Droplet Precautions: • All definite or possible respiratory tract infections until viral infection ruled out (e.g. bronchiolitis, croup, pneumonia, pharyngitis, asthma with fever < 2 years old). • Paroxysmal cough or suspected pertussis. • Cellulitis in child < 5 years old (without portal of entry). • Epiglottitis. • Periorbital cellulitis in child < 5 years old. • Septic arthritis in child < 5 years old. • Meningitis (Contact Precautions as well for pediatrics). I.H FACILITY • •
DROPLET CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY DROPLET CONTACT PRECAUTIONS SIGN Petechial or ecchymotic rash with fever (etiology unknown or suspected meningococcemia). Suspected hemorrhagic fever without pneumonia, acquired in appropriate endemic area (Contact Precautions as well; use Airborne Precautions if pneumonia present; Public Health must be notified).
Specific Etiology Requiring Droplet Precautions: • Diphtheria, pharyngeal (C. diphtheria). • Hemophilus influenza type b (HIB) invasive infections in children until 24 hours of appropriate antibiotic received (not necessary if the child has received HIB vaccine). • Mumps. • Nonimmune mumps contact in potentially infectious stage of incubation period (10 days after first contact through 26 days after last contact). • Mycoplasma pneumonia. • Neisseria meningitidis invasive infections until 24 hours of appropriate antibiotic received. Infection Prevention & Control-IH0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
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• • • •
Parvovirus B 19 - chronic infection in immunocompromised patient or transient aplastic crisis in patient with hemoglobinopathy. Pertussis (B. pertussis) until 5 days of appropriate antibiotic received. Plague, pneumonic (Yersinia pestis). Rubella, including congenital rubella (Contact Precautions as well). I.H FACILITY
• • • •
DROPLET CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY DROPLET CONTACT PRECAUTIONS SIGN Nonimmune rubella contact in potentially infectious stage of incubation period (7 days after first contact through 21 days after last). Streptococcus group A invasive disease (until 24 hours of appropriate antibiotic received). Streptococcus group A pharyngitis, pneumonia, scarlet fever in children (until 24 hours of appropriate antibiotic received). Viral respiratory tract infections (Contact Precautions as well), including Adenovirus, Parainfluenza virus, Rhinovirus, Respiratory Syncytial Virus (RSV) and Influenza.
I.H FACILITY
DROPLET CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY
•
3.0
DROPLET CONTACT PRECAUTIONS SIGN Lassa, Ebola, Marburg and other hemorrhagic fevers without pneumonia (Contact Precautions as well). I.H FACILITY
DROPLET CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY
DROPLET CONTACT PRECAUTIONS SIGN
GUIDING PRINCIPLES Droplets do not remain suspended in the air and usually travel less than two metres. Microorganisms contained in these droplets are then deposited on surfaces in the patient’s immediate environment and some microorganisms remain viable for extended periods of time. Contact transmission can then occur by touching surfaces and objects contaminated with respiratory droplets.
4.0
PROCEDURE As well as Routine Practice, Droplet Precautions includes the following: 4.1
Accommodation • Single room with toilet and hand washing sink preferred. o Door may remain open. o Place Droplet Precautions sign on door. Refer to:
•
•
I.H FACILITY
DROPLET PRECAUTIONS SIGN
NON I.H. FACILITY
DROPLET PRECAUTIONS SIGN
Cohort. o Patients known to be infected with the same organism (identified by culture or rapid antigen test) may be grouped together in the same room. o Contact Infection Control regarding appropriateness of cohorting. Shared room. o Maintain spatial separation of at least 2 metres between patients. o Roommates should be selected based on their ability to comply with precautions. o Roommates should not be at high risk of serious disease if transmission occurs. o For newborn nurseries, a single room is not necessary if there is a 2 metre aisle between infant stations. o For coughing patients, triage away from waiting area to a single room as soon as possible, or maintain a 2 metre spatial separation.
Infection Prevention & Control-IH0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
Page 2
5.0
4.2
PPE • A surgical/procedure mask and eye protection should be worn when within two metres (6 feet) of the patient and when conducting care that promotes respiratory secretions (e.g.) nebulizers, suctioning.
4.3
Transport of Patients on Droplet Precautions • Patient must wear surgical/procedure mask during transport. o If the patient cannot tolerate wearing a mask, transport staff should wear a surgical/procedure mask and eye protection.
4.4
Visitors • Wear surgical/procedure mask when within 2 metres of patient. • For pediatrics, household contacts of children do not need to wear PPE, as they will have already been exposed in the household.
REFERENCES 5.1
Routine Practices and Additional Precautions In all Healthcare Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; August 2009. http://www.oahpp.ca/resources/documents/pidac/RPAP%20-%20PHO%20template%20%20FINAL%20-%202011-07-26.pdf
5.2
Environmental Cleaning for the Prevention and Control of Infections in all Healthcare Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; December 2009. http://www.oahpp.ca/resources/documents/pidac/Environmental%20Cleaning%20BP_ENGLI SH_FINAL_2012-07-15.pdf
5.3
Infection Prevention and Control Manual. Vancouver Island Health Authority (VIHA); 2009.
Infection Prevention & Control-IH0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
Page 3
Droplet Precautions Sign - Form #807903
EFFECTIVE DATE: September 2006 REVISED DATE: July 2007
Infection Prevention & Control-IH0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
Page 4
Infection Prevention & Control-IH0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
Page 5
Droplet / Contact Precautions Sign - Form #807904
EFFECTIVE DATE: September 2006 REVISED DATE: July 2007
Infection Prevention & Control-IH0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
Page 6
Infection Prevention & Control-IH0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
Page 7
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IH0400:
EFFECTIVE DATE: September 2006
Contact Precautions
REVISED DATE: November 2010 REVIEWED DATE:
1.0
PURPOSE Contact Precautions refer to infection prevention and control interventions to be used in addition to Routine Practices and are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact.
2.0
DEFINITIONS Contact Precautions – measures used for diseases caused by epidemiologically important micro organisms that may be transmitted easily by contact with the patient's intact skin or with contaminated environmental surfaces (e.g. Clostridium difficile, MRSA, VRE, RSV). These infections can be transmitted even if the organism has a low infective dose and there is potential for widespread environmental contamination. Clinical Presentation Requiring Contact Precautions: • All diarrhea in patients. • Major burn wound infection. • Extensive desquamating skin disorder with known or suspected infection or significant colonization. • Skin rash compatible with scabies. • Draining infected wound or abscess if drainage cannot be contained by dressing. • Vesicular rash compatible with varicella or disseminated zoster (Airborne Precautions as well). I.H FACILITY •
NON I.H. FACILITY AIRBORNE CONTACT PRECAUTIONS SIGN Hemorrhagic fever, acquired in appropriate endemic area (Airborne Precautions as well).
I.H FACILITY •
AIRBORNE CONTACT PRECAUTIONS SIGN
AIRBORNE CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY AIRBORNE CONTACT PRECAUTIONS SIGN All suspect respiratory tract infections until viral infection ruled out (Droplet Precautions as well) including bronchiolitis, colds, croup, pneumonia, pharyngitis, asthma with fever < 2 years old.
I.H FACILITY
DROPLET CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY
DROPLET CONTACT PRECAUTIONS SIGN
Specific Etiology Requiring Contact Precautions: • Antimicrobial-resistant organisms (AROs). I.H FACILITY
REFER TO IS0300 ANTIBIOTIC RESISTANT ORGANISMS ARO
NON I.H. FACILITY
REFER TO IS0300 ANTIBIOTIC RESISTANT ORGANISMS (ARO)
Infection Prevention & Control-IH0400 Note: In this document the term “patient” is inclusive of patient, resident & client.
Page 1
• • • • • • • • • •
B.cepacia respiratory tract colonization or infection in patients with cystic fibrosis. Diarrhea due to Campylobacter sp., Clostridium sp., pathogenic strains of Escherichia coli, Giardia lamblia, Rotavirus, Salmonella sp., Shigella sp., Yersina sp., C. difficile or Noroviruses. Enteroviral infections in children. Hepatitis A, E in children. Herpes simplex virus: neonatal or disseminated mucocutaneous in children. Scabies or Pediculosis. Polio, acute infantile paralysis. Smallpox, Monkeypox generalized vaccine with eczema vaccinatum. Varicella (Airborne Precautions as well). Zoster: disseminated (Airborne Precautions as well). I.H FACILITY
•
NON I.H. FACILITY AIRBORNE CONTACT PRECAUTIONS SIGN Zoster: extensive, localized zoster that cannot be covered in children or settings where there are susceptible immunocompromised patients (Airborne Precautions as well).
I.H FACILITY •
AIRBORNE CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY AIRBORNE CONTACT PRECAUTIONS SIGN Congenital Rubella (Droplet Precautions as well).
I.H FACILITY •
AIRBORNE CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY AIRBORNE CONTACT PRECAUTIONS SIGN Zoster: localized, in immunocompromised patient (even if covered) until the patient has received 24 hours of antiviral treatment (Airborne Precautions as well).
I.H FACILITY •
AIRBORNE CONTACT PRECAUTIONS SIGN
DROPLET CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY DROPLET CONTACT PRECAUTIONS SIGN Viral respiratory tract infections caused by Adenovirus, Parainfluenza virus, Rhinovirus, RSV, Influenza (Droplet Precautions as well).
I.H FACILITY
DROPLET CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY
•
DROPLET CONTACT PRECAUTIONS SIGN Lassa, Ebola, Marburg, and other hemorrhagic fevers (Airborne Precautions as well). I.H FACILITY
AIRBORNE CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY
AIRBORNE CONTACT PRECAUTIONS SIGN
Terminal Clean – Refers to the process of cleaning and disinfection which is undertaken upon discharge of patient or discontinuation of Contact Precautions. The patient room, cubicle, or bedspace, bed, bedside equipment and environmental surfaces and sinks and bathroom should be thoroughly cleaned before another patient is allowed to occupy the space. The bed linens If a healthcare provider should be removed before cleaning begins. Privacy and enters a Contact shower curtains should be changed. Precautions room without a gown and is then 3.0 GUIDING PRINCIPLES required to perform an activity that requires a 3.1 A gown is required: gown, he/she must remove • In rooms of children who are incontinent or cannot gloves and clean hands, comply with hygiene. exit the room, put on a gown and clean gloves, • In rooms of non-compliant adults who soil the and then return to the environment. room. The gown must be removed and hands cleaned on exit from the Infection Prevention & Control-IH0400 Page 2 room. Note: In this document the term “patient” is inclusive of patient, resident & client.
• •
3.2
4.0
In crowded rooms / bed spaces where there is a likelihood of coming into contact with contaminated furnishings, equipment or other items. When providing direct care, such as physical examination, checking vital signs, bathing or turning the patient, changing clothing, continence care, dressing changes, care of open wounds.
A gown is not required: • When delivering a food tray. • When doing a visual check of a patient at night. • When speaking to a patient without touching any furniture, equipment or item in the patient’s environment.
PROCEDURE As well as Routine Practices, Contact Precautions include the following: 4.1
Accommodation. • Single room with toilet and hand washing sink preferred. o Door may remain open. o Place Contact Precautions sign on door. Refer to:
•
•
I.H FACILITY
CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY
CONTACT PRECAUTIONS SIGN
Cohort o Patients known to be infected with the same organism (identified by culture or rapid antigen test) may be grouped together in the same room. o Contact your Infection Control Practitioner regarding appropriateness of cohorting. Shared Room o Maintain spatial separation of at least 2 metres between patients. o Roommates should be selected based on their ability to comply with precautions. o Roommates should not be at high risk of serious disease if transmission occurs. o For newborn nurseries, a single room is not necessary if there is a 2 metre aisle between infant stations. o The infected or colonized patient should not use the bathroom used by other patients – arrange for commode at the bedside. Commode emptied in soiled utility room. o In Ambulatory and Community settings, place patients who require Contact Precautions in an examination room or cubicle as soon as possible. o In Emergency Rooms place signage on privacy curtain around cubicle.
4.2
PPE • Gloves should be worn when entering the room or patient's designated space in shared room. • Gloves MUST be removed BEFORE leaving the room or the patient's dedicated bed space and hand hygiene performed. • Gown must be worn if skin or clothing will come in contact with the patient or any furnishings, equipment or other item in the patient’s environment. • Remove gown BEFORE leaving the room and do hand hygiene.
4.3
Environment. Do not take extra supplies into patient’s room. • All horizontal and frequently touched surfaces should be cleaned daily and when soiled. • Clean and disinfect shared items • Cover unused equipment with a sheet before patient enters room (e.g. examination table).
Infection Prevention & Control-IH0400 Note: In this document the term “patient” is inclusive of patient, resident & client.
Page 3
•
For patients with C.difficile infection, require twice daily cleaning.
I.H FACILITY
REFER TO IS0200 CLOSTRIDIUM DIFFICILE GUIDELINE
NON I.H. FACILITY
REFER TO IS0200 CLOSTRIDIUM DIFFICILE GUIDELINE
• •
4.4
For Terminal Cleans o Remove and launder curtains. o Extra supplies in room must be disinfected, sent for reprocessing or discarded. o Emergency Department – Terminal clean required only for patients with uncontained draining wounds or diarrhea.
Transport of Patients on Contact Precautions Healthcare provider to wear gloves and gown for direct contact with patient during transport. Patients must follow the 4 C’s prior to leaving their room:
4 C’s Clean Hands: do hand hygiene Clean Clothes: wear a clean gown or clothes. Contained wounds/body fluids: wounds covered with clean dressing. Urine/feces and other body fluids contained. Co-operative: able to follow instructions
4.5
5.0
Visitors • Wear gloves and gown if participating in direct patient care. • Visitors are requested not to use the kitchen, lounges or other facilities in the hospital.
REFERENCES 5.1
Routine Practices and Additional Precautions In all Healthcare Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; August 2009. http://www.oahpp.ca/resources/documents/pidac/RPAP%20-%20PHO%20template%20%20FINAL%20-%202011-07-26.pdf
5.2
Environmental Cleaning for the Prevention and Control of Infections in all Healthcare Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; December 2009. http://www.oahpp.ca/resources/documents/pidac/Environmental%20Cleaning%20BP_ENGLI SH_FINAL_2012-07-15.pdf
5.3
Infection Prevention and Control Manual. Vancouver Island Health Authority (VIHA); 2009.
Infection Prevention & Control-IH0400 Note: In this document the term “patient” is inclusive of patient, resident & client.
Page 4
Contact Precautions Sign - Form #807902
EFFECTIVE DATE: September 2006 REVISED DATE: July 2007
Infection Prevention & Control-IH0400 Note: In this document the term “patient” is inclusive of patient, resident & client.
Page 5
Infection Prevention & Control-IH0400 Note: In this document the term “patient” is inclusive of patient, resident & client.
Page 6
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IH0500:
EFFECTIVE DATE: September 2006
Protective Precautions
REVISED DATE: November 2010 REVIEWED DATE:
1.0
PURPOSE To reduce the potential increased risk severely immunocompromised patients have of acquiring an infection during hospitalization.
2.0
DEFINITIONS Severely immunocompromised patient - patients with an absolute neutrophil count of less than or 9. equal to 0.5 x 10
3.0
4.0
GUIDING PRINCIPLES 3.1
Protective Precautions (formerly called Reverse Precautions) are used for severely immunocompromised patients whose susceptibility to healthcare associated infections (HAIs) are greatly increased. Enhanced infection prevention measures that promote a clean physical environment, managing risks associated with food and water and preventing exposure to contagious diseases within healthcare facilities are necessary to reduce the risk of these patients acquiring an HAI.
3.2
There is insufficient evidence to support the use of Protective Precautions since many of these infections are caused by the patient’s own endogenous flora or opportunistic microorganisms of normal flora and standard definitions for HAIs are indeterminate as to what constitutes an infection in this population and where it was acquired. Prolonged or repeated hospitalization can alter the endogenous flora of these patients and expose them to additional increased risk of acquiring HAIs which could potentially be lethal.
PROCEDURE In addition to Routine Practice, Protective Precautions include the following: 4.1
Accommodation. • A single room. • Avoid areas where there is construction taking place. • Post Protective Precautions sign on the room door. I.H FACILITY
PROTECTIVE PRECAUTIONS SIGN
NON I.H. FACILITY
PROTECTIVE PRECAUTIONS SIGN
4.2
Staff • Staff who have any signs of infection must not care for these patients.
4.3
Visitors • Visitors with any signs or symptoms of infection should be encouraged to avoid patient contact.
Infection Prevention & Control-IH0500 Note: In this document the term “patient” is inclusive of patient, resident & client.
Page 1
4.4
5.0
Specific Recommendations • No potted plants, flowers or fruit baskets should be in the room. • No pets allowed in the room.
REFERENCES 5.1
Additional Precautions in All Health Care Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; August 2009. http://www.oahpp.ca/resources/documents/pidac/RPAP%20-%20PHO%20template%20%20FINAL%20-%202011-07-26.pdf
5.2
Infection Prevention and Control Manual. Vancouver Island Health Authority; 2009.
5.3
APIC Text 2009. http://text.apic.org/item-43/chapter-42a-infection-prevention-measures-forimmune-compromised-populations
Infection Prevention & Control-IH0500 Note: In this document the term “patient” is inclusive of patient, resident & client.
Page 2
Protective/Reverse Isolation Precautions Private Room Required Sign - Form #807905
Infection Prevention & Control-IH0500 Note: In this document the term “patient” is inclusive of patient, resident & client.
EFFECTIVE DATE: September 2006 REVISED DATE: July 2007
Page 3
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IS0100:
Reportable Communicable Diseases
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010 REVIEWED DATE:
1.0
PURPOSE To reduce the risk of transmission of communicable diseases within healthcare facilities and programs.
2.0
GUIDING PRINCIPLES
2.1.
2.2.
3.0
The Infection Prevention and Control Practitioners will facilitate processes to ensure the Reportable Communicable Diseases are reported to Public Health both from the clinical setting and the laboratory setting, using the LIST OF COMMUNICABLE DISEASES IN BC JULY 2009. The Communicable Disease Regulation states in Section 1.2.1 that any person knowing or suspecting that another person is suffering from a communicable disease shall without delay make a report to the medical health officer.
PROCEDURE Contact the Infection Control Practitioner (ICP) as soon as possible when a patient who is known or a suspect case of a Reportable Communicable Disease included in SCHEDULE A is admitted to the facility/program. The ICP will advise regarding reporting process. • If the ICP is unavailable, contact the Communicable Disease (CD) Unit as soon as possible at 1-866-778-7736.
The laboratory is responsible for reporting Schedule B diseases listed in the REPORTABLE COMMUNICABLE DISEASES IN BC (JULY 2009) LIST.
Infection Prevention & Control-IS0100 Note: In this document the term “patient” is inclusive of patient, resident or client.
Page 1
Effective Date: Sept.2006 Revised Date: July 2009
Infection Prevention & Control-IS0100 Note: In this document the term “patient” is inclusive of patient, resident or client.
Page 2
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IS0200:
Clostridium difficile
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010, December 2012 REVIEWED DATE:
1.0
PURPOSE To prevent the transmission of Clostridium difficile infection (CDI) in healthcare facilities including hospitals, residential care homes and community settings and to minimize the risk of complications associated with CDI.
2.0
DEFINITION Clostridium difficile (C. difficile) is a gram-positive spore-forming anaerobic bacillus and colonizes 35% of adults without causing symptoms. Certain strains can produce two toxins: toxin A and toxin B which are responsible for diarrhea. C. difficile produces spores that are resistant to destruction by common types of environmental disinfectants. Spread of C. difficile occurs due to inadequate hand hygiene and environmental cleaning. Hence, consistent hand hygiene and thorough cleaning of the patient environment and equipment are necessary for control. C. difficile can cause asymptomatic infections or may result in severe, life-threatening disease. It can be acquired in both hospital and community settings. In recent years there have been increasing rates of CDI including outbreaks in hospitals associated with a new hypervirulent epidemic strain of C. difficile. Risk factors associated with CDI include antibiotic usage, proton pump inhibitor usage, bowel disease and bowel surgery, chemotherapy, prolonged hospitalization, increased age and immunosuppressive therapy post-transplant. Cluster: a grouping of cases of patients with CDI within a specific time frame and geographic location suggesting a possible association between the cases with respect to transmission Double Clean: repeating a cleaning regimen immediately after it has been done once Infectious Period: the patient is infectious while diarrhea is present. CDI should be suspected in any patient with unexplained diarrhea, particularly those with associated risk factors Isolation Discharge Clean: refers to the process of cleaning and disinfection which is undertaken upon discharge of a patient from a room. The patient room, cubicle, or bed space, bed, bedside equipment, environmental surfaces, hand washing sink and bathroom should be thoroughly cleaned before another patient is allowed to occupy the space. Outbreak: for the purposes of this document, an outbreak is an increase in the number of CDI cases above the number normally occurring in a particular health care setting over a defined period of time
Infection Prevention & Control-IS0200 Note: In this document the term “patient” is inclusive of patient, resident & client.
Page 1
Transmission: direct contact with unwashed hands of healthcare providers, contaminated environmental surfaces, contaminated equipment
3.0
PROCEDURE 3.1
Additional Precautions • In addition to Routine Practices, CONTACT PRECAUTIONS to be initiated at onset of diarrhea • A single room with a dedicated toilet is preferred • If patients with C. difficile must be cohorted then each patient must be assigned their own separate commode/toilet • Commodes must be emptied in the Soiled Utility Room and not in the patient bathroom • Keep commode at the patient’s bedside • The commode must be cleaned and disinfectant after each use • Decrease patient room moves – lowers risk of environmental contamination
3.2 • • 3.3 • •
• •
•
Hand Hygiene Hand Hygiene using soap and water or alcohol-based hand rub (ABHR) is appropriate Assist patients with cleaning their hands, especially after toileting and before meals Environmental Cleaning Use a sporicidal product (accelerated hydrogen peroxide 4.5%) for cleaning and disinfection Clean and disinfect room environmental surfaces and toilet/commode twice per day by: o Double clean with sporicidal – clean once, then clean surfaces again to disinfect (contact time 10 minutes) o Clean toilet bowl with sporicidal disinfectant Rooms cleaned twice per day using procedure steps above – done once in the morning and again in afternoon/evening Signage - use the GREEN CLOSTRIDIUM DIFFICILE CONTACT PRECAUTIONS SIGN o This green signage alerts Housekeeping staff of the need for twice a day cleaning with a sporicidal disinfectant I.H FACILITY
CLOSTRIDIUM DIFFICILE CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY
CLOSTRIDIUM DIFFICILE CONTACT PRECAUTIONS SIGN
The physical act of friction is necessary to remove C.difficile spores.
3.4 • • • 3.5 •
Patient Equipment Dedicate equipment Promote “decluttering” initiatives to facilitate thorough cleaning of surfaces and separation of clean and dirty items and equipment Label equipment to provide an easy indicator of what is clean and what is dirty Communication Provide daily line listing of current patients with CDI to Nursing, Housekeeping and Pharmacy o Nursing Supervisors/PCC’s – to ensure patients are kept on Contact Precautions o Housekeeping – ensures cleaning and disinfection with a sporicidal disinfectant occurs twice daily o Pharmacy – ensures use of CDI pre printed orders and reviews antibiotics and proton pump inhibitors (PPIs) use
Infection Prevention & Control-IS0200 Note: In this document the term “patient” is inclusive of patient, resident & client.
Page 2
3.6 • •
Visitors Provide instructions on the importance of good hand hygiene Must not use the patient’s bathroom
•
Patient Transfer Notify the receiving unit/facility of additional precautions prior to transferring the patient
3.7
3.8 •
3.9 • • •
3.10 • •
4.0
Patient Discharge Provide the Clostridium difficile patient information pamphlet to the patient and family (Form #828152) located in the Infection Prevention & Control website. (NOT AVAILABLE TO NON IH FACILITIES) Document this education in the patient’s chart. Discontinuation of CONTACT PRECAUTIONS for CDI Precautions may be discontinued when the patient has had no diarrhea for 72 hours It is not necessary to have a negative specimen prior to discontinuing isolation Housekeeping will do a Isolation Discharge Clean of patient room when Contact Precautions are discontinued Relapse of Symptoms Relapse refers to the recurrence of the symptoms of CDI within two months of the last infection and symptom-free period – occurs in about 30% of cases If diarrhea recurs – place patient on CONTACT PRECAUTIONS immediately
3.11
Treatment • Use physician pre-printed orders for Clostridium difficile Treatment. http://inet.interiorhealth.ca/infoResources/forms/Documents/829517.pdf
3.11
CDI Outbreaks • Cases of CDI occurring at a rate exceeding the normally expected baseline rate for the health care setting (or unit, floor, ward) during a specified period of time with evidence of epidemiologically linked cases should be considered as an outbreak. • Call together a multidisciplinary Outbreak Management Team (OMT) - must include Infection Prevention & Control, Workplace Health & Safety, Administration, Nursing, Medical Staff, Support Services; may include Medical Health Officer (MHO) • Additional environmental cleaning to include double clean twice per day using sporicidal for all inpatient rooms and bathrooms on affected units that continue to have a high incidence of CDI cases – continue this approach until the incidence decreases • If new cases of CDI continue to be detected, the OMT may consider recommending the closure of the affected units to admissions until the outbreak is controlled • Outbreak declared over when the number of cases has returned to the endemic level • Hold a debriefing session to identify lessons learned and how future outbreaks can be prevented
REFERENCES 4.1
ANNEX C to Routine Practices and Additional Precautions: Testing, Surveillance and Management to Clostridium difficile In All Health Care Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; May 2010. http://www.oahpp.ca/resources/documents/pidac/RPAP%20Annex%20C%20Testing%20Sur veillance%20Management%20of%20C%20diff.pdf
4.2
Best Practice for Environmental Cleaning for Prevention and Control of Infections in nd all Healthcare Settings. 2 Edition. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; May 2012.
Infection Prevention & Control-IS0200 Note: In this document the term “patient” is inclusive of patient, resident & client.
Page 3
http://www.oahpp.ca/resources/documents/pidac/Environmental%20Cleaning%20BP_ENGLI SH_FINAL_2012-07-15.pdf 4.3
Clostridium difficile Infection (CDI) Toolkit. Provincial Infection Control Network of BC; 2012; http://www.picnetbc.ca/education-training/60/clostridium-difficile-infection-(cdi)-toolkit
4.4
Fact Sheet Clostridium difficile. Public Health Agency of Canada; 2011. http://www.phac-aspc.gc.ca/id-mi/cdiff-eng.php
4.5
A Review of C. difficile Control Measures….. Dr. Michael Gardam, Director of Infection Prevention & Control, University Health Network and Women’s College Hospital, Toronto, Ontario; February 2012.
See the RESIDENTIAL CARE PLAN – Resident with Clostridium difficile Associated Diarrhea
See the ACUTE CARE PLAN – Acute care plan for Clostridium difficile Associated Diarrhea
Infection Prevention & Control-IS0200 Note: In this document the term “patient” is inclusive of patient, resident & client.
Page 4
Infection Prevention & Control-IS0200 Note: In this document the term “patient” is inclusive of patient, resident & client.
Page 5
Resident Name:
RESIDENT CARE PLAN
Date:
Resident with Clostridium difficile Infection RESIDENT CONCERN C-difficile Infection
GOAL Control spread of C-difficile
COMMENTS – Date & Signature
INTERVENTION 1. In addition to Routine Practices, use Contact Precautions: • Dedicate toilet or commode at the onset of diarrhea • Empty contents of commode in Dirty Service Room.
Add pertinent interventions (i.e.) decisions regarding a designated toilet
2. Mobility: If the resident has uncontrolled diarrhea, keep them in their room until the symptoms are resolved or can be easily contained with personal hygiene products. 3. Resident and Visitor Teaching: • Assist residents with hand hygiene – to be done prior to leaving their room, after using the toilet, prior to eating/handling food and when soiled. • Remind visitors of hand hygiene and not to use resident’s bathroom
Environmental Cleaning
Persistent or recurrent diarrhea
Ensure Resident Confidentiality
1. Signage regarding C-difficile infection may be required, 2. Housekeeping needs to be informed to ensure twice daily cleaning is performed. 3. Upon transfer, notify receiving sites additional (contact)precautions are required
Reduce transmission of C-difficile
1. Environmental cleaning of patient room includes double cleans twice per day using a sporicidal (accelerated hydrogen peroxide) for cleaning and disinfection. • Double clean with sporicidal – clean once, then clean surfaces again to Disinfect (contact time 10 minutes) • Clean toilet bowl with sporicidal disinfectant
Prevent recurring infection
2. Rooms cleaned twice per day –once in the morning and again in afternoon/evening 3. Housekeeping will do Isolation Discharge Clean when Contact Precautions are discontinued (resident has no diarrhea for 72 hours) 1. Clostridium difficile preprinted orders available 2. Observe and report progression or recurrence of symptoms. Observe abdomen for distention, ileus or megacolon.
Infection Prevention & Control-IS0200 Note: In this document the term “patient” is inclusive of patient, resident or client.
Page 7
Resident Name:
ACUTE CARE PLAN Date:
Patients with Clostridium difficile Infection Patient CONCERN C-difficile associated infection
GOAL Control spread of C-difficile
INTERVENTION
COMMENTS
1. In addition to Routine Practice, use Contact Precautions o private room with dedicated toilet/commode o empty contents of commode in Dirty Service Room 2. Mobility: The patient should remain in his/her own room unless going to the operating room, attending a medical treatment session, or requiring diagnostic tests. 3. Patient and Visitor Teaching: • Assist patient with hand hygiene – to be done prior to leaving their room, after using toilet, prior to eating/handling food & when soiled. • Remind visitors of hand hygiene and not to use patient’s bathroom
Ensure Patient Confidentiality
Environment al Cleaning
Persistent or recurrent diarrhea
Reduce transmission of C-difficile
Prevent recurring infection
1. Post the Green Contact Precautions sign on outside the patient’s door. 2. When patient goes to another department, or is transferred to another facility, the receiving department or facility MUST be notified of need for additional (Contact) Precautions. 1. Environmental cleaning of patient room includes double cleans twice per day using a sporicidal (sodium hypochlorite or accelerated hydrogen peroxide) for cleaning and disinfection • Double clean with sporicidal – clean once, then clean surfaces again to Disinfect (contact time 10 minutes) • Clean toilet bowl with sporicidal disinfectant 2. Rooms cleaned twice a day – done once in the morning and again in afternoon 3. Housekeeping will do an Isolation Discharge Clean when Contact Precautions are discontinued (patient has no diarrhea for 72 hours) 1. Clostridium difficile pre-printed orders available 2. Observe and report progression or recurrence of symptoms. Observe abdomen for distention, ileus or megacolon.
Infection Prevention & Control-IS0200 Note: In this document the term “patient” is inclusive of patient, resident & client.
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IS0300:
Antibiotic Resistant Organisms
(ARO)
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010 REVIEWED DATE:
1.0
PURPOSE To prevent and control the transmission of Antibiotic Resistant Organisms (AROs) in hospital, residential and community settings.
2.0
DEFINITION Alcohol-based Hand Rub (ABHR) – preferred method of hand hygiene when hands are not visibly soiled. Antibiotic Resistant Organism (ARO) – microorganisms that have developed resistance to the action of several antimicrobial agents and that is of special clinical or epidemiological significance. This guideline will refer primarily to MRSA, VRE and ESBLs. Other multidrug resistant organisms such as the Acinetobacter and Pseudomonas spp. are also emerging in healthcare settings. Cohorting - the placement and care of patients in the same room, who are infected or colonized with the same microorganism; or placing those who have been exposed together to limit risk of further transmission. Colonization – the presence, growth and multiplication of an organism in one or more body sites without observable clinical symptoms. The patient will be asymptomatic MRSA colonization may occur in the nose, perinieum, decubitus ulcers, sputum, urine and at sites of invasive devices such as feeding tubes and tracheosotomies. VRE colonization occurs primarily in the feces. Community-associated Methicillin-resistant Staphylococcus aureus (CA-MRSA) – MRSA cases in persons from the community and who have not had recent exposure to the healthcare system. Contact – an individual who is exposed to a person, colonized or infected, with an ARO in a manner that allows potential transmission to occur, i.e. roommate. Decolonization – the use of topical and systemic antimicrobials to eradicate colonization of resistant bacteria. Current evidence does not recommend MRSA decolonization therapy as this may promote antibiotic resistance, long-term efficacy is poor and systematic therapy may lead to adverse events. Enterococci – bacteria normally found in the gastrointestinal tract of 95% of healthy people. Enterococci may contaminate open wounds and occasionally, are capable of causing invasive disease, particularly in severely immunocompromised people. ESBL – Extended Spectrum Beta Lactamase producing organisms – a group of Gram-negative bacteria (predominantly bowel organisms) such as E.coli and Klebsiella, that produce enzymes that break down antibiotics, rendering them useless. Significant infections include urinary tract infections and surgical wound infections.
Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
Page 1
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, etc. MRSA - Methicillin Resistant Staphylococcus Aureus – strains of Staphylococus Aureus that are resistant to oxacillin (cloxacillin) and cephalosporins. Most people with MRSA are colonized. High risk groups in the community include injection drug users, homeless persons, chronically ill persons, individuals taking frequent or prolonged courses of antibiotics and individuals who are in hospital for longer than 48 hours. Screening – a process to identify patients at risk for being colonized with MRSA and/or VRE and if risk factors are identified, obtaining appropriate specimens and ensuring Additional Precautions are implemented. Staphylococcus Aureus (S. Aureus) – a bacteria normally found in the nose and on the skin of 25 35% of healthy people. It can cause infections such as impetigo, boils, abscesses, wound infections or invasive disease such as pneumonia. Surveillance – continuous observation that leads to early detection of newly emerging pathogens, allows for the monitoring of epidemiologic trends, including detection of outbreaks and for measuring the effectiveness of Infection Prevention and Control interventions. VRE - Vancomycin Resistant Enterococcus – enterococci that have acquired resistance to vancomycin. Most people with VRE are colonized. There is no evidence that infection with VRE is associated with greater mortality than infection with vancomycin sensitive enterocci.
3.0
GUIDING PRINCIPLES 3.1
Due to the limited number of single rooms available in acute care use the Admitting Algorithm for Private Room Allocation to determine priority for the single room assignments. REFER TO ADMITTING ALGORITHM FOR PRIVATE ROOM ALLOCATION (NOT AVAILABLE TO NON IH FACILITIES)
3.2
How are AROs Spread? Note The single most important mode of transmission for AROs in a health care setting is via transiently colonized hands of health care workers who acquire it from contact with colonized or infected patients, OR after handling contaminated material or equipment
3.3
Positive ARO patients will be flagged (electronic notification) in the patient’s electronic record by Infection Control. Flags must protect the confidentiality of the patient.
3.4
The ARO status of a patient should not affect the decision about accepting the individual in transfer from another healthcare setting or department and a negative specimen is not required to transfer a patient.
3.5
Communication is extremely important in regards to the ARO status of patients: • Notify the necessary healthcare facilities of positive results when patients are identified as being ARO positive during their admission or following transfer or discharge.
Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
Page 2
4.0
3.6
In high risk areas of acute care such as ICUs, burn units, transplantation units or cardiothoracic units any patients potentially exposed to a known MRSA or VRE positive patient should have screening cultures performed. However, in other situations screening of contacts may not be practicable as there are limited possibilities to intervene based upon results.
3.7
An outbreak of MRSA or VRE occurs when there is an increase in the rate of new cases (infected and colonized) over the baseline rate, or a clustering of new cases due to the transmission of a specific microbial strain(s) in a healthcare setting. Infection Control would call together a multidisciplinary team to review the situation and provide guidance and support in regards to appropriate control measures to implement.
PROCEDURE
4.1.
Acute Care Routine Screening for AROs • All patients being admitted to acute care for 24 hours or more require screening. Follow procedure using Routine Screening for ARO tool. I.H FACILITY
ROUTINE SCREENING FOR ARO
NON I.H. FACILITY
• • • • • •
ROUTINE SCREENING FOR ARO Screening should be completed as a part of the initial patient admission history and assessment or at least within 24 hours of admission. NOTE: Known MRSA positive patients only require VRE screening. NOTE: Known VRE positive patients only require MRSA screening. NOTE: There is no screening protocol for ESBLs. NOTE: If the patient is unable to answer the screening questions, please ask the patient’s family for information AND review the patient’s electronic record for medical history and previous admissions. All patients who have been hospitalized anywhere for more than 48 hours within the last 3 months require MRSA and VRE screening swabs to be done as follows: MRSA
Nares, Groins, Wound(s) if any
VRE
Rectal
MRSA
Nares, Groins, Wound(s) if any
VRE
Peri-anal Swab
Adults
Pediatric/Neonatal Neutropenic patients (Rectal swabs are not recommended for these patients)
MRSA
VRE
Nares, Groins, Wound(s) if any
Peri-anal Swab
AS WELL AS ROUTINE PRACTICES, USE CONTACT PRECAUTIONS WHICH INCLUDE THE FOLLOWING: I.H FACILITY
REFER TO IH0400 CONTACT PRECAUTIONS GUIDELINE
NON I.H. FACILITY
REFER TO IH0400 CONTACT PRECAUTIONS GUIDELINE
Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
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4.2
Hand Hygiene I.H FACILITY
REFER TO IF0200 HAND HYGIENE GUIDELINE
NON I.H. FACILITY
REFER TO IF0200 H AND HYGIENE GUIDELINE • Hand hygiene with plain soap and water or an ABHR after contact with ARO patient. • In ambulatory/clinic settings, hand hygiene facilities must be available and patients are instructed to perform hand hygiene upon arrival and before leaving.
4.3
Accommodation • All known ARO positive and high risk patients assessed with diarrhea or large draining wounds will be placed on Contact Precautions in a private room if possible. • Single room with toilet and hand washing sink preferred. o Door may remain open. o Place CONTACT PRECAUTIONS sign on door. I.H FACILITY
CONTACT PRECAUTIONS SIGN
NON I.H. FACILITY
CONTACT PRECAUTIONS SIGN
• Cohort o Patients confirmed with the same ARO organism may be grouped together in the same room. o Contact your ICP regarding appropriateness of cohorting. • Shared room o Patients who require ARO screening swabs and do not have diarrhea or large draining wounds can be placed in a shared room. o Maintain spatial separation of at least 2 metres between patients. 4.4
PPE • Wear gloves when entering the room or patient's designated space in shared room. • Gloves MUST be removed BEFORE leaving the room or the patient's dedicated bed space and hand hygiene performed. • Gown must be worn if skin or clothing will come in contact with the patient or any furnishings, equipment or other item in the patient’s environment. • Remove gown BEFORE leaving the room and do hand hygiene. • Surgical/procedure mask and eye protection to be worn by healthcare provider within two metres of patient if patient has MRSA in their respiratory tract AND has signs and symptoms of a respiratory tract infection/productive cough.
4.5
Equipment Dedicate equipment to a single patient. Shared equipment must be cleaned and disinfected between use on patients. Do not take extra supplies into patient’s room. Do not take patient chart into the room. • Clean and disinfect equipment used for transport after each use.
4.6
Environment: • Hospital grade disinfectants are active against AROs and general routine cleaning and disinfection methods are adequate for dealing with AROs. • All horizontal and frequently touched surfaces should be cleaned daily and when soiled. • Clean and disinfect shared items • Cover unused equipment with a sheet (e.g. examination table) to prevent unnecessary contamination. • For Terminal Cleans - remove and launder curtains. o Extra supplies in room must be disinfected, sent for reprocessing or discarded.
Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
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4.7
Transport of Patients on Contact Precautions With any interdepartmental or inter-facility transfers, ensure transport personnel and receiving personnel are notified of necessary precautions. • Healthcare provider to wear gloves and gown for direct contact with patient during transport. • Patient to wear a surgical/procedure mask only if MRSA positive AND has signs and symptoms of a respiratory tract infection.
•
•
Patients must follow the 4 C’s prior to leaving their room:
4 C’s Clean Hands: do hand hygiene Clean Clothes: wear a clean gown or clothes. Contained wounds/body fluids: wounds covered with clean dressing. Urine/feces and other body fluids contained. Co-operative: able to follow instructions.
PATIENTS DO NOT NEED TO WEAR GLOVES OR ISOLATION GOWNS WHILE OUTSIDE THEIR ROOM. Patients should not use common areas of the hospital such as the cafeteria or lounge or enter other patient’s rooms. 4.8
Patient/Family Teaching • Provide the appropriate ARO patient information pamphlet to the patient and family available on the INFECTION PREVENTION & CONTROL WEBSITE. (NOT AVAILABLE TO NON IH FACILITIES).
4.9
Visitors • Wear gloves and gown only if participating in patient care. • Hands must be washed upon entering and leaving the patient’s room. • Visitors are requested not to use the kitchen, lounges or other facilities in the hospital. • Visitors are to wear a mask only if patient is ARO positive and has signs and symptoms of a respiratory tract infection.
See the Acute Care Plan Acute Care Plan for AROs 4.10
Surgical Settings (OR, PAR, DCS) • REFER TO SURGICAL SERVICES PRACTICE M ANUAL. (NOT AVAILABLE TO NON IH FACILITIES).
4.11
Outpatient Settings • For all outpatients and diagnostic areas (Radiation Therapy, Ambulatory Care, Diagnostic Imaging, etc) additional ARO screening is not required. • Instruct patients to wash their hands upon entering and leaving the outpatient setting. • Clean and disinfect all equipment used after each patient visit.
4.12
Maternity/Newborn Nursery • All babies admitted to the Nursery from another hospital are screened for VRE and MRSA and placed on Contact Precautions; if swab results are negative, Contact Precautions are discontinued.
Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
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• • • •
4.13
If the MOM OF A BABY COMING FROM ANOTHER HOSPITAL is ARO positive, screen the baby and regardless of results, the baby remains on Contact Precautions. ARO positive moms must be placed on Contact Precautions and if possible, the newborn rooms in with the mom – if rooming in is not possible, then the newborn in placed on Contact Precautions in the Nursery. ARO positive mom does not require PPE when in the Nursery with her newborn – ensure good hand hygiene is practiced. The newborn of an ARO positive mom does not require screening, nor should an Alert be entered unless a positive test result is received.
Dialysis Settings • Screening for MRSA and VRE should be done: o On initial admission to any hemodialysis or peritoneal dialysis facility. o Upon returning from an admission to an acute care hospital or care facility. o Upon returning from travel (within or outside BC, for any time period). o Visiting dialysis patients should be screened for MRSA and VRE upon their initial arrival to the dialysis unit; admission to any hemodialysis unit should not be denied on the basis of ARO status. o Subsequent screening on negative patients should occur yearly. o Patients with a laboratory-confirmed ARO should not be routinely screened for the known/alerted ARO. o Patients who are known MRSA positive should be screened for VRE. o Patients who are known VRE positive should be screened for MRSA. • MRSA decolonization is not routinely recommended because of repeated failures to achieve sustainable or predictable de-colonization. • Contact Precautions need to be implemented for all ARO positive patients which can be done at the bed/chair side; if the risk assessment for signs and symptoms of infection indicate that the patient has an uncontained draining wound or uncontrolled diarrhea, then a private room is preferred for their dialysis treatment. • The patient’s dialysis station must be thoroughly cleaned prior to the next patient’s treatment regardless of ARO status.
Residential Care
4.14 •
A residential care facility is the resident’s “home” and infection control precautions must be balanced with promoting an optimal, healthy lifestyle for the residents. Studies indicate that residents who are colonized or infected with AROs do not endanger the health of staff or other residents, particularly when healthcare providers consistently use Routine Practices when providing ALL care in these settings.
I.H FACILITY
REFER TO IH0100 – ADDITIONAL PRECAUTIONS FOR ALL CARE AREAS GUIDELINE
NON I.H. FACILITY
REFER TO IH0100 – ADDITIONAL PRECAUTIONS FOR ALL CARE AREAS GUIDELINE
•
Hand hygiene and cleaning and disinfection of shared equipment are the most important ways to reduce risk of transmission of any AROs
•
Screening for AROs is not a recommended practice in Residential Care in BC.
Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
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• • • • • •
• •
•
4.15
Signs are not required to be placed on the door or at the entrance to the resident’s room of a resident who is colonized or infected with an ARO. ARO positive persons should not be denied admission to Residential Care facilities. ARO positive residents are accommodated based on a case by case review and placed with low-risk roommates. Roommates and their families do not need to be advised of the colonization status of the resident with an ARO - in fact this would constitute a breach of confidentiality. Temporary relocation may be necessary if the status of residents colonized with an ARO changes in a way that shedding and transferring their bacteria increases. Residents colonized or infected with an ARO may use common living areas, recreational and socializing areas, and dining facilities, as long as they do not have uncontrolled diarrhea or large draining wounds that cannot be covered and contained. Residents must be assisted to do hand hygiene prior to leaving their rooms. They should not be confined to their room or restricted in their activities or interaction with other residents. Designated equipment and supplies should be identified and stored in a manner that prevents use by or for other residents. Slings should be dedicated to individual residents and be laundered regularly. See the RESIDENTIAL ARO CARE PLAN
Community Care •
Home and Community Care Programs must balance infection control precautions with promoting an optimal, healthy lifestyle for the client, particularly in view of the fact that colonization or infection with an ARO may persist indefinitely. Experience to date does not indicate that clients who are colonized or infected with these microorganisms pose a health risk to healthcare providers, or to other household contacts, particularly when healthcare providers consistently use Routine Practices when providing ALL care in these settings. REFER TO IH0100 – ADDITIONAL PRECAUTIONS FOR ALL CARE AREAS
Hand hygiene and cleaning and disinfection of shared equipment are the most important ways to reduce risk of transmission of any AROs • • •
• •
•
ARO positive persons should not be denied admission to Community Care programs. Clients colonized or infected with an ARO may participate in all recreational and social activities. Open wounds or lesions should be covered with clean, dry dressings. Teach, encourage and remind clients who are able to participate in self-care the importance of hand hygiene, especially after using the toilet and before eating or preparing food. Clients who have difficulty in self-care should be assisted with hand hygiene. After bathing, the tub should be cleaned and disinfected with a household disinfectant. The clients’ towels should not be shared with others. Limit the amount of supplies that are brought into the home (e.g. dressing/supplies). Dedicate patient care equipment, if possible and leave in the home until the patient is discharged from home care services. The equipment should be cleaned and properly disinfected after the patient is discharged. Place reusable items in a plastic bag for transport to another site for subsequent cleaning and disinfection. Clean and disinfect any patient care equipment (e.g. stethoscopes) that cannot remain in the home before removing them from the home. There is no need to disclose colonization with AROs in the workplace, school or child care setting. Anyone entering the workplace, school, child care or shelter setting should cover all draining wounds or skin lesions with a clean dry dressing before entering any of these group settings. SEE COMMUNITY ARO CARE PLAN
Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
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5.0
REFERENCES 5.1
Best Practices for Infection Prevention and Control of Resistant Staphylococcus Aureus and Enterococci in All Healthcare Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; March 2007.
http://www.health.gov.on.ca/english/providers/program/infectious/diseases/best_prac /bp_staff.pdf 5.2
Routine Practices and Additional Precautions for Preventing theTransmission of Infection in Healthcare, Health Canada Infection Control Guidelines; 1999.
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/99vol25/25s4/index.html (NOT AVAILABLE TO NON IH FACILITIES) 5.3
Infection Prevention and Control Manual. Vancouver Island Health Authority (VIHA); 2009.
5.4
Antibiotic Resistant Organisms Prevention and Control Guidelines Provincial Infection Control Network (PICNet) – BC; November 2008.
http://www.picnetbc.ca//sites/picnetbc2/files/Guidelines/ARO_Guidelines_final_Nove mber2008.pdf
Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
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ACUTE CARE PLAN FOR AROs (MRSA, VRE, ESBL, & OTHERS) PATIENT CONCERN Colonization:
MRSA VRE ESBL Other
COMMENTS – Date & Signature
GOAL
INTERVENTION
Control spread of ARO
1. Initiate Contact Precautions (ARO Guidelines in the Infection Control Manual). 2. In addition to Contact Precautions, consider the colonized site: • Sputum: Droplet/Contact Precautions may be considered. • URINE: The patient should only use the toilet in his/her room. • Stool, groin, axilla, device insertion site and nares, use Contact Precautions. 3. Mobility: The patient should remain in his/her private room unless going to the operating room, attending a medical treatment session, or needing diagnostic tests. 4 C’s should be adhered to (see below). Notify the receiving department. 4 C’s: • Clean Hands: Wash hands for 15 s with soap and water or alcohol based hand rub (ABHR). • Clean Clothes: wear clean patient gown or clean clothes. • Contain wounds/body fluids: wounds covered with clean,dry dressing. Urine/feces and other body fluids contained. • Co-operative: able to follow instructions. Patients with a cough and ARO cultured from the sputum must wear a surgical/procedure mask when leaving their room for medically necessary reasons. 4. Patient and Visitor Teaching: (see pamphlet #807272 - MRSA in Acute Care, #807921 - ESBLs in Acute Care, #807918: VRE) • Ensure compliance with hand washing and appropriate use of ABHR – to be done prior to leaving their room, after using the toilet, prior to eating/handling food and when soiled. • Teach visitors re: hand washing as above and use of appropriate PPE. • Visitors are not required to wear PPE unless participating in direct patient care or if patient has large uncontained draining wounds or uncontained body fluids. • Visitors should wear a mask if the patient has a cough and an ARO cultured in the sputum. • Visitors and patients who leave the room are asked not to use the kitchen, lounges or other facilities in the hospital. 5. Safety: Compliance with hand washing and hand hygiene recommendations requires continuous reinforcement! 6. Documentation: Each shift, check off on the patient record that the appropriate care plan has been followed.
Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
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ARO Infection
Ensure Patient Confidentiality
1. Signage regarding Contact Precautions is required outside patient’s room. 2. Information about the patient’s ARO status is to remain confidential among direct care providers (i.e. housekeeping and dietary staff only need to know type of precautions, not patient condition). 3. When patient goes to another department, or is transferred to another facility, the receiving department or facility MUST be notified of ARO status.
Stabilize, eradicate infection
1. Physician to coordinate antibiotic regime if required. 2. In addition to Contact Precautions, contact the ICP to determine necessary additional activity restrictions and/or care interventions.
Effective Date: September 2006
Revised Date: Feb 2011
Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
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RESIDENTIAL CARE PLAN FOR AROs (MRSA, VRE, ESBL, & OTHERS) RESIDENT CONCERN Infection:
MRSA VRE ESBL Other
Site:
Wound Stool Urine Sputum
GOAL Control spread of ARO
INTERVENTION 1. In addition to Routine Practices, consider the infected site: • Room placement may need to be reviewed with ICP. • WOUND: Cover open wounds with dressing or clothing when resident is out of room. • URINE or STOOL: If possible, resident to have separate toilet (assign a bathroom or commode). Empty foley catheter contents and commode contents in Soiled Utility Room, not in a common use toilet. • SPUTUM: If possible residents with symptoms of respiratory infection should be kept in their rooms until symptoms resolve. 2. Mobility: The resident is not restricted from common living areas, dining facilities or recreational and socializing activities unless the resident has diarrhea, pneumonia or copiously draining wounds. Any restrictions are only in place until the symptoms resolve. The 4 C’s should be adhered to (see below). 4 C’s: • Clean Hands: Wash hands for 15 s with soap and water or alcohol based hand rub (ABHR). • Clean Clothes: wear clean clothes every day. • Contain wounds/body fluids: wounds covered with clean, dry dressing. Urine/feces and other body fluids contained. • Co-operative: able to follow instructions. 3. Resident and Visitor Teaching: (see pamphlet #807271 - MRSA in Residential Care, #80792 - ESBLs in Residential Care, #807918 - VRE) • Assist with hand washing and appropriate use ABHR – to be done prior to leaving their room, after using the toilet, prior to eating/handling food and when soiled. • Teach visitors re: hand hygiene as above. 4. Safety: Compliance with hand hygiene recommendations requires continuous reinforcement! Equipment that is not dedicated to resident use must be cleaned and disinfected between uses.
Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
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COMMENTS – Date & Signature Add pertinent interventions (i.e. decisions regarding a designated toilet) and highlight areas under intervention that apply to resident
Ensure Resident Confidentiality
1. Signage regarding ARO status is NOT required. 2. Information about the resident’s ARO status is to remain confidential among direct care providers. Upon transfer, notify receiving sites and transfer personnel of ARO status – teach resident and visitors regarding precautions taken at acute site (Contact Precautions, single room – see pamphlet #807272 - MRSA in Acute Care, #807921 - ESBLs in Acute Care).
EFFECTIVE DATE: September 2006
REVISED DATE: Feb 2011
Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
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CLIENT CONCERN Infection:
MRSA VRE ESBL Other
Site: Wound Stool Urine Sputum
COMMUNITY CARE PLAN FOR AROs (MRSA, VRE, ESBL & OTHERS) GOAL Control spread of ARO
INTERVENTION 1. Adhere to the ARO Guidelines in the Infection Control Manual. 2. In addition to Routine Practices, consider the infected site: WOUND: Cover open wounds when out of room with dressing or clothing URINE or STOOL: If possible, client should have separate toilet. Empty foley catheter contents in designated toilet. When separate toilet not available, the shared toilet requires routine cleaning with a household disinfectant. SPUTUM: If possible clients with symptoms of respiratory infection should be requested to stay at home until symptoms resolve. 3. Mobility: The client is not restricted in home or public unless there is an open draining wound and then public pools and contact sports or other skin to skin contact should be avoided until the wound is healed. Client should notify any medical personnel of MRSA status prior to appointments. Teach client to follow the 4 C’s: 4 C’s: • Clean Hands: Wash hands for 15 s with soap and water or alcohol based hand rub (ABHR) often while at home and in the community. Remind visitors to practice good hand hygiene. • Clean Clothes: wear clean clothes every day and practice good personal hygiene. • Contain wounds/body fluids: wounds covered with clean, dry dressing or clothing; urine/feces and other body fluids container. • Co-operative: able to follow instructions. Inform others in the household of the need for good hand hygiene. (See Pamphlet #807272 – MRSA in Acute Care: section on “When you go home”, #807921 – ESBLs in Acute Care, #807918 - VRE). 4. Client & Family Teaching: Assist with hand washing with plain soap – to be done prior to leaving their home, after using the toilet, prior to eating/handling food and when soiled. 5. Safety: Compliance with hand washing and hand hygiene recommendations requires continuous reinforcement!
Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
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COMMENTS Add pertinent interventions to CHW careplan; i.e. decisions regarding a designated toilet and clothing over open wounds will need to be included in the CHW careplan
ARO Infection
Ensure Client Confidentiality
1. Signage regarding ARO status is NOT required 2. Information about the client’s ARO status is to remain confidential among direct care providers 3. Notify acute or residential site of ARO status upon transfers – teach client and visitors regarding precautions taken at acute site (Contact Precautions, single room)
Stabilize, eradicate infection
1. Physician to coordinate antibiotic regime 2. In addition to routine practices and colonization interventions, contact the ICP to determine necessary additional activity restrictions and/or care interventions.
EFFECTIVE DATE: September 2006
REVISED DATE: Nov 2010
Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
Page 14
To ensure client confidentiality, DO NOT write the ARO status on the CHW careplan.
Use of gloves & hand hygiene is part of Routine Practices
Acute Care Admission Screening for MRSA and VRE
Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
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Infection Prevention & Control-IS0300 Note: In this document the term “patient” is inclusive of patient, resident or client.
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IS0400:
Scabies/Lice
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010 REVIEWED DATE:
1.0
PURPOSE To prevent transmission of scabies and lice to patients and staff.
2.0
DEFINITIONS Scabies • Scabies is a contagious parasitic infestation caused by a mite, Sarcoptes scabiei. • Scabies infestations are identified by the following characteristics: o Skin penetration is visible as papules or vesicles. o Linear burrows formed by the mite under the skin. o Severe pruritus. These lesions commonly appear in interdigital spaces, anterior surfaces of wrists and ankles, axillae, skin folds, genitalia, belt-line and abdomen. Itching may be intense, especially at night and lesions may become secondarily infected due to scratching. Crusted (Norwegian ) scabies presents as a crusty, scaly dermatitis usually on hands and feet, including dystrophic nails. Some affected individuals may have a generalized erythematous eruption. Norwegian scabies is highly infectious owing to the large numbers of mites present. Definitive diagnosis of scabies infestation is by microscopic examination of mites extracted by a needle or scalpel (skin scraping). Lice Lice (pediculosis) are called ectoparasites because they live outside the host’s body. There are three types of human lice which are usually, but not always, confined to a certain part of the body. They are named according to the region of the body that they infest or their general appearance: head louse, body louse, and pubic or crab louse. These creatures cannot fly or jump, but head and body lice move quickly, passing rapidly from host to host. Head Lice Head lice generally prefer the fine hairs of the head especially around the ears and the nape of the neck or eyebrows and eyelashes. Adult larvae and nits are visible to the naked eye: • Adult lice are reddish-brown. • Unhatched eggs are pearly white. • Hatched eggs are translucent.
Infection Prevention & Control-IS0400 Note: In this document the term “patient” is inclusive of patient, resident or client.
Page 1
Infectious Period • Scabies and lice can be transmitted up until the time they are eradicated by treatment with 5% permethrin cream. • The incubation period for primary infestation occurs as early as 10 days, but it is typically 4 – 6 weeks. Transmission • Scabies and lice are transmitted through direct or indirect contact. • Although blood and body fluids are not affected by these infestations, the patient’s clothing, bed linen, and mattress are contaminated by direct contact with the infected patient. • Head lice are transmitted through contact with infested hair or with articles such as brushes, combs, headgear, or clothing of the infested person. • Transmission of pubic lice is usually by sexual contact. 3.0
PROCEDURE 3.1
Additional Precautions • Patients with scabies or lice are placed on Contact Precautions • Refer to IH0400 – Contact Precautions Guideline until 24 hours following treatment. • I.H FACILITY
REFER TO IH0400-CONTACT PRECAUTIONS GUIDELINE
NON I.H. FACILITY
REFER TO IH0400-CONTACT PRECAUTIONS GUIDELINE
• •
3.2
In persons with crusted scabies, the length of additional precautions may be longer. Staff to wear a gown and gloves for all patient contact until the treatment has been completed and Contact Precautions discontinued.
Treatment • Ordered by the attending physician. • 5% permethrin cream applied as directed. Milder doses may be required for children and pregnant or lactating women. Itching may persist for days to weeks following treatment. This is not to be mistaken for treatment failure.
•
Carefully examine the patient for new burrows in seven days. If there is evidence of continued infestation, treatment may be repeated if considered necessary - ordered by the attending physician.
3.3
Staff Contact Workplace Health and Safety if symptomatic.
3.4
Handling Patient’s Clothing, Linen And Laundry • Place patient’s personal clothing in a plastic bag and securely close the bag. Send this laundry home with the family to be laundered. • Routine Practices are used for handling all laundry items – place soiled linen in appropriate plastic laundry bag and send to Laundry for cleaning.
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3.5
3.6
4.0
Housekeeping Perform routine cleaning. I.H FACILITY
REFER TO IF0100- ROUTINE PRACTICES FOR ALL CARE AREAS GUIDELINE
NON I.H. FACILITY
REFER TO IF0100 – ROUTINE PRACTICES FOR ALL CARE AREAS GUIDELINE
Management of Scabies Outbreaks See B.C. Centre for Disease Control (BCCDC) for policy: http://www.bccdc.ca/NR/rdonlyres/41348278-088C-4E58-856D93EA6FDA6EA3/0/InfectionControl_GF_Scabies_Feb_2005.pdf
REFERENCES 4.1
APIC Text 2009. http://text.apic.org/item-96/chapter-92-parasites/basic-principle.
4.2
BCCDC Communicable Disease Manual http://www.bccdc.ca/NR/rdonlyres/41348278-088C-4E58-856D93EA6FDA6EA3/0/InfectionControl_GF_Scabies_Feb_2005.pdf.
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IS0500A:
Tuberculosis
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010 REVIEWED DATE:
1.0
PURPOSE The goal of the Tuberculosis (TB) Management Program is to prevent transmission of TB to staff and patients.
2.0
DEFINITIONS The most common site of TB infection is in the upper regions of the lungs. Mycobacterium tuberculosis is spread by the airborne route when patients expectorating viable tubercle bacilli contaminate the surrounding airspace. Aerosolized tubercule bacilli can be inhaled by susceptible patients and staff and can lead to primary tuberculosis infection. The incubation period for TB is between two and twelve weeks. Pulmonary and laryngeal TB are the only types of TB that are spread via the airborne route. In Canada, TB occurs in well-defined populations including Aboriginal Canadians, the urban poor or immigrants from high-incidence countries in Asia, Eastern Europe, Africa and Latin America. Immunocompromised persons such as those with HIV and diabetes are also at an increased risk of developing active TB. Other groups at risk include people who live or work in residential care facilities (e.g. jail, nursing homes, drug treatment centers), alcoholics, indigent persons and IV drug users. Persons who live in the same household with a high risk individual are also at risk. Because healthcare providers have frequent contact with persons in these groups, the risk of transmission of TB remains an important potential occupational hazard.
3.0
GUIDING PRINCPLES A HIGH INDEX OF SUSPICION MUST BE MAINTAINED – EARLY DIAGNOSIS IS KEY IN PREVENTING HEALTHCARE ASSOCIATED TRANSMISSION FROM INFECTIOUS CASES WHICH OFTEN OCCURS BEFORE DIAGNOSIS.
3.1
Determinants of TB Transmission • TB is spread by the inhalation of airborne organisms when a patient coughs, sneezes or speaks – once infectious particles have been aerosolized, they are spread throughout a room or building by air currents and can be inhaled by other individuals. • Procedures associated with increased risk of generation of infectious aerosolized particles including bronchoscopy, laboratory and autopsy procedures, cough inducing procedures (i.e. sputum induction), administration of aerosolized therapies that induce coughing and irrigation of TB-infected wounds. • Patients with respiratory secretions that are acid-fast bacilli (AFB) smear positive are more infectious than those whose smear results are negative. • Patients with laryngeal involvement are particularly contagious. • The risk of transmission increases with the increasing amount of time spent with an infectious patient without wearing appropriate personal protective equipment (PPE).
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•
In buildings with sealed windows and mechanical ventilation systems, recirculation of air can contribute to transmission in healthcare facilities.
3.2
Risk classification: healthcare facilities • Classification is based on the number of active inpatient beds and the number of TB cases of all forms and sites. Hospital with > 200 beds: < 6 TB patients admitted annually = low risk. > 6 TB patients admitted annually = medium risk. Hospital with < 200 beds AND other facilities such as long-term care: < 3 TB patients admitted annually = low risk. > 3 TB patients admitted annually = medium risk. • In Medium-risk hospitals a TB management committee is recommended, whose members should include persons with day-to-day responsibility for infection prevention and control and employee health, representation from senior administration, laboratory, nursing, medicine, other health disciplines (e.g. respiratory technology) and public health (additional members may be added from support services such as pharmacy, housekeeping, physical plant).
3.3
Risk classification: healthcare workers • High-risk activities including cough-inducing procedures (sputum induction, pentamidine aerosol), autopsy, morbid anatomy and pathology examination, bronchoscopy, designated mycobacteriology laboratory procedures, especially handling cultures of M. tuberculosis. • Intermediate-risk activities including regular direct patient contact (e.g. by nursing, respiratory, social workers, physiotherapists, housekeeping) on units to which patients with active TB may be admitted. • Low-risk activities including minimal direct patient contact (medical records, administration, maintenance) and those who work on units where TB patients are unlikely to be admitted such as obstetrics or pediatrics. • IH WH&S (Workplace Health & Safety) have developed a tool and will work collaboratively with Infection Control Practitioners to establish risk classifications – REFER TO THE FACILITY TUBERCULOSIS RISK ASSESSMENT FORM. • Recommend that all facilities make available to their healthcare workers annual summary information on the clinical, epidemiologic and microbiologic features of patients whose TB is diagnosed within the hospital – will help to increase awareness of TB in the patient population served by the hospital.
3.4
Early identification of patients with suspected TB • Symptoms consistent with active TB include fever, cough for more than 3 weeks, unexplained weight loss, hemoptysis, loss of appetite, and night sweats. • Chest x-ray done in suspect cases. • Sputum specimens tested for acid-fast bacilli (AFB) in suspect cases o Collect 3 sputum specimens 8 – 24 hours apart and at least one should be collected in the early morning upon awakening. o Do gastric aspirates in children too young to produce sputum.
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4.0
PROCEDURE There are 6 specific processes: • Airborne Precautions • Environmental Engineering Controls • Respiratory Protection • Personal Controls: Screening and follow-up • Contact Investigation for Patient & Staff • Discharge Planning 4.1
Airborne Precautions (back to PROCEDURE) Inform Infection Prevention and Control of all patients with confirmed TB and patients who have a high suspicion of TB who are in the facility. • Patient must be placed on Airborne Precautions in an appropriately ventilated Airborne Isolation Room •
I.H FACILITY
REFER TO IH0200 – AIRBORNE PRECAUTIONS GUIDELINE
NON I.H. FACILITY
• •
•
REFER TO IH0200 – AIRBORNE PRECAUTIONS GUIDELINE. If an Airborne Isolation Room is not available then arrange to have the patient transferred to a facility with the necessary room requirements as quickly as possible. Staff entering the room must wear approved respiratory protection (will be referred to as N95 respirators for remainder of document), ensuring the seal checks are done when the N95 respirator is put on
I.H FACILITY
REFER TO IH0200 – AIRBORNE PRECAUTIONS GUIDELINE
NON I.H. FACILITY
• • • • •
REFER TO IH0200 – AIRBORNE PRECAUTIONS GUIDELINE.
Visitors entering the room should be offered an N95 respirator, staff to teach the seal check and how to put the N95 respirator on. Visits by children should be discouraged because of their increased susceptibility. Patient is to leave the room for essential procedures only and is to wear a surgical/procedure mask when outside their isolation room. Exceptions due to extenuating circumstances must be reviewed and approved by the attending physician & Infection Control – a written order is required. Notify receiving departments of Airborne Precautions requirements – staff will need to wear an N95 respirator when the patient is unable to wear a surgical/procedure mask. If transport between facilities is required, patient should be transported in wellventilated vehicles (i.e. with the window open) and attendants should wear an approved respirator mask – DO NOT use public transportation.
4.1.1
Special Situations: • ICU o Maintain Airborne Precautions. o Place patient in an Airborne Isolation Room with door closed. o Staff must wear N95 respirator.
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o
o
4.1.2
If intubation and mechanical ventilation is required, an appropriate bacterial filter should be placed on the endotracheal tube to prevent contamination of the ventilator and the ambient air. Use closed suction apparatus for endotracheal suctioning.
•
Surgery o Surgery should be postponed or scheduled at the end of the day. o If intubation and mechanical ventilation is required, an appropriate bacterial filter should be placed on the endotracheal tube to prevent contamination of the ventilator and the ambient air. o Use Airborne Isolation Room (if available) for procedure. o Staff must wear N95 respirator. o Door to room patient is in must remain closed.
•
Minor procedures that are not high risk for TB transmission o Refers to urgent procedures needed for medical care that cannot be postponed until the patient is deemed non-infectious such as blood work or diagnostic imaging. o Preference is to perform procedure in room with appropriately ventilated negative pressure with staff wearing approved N95 respirator. o If not possible, patient should be instructed to wear a surgical/procdure mask during procedure, recovery and transport. Patient should be instructed to keep the mask on and change the mask if it becomes wet.
Discontinuation of Airborne Precautions for Patients with suspect TB - on approval only by the Infection Prevention & Control Practitioner, the Respirologist, the Infectious Diseases Physician or the Medical Director for Infection Prevention and Control • When three successive samples of sputum are negative on smear, unless TB is still strongly suspected, cultures are pending and no other diagnosis has been made. • The sputum specimens should be collected 8-24 hours apart and at least one should be an early morning specimen. • When another definitive diagnosis is made and active TB is considered unlikely.
Note: A single negative AFB smear from bronchoalveolar lavage (BAL) does NOT definitively exclude active TB and three induced sputum specimens have superior yield for the diagnosis of active TB than a single bronchoscopy. •
• •
Patients with smear-positive TB – require three consecutive negative sputum smears - the sputum specimens should be collected 8-24 hours apart and at least one should be an early morning specimen AND there should be clinical evidence of improvement AND evidence of adherence to at least 2 weeks of multidrug therapy based on the antibiotic sensitivity of the patient’s organism. Patients with smear-negative, culture-positive TB – discontinue Airborne Precautions after 2 weeks of appropriate multidrug therapy as long as there is clinical evidence of improvement. In the event that a smear-positive, culture-negative condition develops during treatment, Airborne Precautions may be discontinued provided three
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•
•
4.2
4.3
consecutive sputum specimens are culture negative after 6 weeks of incubation. Patients with active Multidrug resistant (MDR-TB) – must remain in Airborne Precautions for the duration of their hospital stay or until three consecutive sputum cultures are negative after 6 weeks of incubation; if discharge is being planned, refer to 7.0 DISCHARGE PLANNING. Patients with pleural TB – if unable to collect sputum cultures, recommend bronchoscopy to obtain specimens to rule out pulmonary TB – must ensure samples are taken from various areas of effusion.
Environmental Engineering Controls (back to PROCEDURE) 4.2.1
Ventilation • Newly constructed Airborne Isolation Rooms should have 12 air changes per hour; pre-existing rooms should have at least 6 air changes per hour or as per current CSA Standards. • The direction of air flow should be from the hall and into the room and then exhausted outdoors. • Direction of air flow should be tested with smoke tubes at all four corners of the door daily when the room is occupied, unless the room is equipped with automatic pressure monitoring. • Windows and doors should be kept closed at all times. • The air changes and direction of air flow should be verified at least every 6 months AND if any changes occur such as HVAC equipment failure or alarm failure. • Time needed to remove airborne contaminants after generation of infectious droplet nuclei has ceased is 45 minutes.
4.2.2
Sputum Induction, Pentamidine Aerosol, Bronchoscopy Suites and Autopsy Suites • Airborne Isolation Room requires at least 12 air changes per hour or as per current CSA Standards. • Time needed to remove airborne contaminants after generation of infectious droplet nuclei has ceased is 45 minutes.
Respiratory Protection Program (back to PROCEDURE) • • •
• •
Current recommendations call for particulate respirator masks that filter 95% of particles of 1 micron or larger and have less than 10% leak to protect workers against airborne TB. Most common product used are NIOSH-designated N95 respirators. Healthcare providers require education regarding the occupational risk of TB, the role of respiratory protection to reduce that risk, the importance of wearing the N95 respirator properly, doing a seal check each time the N95 respirator is put on so that there is a tight facial seal and ensuring the N95 respirator is put on correctly before entering the patient’s room. N95 respirators must be available for staff whenever a patient is identified who is suspected of or confirmed to have active TB. N95 respirators should be worn by workers involved in the transport of patients suspected of or confirmed as having active TB, e.g. ambulance workers, particularly when patient cannot wear a surgical/procedure mask.
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• • •
4.4
4.5
N95 respirators should be available for caregivers, e.g. community healthcare workers who may have to provide care while waiting for patient transfer to a facility with appropriate environmental controls. TB patients can wear surgical/procedure mask when they leave their rooms as these mask are effective in trapping the large infectious particles expelled by TB patients. Visitors should be offered an N95 respirator, staff to teach the seal check and how to put the mask on.
Personal Controls: Screening & Follow-up (back to PROCEDURE) 4.4.1
Baseline Tuberculin Skin Testing (TST) For Healthcare Workers • Appropriate baseline TST for all potentially exposed healthcare workers in all healthcare settings is important (BCCDC TB Control does not recommend a two step TST). • Upon hire, all employees should have a TST unless they have documented results of a prior positive test. • Workers with reactions of less than 10 mm induration should be considered TST negative for baseline screening purposes. • Workers with a reaction of 10 mm induration or greater on the test should be considered TST positive, be referred for chest radiography and medical evaluation and consideration of prophylactic treatment of Latent TB Infection (LTBI). • Healthcare workers with history of a positive TST should not receive further TSTs – performing annual chest radiography of asymptomatic TST-positive staff is not recommended (Pg. 338 Canadian TB Standards 2007).
4.4.2
TST Following Unprotected Exposure • Any healthcare worker who has unprotected exposure to a patient who is confirmed to have active, contagious TB must be considered at risk of infection. • For TST-negative workers, a TST should be done as soon as possible and, if negative, repeated after 8 to 12 weeks. If TST conversion occurs, the worker should be referred for chest radiography and medical evaluation. • For TST-positive workers, the worker should be educated regarding the signs and symptoms of TB and if such symptoms develop, chest radiography should be performed and three sputum specimens should be tested for AFB.
4.4.3
Periodic TST for Workers in Medium Risk Hospitals and Programs OR Those Performing High Risk Activities in All Hospitals • Annual TST is recommended for healthcare workers with negative baseline TST who are involved in moderate-risk activities in medium-risk hospitals AND for workers involved in high-risk activities in all hospitals.
Contact Investigation for Patients and Staff (back to PROCEDURE) (A person identified as having come in contact with a case of active disease. The degree of contact is usually further defined on the basis of closeness. Contacts may be classified as close, casual or community.)
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•
• • • • • • •
When a case of TB is identified and appropriate Airborne Precautions had not been implemented, a large number of contacts who need to be assessed can result. This includes patients, hospital staff, physicians, volunteers and visitors who were exposed to the case during the infectious period. If the case arrived from the community or was transferred from another facility, contacts outside the institution would also need to be considered. ICP to work collaboratively with the Communicable Disease (CD) Unit, WH&S and medical staff to ensure appropriate contact investigation and follow up is implemented promptly. Patients are considered a contact if they have shared a room with another patient confirmed with TB – they have had regular, prolonged contact with the source case and share breathing space daily. Patient contacts are NOT infectious and DO NOT require Airborne Precautions, however, they do require follow up evaluation by their family physician. ICP notifies CD Unit of positive active TB case and potential contacts in hospital – Public Health will assist in follow up of discharged patients, visitors and volunteers. ICP notifies WH&S regarding the contact investigation of an active case of TB – WH&S will carryout follow up for staff exposures (Section 5.2 above). ICP notifies the ‘contact’ patient’s attending physician regarding the potential exposure of their patient to an active TB case and advises that follow up is necessary - if patient still in hospital, a baseline TST can be done by the institution. • ICP notifies the Patient Transport Office (PTO) of potential external contacts such as ambulance personnel, first responders and other transport services and advises that follow up is necessary – PTO will ensure contact is made with the necessary providers in this regard.
4.6
Discharge Planning (back to PROCEDURE) • Initially smear-positive patients may be discharged home even if they are still smear positive provided a smooth transition plan has been developed between the hospital and community public health for follow–through provision of TB medications and ongoing care. • Some TB patients may be noncompliant, homeless or have circumstances where community care is unlikely to succeed and may need hospitalized provision of treatment medications until they become non-infectious (sputum is smear negative) – this process may be voluntary by the patient OR under an Order by the Medical Health Officer under the Health Act. • Once all parties have been notified and a discharge date has been agreed upon (minimum of 3 working days required to ensure services are in place), the discharge can proceed. • Public Health is responsible for evaluating conditions necessary for the discharge to proceed including directly observed therapy (DOT) if indicated, evaluation of household air recirculation in housing units such as apartment complexes, review of household contacts including infants and children, patient counseling about precautions necessary during infectious period of disease and to refrain from going into any other indoor environment where TB transmission could take place AND if patient has to attend an outpatient clinic, they must wear a mask until they are no longer infectious.
4.7
Process/Protocol • As soon as possible after an in-patient is confirmed as having active pulmonary tuberculosis, the CD Unit will coordinate a case teleconference – this is a collaborative process for the purpose of information sharing, identification of case contacts, early recognition of discharge planning needs and coordination of key stakeholders, including:
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CD Unit. Hospital Transition Nurse/Discharge Planner (specific to unit where patient is located). o Patient Care Coordinator [PCC] (specific to unit where patient is located). o Hospital Infectious Disease Pharmacist [or designate]. o Urban Outreach Social Worker (if case in Kelowna). o Urban Outreach Case Manager (if case in Kelowna). o Public Health Nurse (specific to geographic area). o Hospital Social Worker (if patient not an Urban Outreach client). o Home & Community Care Manager [or designate] (specific to geographic area). o Occupation Health Nurse Specialist. o Hospital Infection Control Practitioner. o WH&S Consultant (for fit-testing), Community Infection Control Practitioner and others may join teleconference as needed. Needs to be a collaborative process between the hospital physician, MHO and consultant TB physician from BCCDC TB Control division to determine appropriateness of discharge. MHO will notify public health services to assure the out-patient prescription medications are in place and that community protection protocols are established, should the patient still be infectious. CD Unit will coordinate with local Public Health Nursing staff and the hospital discharge planner, to ensure an adequate discharge plan is in place prior to patient release. Notify family doctor for an appropriate follow-up appointment. Notify Home/Community Care Services to prepare for receiving and attending the patient, giving sufficient time to allow for adequate fit-testing and education of staff, if required. Notify transport services, if required. Once all parties have been notified and a discharge date has been agreed upon, (minimum of 3 working [Mon-Fri] days required to ensure services are in place additional time may be required depending on the complexity of the case), the discharge can proceed. o o
• • • • • • •
5.0
REFERENCES: 5.1
Canadian Tuberculosis Standards 6th Edition by The Public Health Agency of Canada and The Lung Association, 2007; Chapter 16.
5.2
APIC Text of Infection Control and Epidemiology 3rd Edition 2009; Chapter 91.
5.3
Canadian Standards Association CAN/CSA-Z317.2-01 Special Requirements for Heating, Ventilation, and Air Conditioning (HVAC) Systems in Health Care Facilities 2008.
5.4
WorksafeBC Occupational Health and Safety Regulations available: http://www2.worksafebc.com/Publications/OHSRegulation/Part8.asp#SectionNumber:8.3 2RespiratoryProtection%20available%20at
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TUBERCULOSIS MANAGEMENT PROGRAM QUICK REFERENCE Goal is to prevent transmission of TB to staff and patients Early diagnosis necessary If TB suspected, implement Airborne Precautions immediately – place patient in Airborne Isolation room and staff to wear N95 respirators Place appropriate Airborne Precautions sign on door and ensure that the negative pressure is turned on and working. Room pressure must be checked each shift. Collect 3 sputum specimens 8 – 24 hours apart with at least one being an early morning specimen Patient to wear surgical/procedure mask when outside of Airborne Isolation room Visitors to be offered N95 respirator – teach re seal check Children should not visit Discontinue Airborne Precautions only on approval from ICP, Infectious Disease physician, Respirologist, or Medical Director for IP&C When Airborne Precautions are discontinued and room is cleaned, 45 minutes is required to remove airborne contaminants Discharge planning done collaboratively with Public Health and others – requires minimum of 3 working days to ensure necessary services are organized and available
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Infection Prevention & Control-IS0500A Note: In this document the term “patient” is inclusive of patient, resident & client.
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IS0500B
Tuberculosis Risk Screening – Residential Facilities
EFFECTIVE DATE: July 2007 REVISED DATE: November 2010 REVIEWED DATE:
1.0
PURPOSE Persons with active pulmonary tuberculosis are excluded from admission to a Residential Care Facility. The Medical Health Officer may make alternative policy decisions based on local disease incidence and prevalence.
2.0
DEFINITIONS High Risk Clients who require screening are defined as follows: • Born in or lived in a foreign country known for its high prevalence of tuberculosis. These countries include China, Vietnam, Philippines, Hong Kong, India subcontinent, *Eastern Europe, Africa, Mexico, Korea, Indian Subcontinent including Bangladesh, Bhutan, India, Myanmar, Nepal, Pakistan, Sri Lanka, Tibet. • Aboriginals (including Status, Non-Status, Metis and Inuit). • Persons with symptoms compatible with possible pulmonary tuberculosis, i.e. productive, prolonged cough, hemoptysis, chest pain, fever, chills, night sweats, tires easily, loss of appetite and/or unexplained weight loss. • Previous history of tuberculosis. • Immunocompromised or illness affecting immunity. • History of non-resolving pneumonia. • History of substance abuse, i.e. illicit drug or alcohol abuse. o Eastern Europe: Albania, Belarus, Bosnia, Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Macedonia, Moldova, Poland, Romania, Slovakia, Ukraine, Yugoslavia.
3.0
GUIDING PRINCIPLES All persons being admitted to a licensed Residential Care Facility are to be assessed for their risk of tuberculosis and this information will be recorded on the resident’s chart. This process needs to be completed prior to the person being admitted to the care facility and may occur while the individual is still living at home in the community or while the person is in the hospital and cannot return to the community. This does not include “short stays” ( 48 hours (unless an indwelling medical device in place) OR o prior contact with any Health Care facility including surgery, dialysis and LTC admissions in previous 12 months OR o newborns if mother not known to be a case on admission or suspected to be colonized o does not include Emergency Room and Ambulatory Care outpatient visits.
Pneumonia Definitions - Pneumonia identified by using a combination of the following criteria: • Radiologic - two or more serial chest x-rays with new or progressive & persistent infiltrate, consolidation, cavitation (only one x-ray if no lung/heart disease). • Clinical S&S- breath sounds, fever, altered mental status, sputum, cough, increased respiratory rate or oxygen needs. • Lab - sputum culture, elevated WBC. 4.4.1
Ventilator Associated Pneumonia (VAP) • Clinical presentation meets criteria for Pneumonia, including x-ray confirmation. • There is no minimum time for a patient to be on a ventilator for a VAP to be identified …as long as the organism isn’t present/incubating on insertion of ET tube. • Aspiration pneumonia is considered healthcare-associated if the aspiration occurred during intubation and the criteria for pneumonia is met (a VAP occurring as part of the ventilation process).
4.4.2
Post Procedure Pneumonia (PPP) • Clinical presentation meets criteria for Pneumonia, including x-ray confirmation. • Detected prior to discharge following inpatient operation. • Does not include PPP following outpatient operations (as per NHSN 2008 guidelines).
Central Line Infection (CLI) Definition – surveillance restricted to Intensive Care Unit (ICU) patients with a central line who: • Have a recognized pathogen cultured from one or more blood cultures, unrelated to infection at another site (includes common skin contaminant if cultured from 2 or more blood cultures drawn on separate occasions not more than 2 days apart). • Blood Stream Infection (BSI) not present prior to insertion of central line. • BSI onset during ICU stay or within 48 hours of leaving ICU. • There is NO minimum period of time that the central line must be in place in order for the BSI to be considered central-line associated.
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• • •
4.6
Central line: An intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring. PICC (peripherally inserted central catheter) or PIC line is inserted in a peripheral vein and then advanced through increasingly larger veins toward the heart until the tip rests in the distal superior vena cava is considered a central line. Non-lumened devices inserted into central blood vessels or the heart (i.e. pacemaker) are not considered central lines if fluids are not infused, pushed or withdrawn through the device.
Lower Respiratory Tract Infection (LRI) / Pneumonia Definition in Residential Care Criteria: At least THREE of the following: • New or increasing cough. • New or increased sputum production. • Fever (>38C). • Pleuritic chest pain. • New or increased physical findings on chest examination (rales, rhonchi, wheezes, bronchial breathing). • Change of status in breathing difficulty (new or increased SOB, or respiratory rate >25 per minute, or worsening mental or functional status). Pneumonia Criteria: same as (LRI) PLUS: Chest radiograph indicative of pneumonia, OR a physician diagnosed pneumonia based on clinical assessment. 1. Interpretation of a chest radiograph (demonstrating pneumonia, probable pneumonia, or presence of a new infiltrate). BOTH of the following must be met:
AND 2. At least TWO of the signs and symptoms listed above under LRI.
4.7
Skin & Soft Tissue Infection (SSTI) Definition in Residential Care Criteria: Must have ONE of the following: • Pus present at a wound, skin, or soft tissue site OR • Four or more of the following S&S: fever (>38C), site swelling, site tenderness, site redness, heat at site, worsening mental or functional state. Stratified into 3 categories: • Cellulitus which must be diagnosed by physician – defined as “infection that extends into subcutaneous tissues; usually quite painful and tender, occurring most often on the legs, usually below the knee; often accompanied by red, edematous, indurated skin markings” (APIC Text, 2009, Ch 96). • Chronic ulcer – decubitus, pressure, arterial. • Skin/wound – may be secondary to injury.
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4.8
Catheter Associated Urinary Tract Infection (CAUTI) in Residential Care Criteria: Must have at least TWO of the following: • Fever (>38C) or chills, new flank or supra-pubic pain or tenderness, change in character of urine (new bloody urine, foul smell, or amount of sediment), worsening of mental or functional status AND Culture results correlating with above symptoms
5.0
REFERENCES 5.1.
Antibiotic Resistant Organisms Prevention and Control Guidelines. Provincial Infection Control Network (PICNet) – BC; November 2008. http://www.picnet.ca/practice-guidelines
5.2.
Best Practices for Surveillance of Healthcare Associated Infections in Patient and Resident Populations. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; October 2011. http://www.oahpp.ca/resources/documents/pidac/Surveillance_3-3_ENGLISH_2011-1028%20FINAL.pdf
5.3.
CDC/NHSN surveillance definition of healthcare associated infection and criteria for specific types of infections in the acute care setting; American Journal of Infection Control; 2008.
5.4.
Clostridium difficile Infection (CDI) Surveillance System. Provincial Infection Control Network (PICNet) – BC; 2008. http://www.picnet.ca/surveillance-research/110/cdi-(c.-difficile-infection)
5.5.
McGeer, A. et al. Definitions of Infections for Surveillance in Long Term Care Facilities. American Journal of Infect Control. 1991 Feb 19(1):1-7.
5.6.
The Canadian Nosocomial Infection Surveillance Program (CNISP); Central Venous Catheter-Associated Bloodstream Infection 2006; MRSA 2006; VRE 2007; CDI 2007.
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IV0300:
Surgical Site Infections (SSIs)
EFFECTIVE DATE: September 2006 REVISED DATE:
November 2010
REVIEWED DATE:
6.0
PURPOSE To identify the potential risks associated with surgical procedures and Surgical Site Infections (SSIs) and include this information in the risk stratification and data analysis of SSIs.
7.0
DEFINITIONS SSIs – Surgical Site Infections occur as a complex interaction between the microbial contamination of the surgical site, the host response, and the local environment at the site of contamination. Most SSIs are caused by the host’s own endogenous flora. An SSI is generally considered to be present when purulent drainage is identified at the surgical site. SSI rates are the percentage of surgical incisons that are infected and are usually stratified based on the Surgical Wound Classification. Surgical Wound Classification – a system of categorizing surgical procedures into risk groups based on the likelihood of contamination of the surgical site at the time of the operative procedure. The four classes of wounds include: Clean Wounds (Class I) – uninfected operative wound in which no inflammation is encountered, involve access only to the sterile body sites and carry the lowest risk (e.g. less than 5%) of surgical site infection. Clean-Contaminated Wounds (Class II) – those in which respiratory, gastrointestinal, urinary, or genital tracts were involved under controlled conditions and without unusual contamination. A minor break in surgical sterile technique in an otherwise clean procedure would fit into this class. Contaminated Wounds (Class III) – carry a high risk (e.g. 10 to 15%) of infection often because they involve unusual contamination from a non-sterile site (e.g. large bowel resection contaminated with faecal material). Dirty Wounds (Class IV) – are those with retained devitalized tissue, foreign bodies, fecal contamination, delayed treatment or from a dirty source. A perforated viscus may be encountered. A wound with acute bacterial inflammation with pus encountered during the procedure is also included in this class. Surgical Site Infection definitions include the following: Superficial Incisional Surgical Site Infection – infection occurs within 30 days of the operation and infection involves only skin or subcutaneous tissue of the incision. This does not include stitch abscess, infection of an episiotomy or newborn circumcision site or infected burn wound. Deep Incisional Surgical Site Infection – infection occurs within 30 days after the operation if no implant is left in place or within 1 year if implant is in place and infection appears related to the operation and involves deep soft tissues (e.g.) fascial and muscle layers of the incision. Infections that involve both superficial and deep incision sites are reported as deep incisional SSI. An organ/space SSI that drains through the incision is reported as a deep incisional SSI.
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Organ/Space Surgical Site Infection – infection occurs within 30 days after the operation if no implant is left in place or within 1 year if implant is in place and infection appears related to the operation and involves any part of the anatomy (e.g.) organs or spaces other than the incision which was opened or manipulated during the operation.
8.0
9.0
GUIDING PRINCIPLES 8.1
The Centres for Disease Control and Prevention (CDC) estimates that 2.7% of surgical procedures are complicated by SSIs which translates into an extra hospital stay of approximately 6.5 days for each SSI.
8.2
Prevention of SSIs consists of: • Minimizing access of bacteria to the surgical site through the use of antiseptic scrubs, skin prep procedures, sterile barriers used during operative procedure, environmental controls and prophylactic antibiotics. • Enhancement of the Host during the operative procedure through administration of supplemental oxygen and prevention of hypothermia and hyperglycemia. • Delayed Primary/Secondary Closure is a viable option for massive disruptions of the colon (e.g.) gunshot wound or pancreatice abscess.
PROCEDURE Classification of Surgical Procedures is done by the Operating Room staff – refer to http://inet.interiorhealth.ca/infoResources/clinresources/Documents/Operative%20Wound%20Classifi cation%20Reference%20Guide.pdf
10.0
REFERENCES 10.1
CDC/NHSN surveillance definition of healthcare associated infection and criteria for specific types of infections in the acute care setting; American Journal of Infection Control; 2008.
10.2
APIC Text 2009; http://text.apic.org/item-24/chapter-23-surgical-site-infection/basicprinciples.
10.3
Guideline for Prevention of Surgical Site Infection 1999. Infection Control & Hospital Epidemiology; Vol 20; No.4 247-278.
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IV0400:
Gastrointestinal Outbreak
Guidelines
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010 REVIEWED DATE:
1.0
PURPOSE This guideline has been developed in collaboration with the Communicable Disease (CD) Unit and provides guidance for healthcare facilities when a Gastrointestinal Outbreak is suspected. To link to the Communicable Disease site for documents, specifically Gastrointestinal Illness Outbreak Guidelines: http://inet.interiorhealth.ca/clinical/CDunit/Pages/default.aspx
I.H FACILITY
GI INFECTION CONTROL OUTBREAK CHECKLIST
NON I.H. FACILITY
GI INFECTION CONTROL OUTBREAK CHECKLIST
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Infection Prevention & Control-IV0400 Note: In this document the term “patient” is inclusive of patient, resident & client.
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Infection Prevention & Control-IV0400 Note: In this document the term “patient” is inclusive of patient, resident & client.
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IV0500:
Respiratory Infection (RI) Outbreak
Guidelines
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010 December 2012 REVIEWED DATE:
1.0
PURPOSE This guideline has been developed in collaboration with the Communicable Disease (CD) Unit and provides guidance for healthcare facilities when a Respiratory Infection Outbreak is suspected. To link to the Communicable Disease site for documents, specifically Prevention & Control of Respiratory Outbreaks: http://inet.interiorhealth.ca/clinical/CDunit/Pages/default.aspx
I.H FACILITY
RI INFECTION CONTROL OUTBREAK CHECKLIST
NON I.H. FACILITY
RI INFECTION CONTROL OUTBREAK CHECKLIST
Infection Prevention & Control-IV0500 Note: In this document the term “patient” is inclusive of patient, resident & client.
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Infection Prevention & Control-IV0500 Note: In this document the term “patient” is inclusive of patient, resident & client.
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Infection Prevention & Control-IV0500 Note: In this document the term “patient” is inclusive of patient, resident & client.
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IV0600:
Communicable Diseases in
Employees
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010, December 2012 REVIEWED DATE:
1.0
PURPOSE To provide guidance in the prevention and management of healthcare provider exposures to and infections with infectious diseases in the work place.
2.0
DEFINITIONS Exposure – may occur when a healthcare provider is in direct or indirect contact with patient or coworker who has a known or suspected infection with a communicable disease. This contact may occur through, but is not limited to, needle-stick, injuries, splashes, airborne droplets, contact with nasal or throat secretions or close contact during examinations/treatment. Healthcare Provider – includes Interior Health staff, physicians, students, volunteers, and all persons who work within the Interior Health facilities. Risk Assessment – healthcare providers are at risk of exposure to communicable diseases because of their contact with patients or material from patients with infections both diagnosed and undiagnosed. Use of immunization agents assists in protecting patients and healthcare providers from becoming infected.
3.0
GUIDING PRINCIPLES – Refer to AV0900 – Prevention and Management of Occupational Exposure to Communicable Diseases: AV0900 – Prevention and Management of Occupational Exposure to Communicable Diseases
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PROCEDURE 4.1
EMPLOYEE WORK RESTRICTIONS WITH COMMUNICABLE DISEASES
Employees may not work in the healthcare environment during the known period of communicability for: Chickenpox (Varicella Until all lesions are dried and crusted and no new lesions are forming. zoster) Diarrhea/Vomiting Until 48 hours after symptoms have resolved. Influenza
Restrict until 5 days after symptoms began or until symptoms have resolved whichever is longer.
Measles (Rubeola)
Until 4 days after rash appears, or duration of illness in Immunodeficient individuals.
Mumps
For 9 days after onset of swelling; less if swelling has subsided.
Parvovirus B19 (fifth’s disease)
No restriction but pregnant workers are not to care for children with Parvovirus and aplastic crisis or immunosuppressed patients with chronic Parvo infection and anemia.
Pertussis
Restrict until 3 week after onset of paroxysmal cough or 5 days of appropriate treatment is completed.
rd
Rubella (German measles) Scabies or Pediculosis
Until 5 days after rash appears. Until 24 hours after initiation of appropriate treatment.
Shingles (Herpes zoster)
Patient contact is limited to immune patients and lesions are covered.
Tuberculosis
Until receiving appropriate therapy and clinical improvement. The employees physician shall review the case prior to allowing the employee to return to work.
Employees may or may not require work restrictions due to specific acute infections or carrier states. Group A Streptococcus or Staphylococcus
No restriction unless clearly associated with disease transmission.
Acute hepatitis B, or HBsAg positive Acute hepatitis C HIV positive or AIDS
Individual evaluation by Employee Health. Work restriction will depend upon the employee's hygiene and preventing his/her blood and other body fluids from contacting others.
Neisseria meningitidis (meningococcus)
No restriction or treatment for carrier state required; for acute meningococcal disease, including meningitis, employees would be too ill to work.
Amebiasis, Salmonella, Campylobacter, Shigella, Cholera, Worms/Parasites Hepatitis A
Food handlers are restricted. In other healthcare providers, evaluation by Employee Health is necessary.
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Employees must be evaluated by Employee Health or their private physician regarding their work area if they have certain signs or symptoms of the following conditions: Draining abscesses, boils Exudative dermatitis Herpes simplex (whitlow, stomatitis) Uncontrolled respiratory symptoms/infections Impetigo Conjunctivitis
See Workplace Health & Safety
4.2 SUSCEPTIBLE EMPLOYEES Exposure of susceptible employees to specific communicable diseases may require restriction from work during the incubation period, for example: Chickenpox, Varicella
Incubation period is 10-21 days after exposure; restriction would be from day 8 after first exposure thru day 21 after last exposure (up to 28 days if given VZIG varicella zoster immune globulin) or, if disease develops, until the last crop of vesicles is dried and crusted.
Measles, Rubeola
Incubation period is 7-18 days; restriction would be, as per BCCDC Communicable Disease Manual update March 2010, from day 5 after first exposure to day 21 after last exposure; if disease develops, until 4 days after onset of rash. Live vaccine given to susceptibles within 72 hours of exposure may prevent illness.
Mumps
Incubation period is about 16 to 18 days: restriction would be from 12 until 25 days after exposure; if disease develops, for 9 days after onset of parotid gland swelling, but less if swelling has subsided. Immunization of susceptible persons following exposure is of uncertain value.
Rubella
Incubation period is 14-21 days; restriction would be from day 7 after exposure through day 23; if disease develops, until 4 days after rash appears.
4.3
Occupational Exposure to a Communicable Disease Infection Control Practitioner will complete the Communicable Disease Notification Tool and forward it to the CD Unit and IH Occupational Health.
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5.0
REFERENCES 5.1
Prevention and Control of Occupational Infections in Healthcare. Public Health Agency of Canada (PHAC); March 2002.
5.2
Guidelines for Infection Control in Healthcare Professionals. Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deithman SD. AJIC (American Journal of Infection Control), vol. 1998;26(3):289-354
5.3
Control of Communicable Diseases Manual. 19th Edition. David L. Heymann (2008).Published American Public Health Association, WA DC
5.4
AV0900 - PREVENTION AND MANAGEMENT OF OCCUPATIONAL EXPOSURE TO COMMUNICABLE DISEASES; IH Administrative Policy Manual – AV Workplace Health and Safety; December 2009. http://inet.interiorhealth.ca/infoResources/policies/Documents/Prevention%20and%2 0Management%20of%20Exposure%20to%20Communicable%20Diseases.pdf
5.5
BCCDC Communicable Disease Manual, http://www.bccdc.ca/dis-cond/commmanual/default.htm
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IX0100:
Microbiology Specimen Collection
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010 REVIEWED DATE:
2.0
PURPOSE To provide a broad overview of microbiology specimen collection processes that are used to identify the agent of an infectious process, to assist in choosing appropriate antimicrobial therapy and to provide epidemiological information.
3.0
4.0
GUIDING PRINCIPLES 3.1
It is the responsibility of the attending physician to initiate microbiological studies. No routine cultures will be collected without a physician's order.
3.2
Obtain specimens for culture and sensitivity before antimicrobial therapy is started if possible.
3.3
Staff shall consider all specimens to be infectious and shall contain specimens in a way that prevents spilling and leakage during transport.
3.4
Ensure that specimens and the appropriate documentation goes to the laboratory as soon as possible.
3.5
Routine collection of environmental cultures is seldom indicated because they rarely provide meaningful information. They will not be processed unless approved by Infection Control.
PROCEDURE Refer to the Laboratory Department Manual at the local site (or referral site) for microbiology specimen collection information.
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IX0200:
Prevention & Control of Catheter Associated Urinary Tract Infections (CAUTI)
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010 REVIEWED DATE:
6.0
PURPOSE To provide evidence-based practice guidance for the prevention of Catheter-Associated Urinary Tract Infection (CAUTI) in hospital, residential and community settings.
7.0
DEFINITIONS Aseptic Technique – must be used for the insertion of urinary catheters; includes sterile equipment, e.g. gloves, drapes, sponges and catheters, a sterile or antiseptic solution for cleaning the meatus and a single-use packet of sterile lubricant jelly for insertion. Bacteruria – presence of bacteria in the urine; patients are often asymptomatic and do not require antibiotic treatment or prophylaxis. Catheter-Associated Urinary Tract Infection (CAUTI) – includes those infections in which a patient has/had an indwelling urinary catheter in place. A urinary catheter provides a portal of entry into the urinary tract. Bacteria may ascend into the tract via either the external or internal surface of the catheter. Condom Catheter – a soft flexible sheath that fits over the penis and is attached to a urinary drainage bag; used for bladder management instead of an indwelling Foley catheter. Indwelling Foley Catheter – a drainage tube that is inserted into the bladder through the urethra, is left in place, and is connected to a closed drainage system. Intermittent (“in-and-out”) Catheterization – involves brief insertion of a catheter into the bladder through the urethra to drain urine at intervals; often used for bladder management with para and quadrapalegic patients. Suprapubic Catheter – a catheter that is surgically inserted into the bladder through an incision above the pubis. Surveillance Definition for CAUTI – patient with an indwelling urinary catheter must demonstrate AT LEAST TWO OF: fever, chills, new flank or suprapubic pain or tenderness, sudden and new change in character of urine, sudden unexplained worsening of mental or functional status. A urine culture result which correlates to these symptoms may also be diagnostic. Urinary Tract Infection (UTI) – a symptomatic bladder infection characterized by frequency, urgency, dysuria, or suprapubic pain.
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8.0
GUIDING PRINCIPLES 8.1
8.2
9.0
UTIs are the most common healthcare associated infection (HAI) in acute and residential care and contributes to increased mortality and costs (diagnostic tests, antibiotics, and increased length of stay). UTIs are usually related to instrumentation of the urinary tract, the most frequently implicated being bladder catheterization. The chance of infection increases 5-7% for every day a catheter is left in. Reasons for short term catheter use include: • Management of acute urinary retention. • Bladder decompression during and following surgery. • Monitoring urinary output, especially in the critically ill patient.
8.3
Reasons for long term catheter use include: • Urinary incontinence complicated by urinary retention. • Chronic urinary retention associated with bladder outlet obstruction not amenable to management using other methods. • Management of a non-healing stage 3 or 4 pressure ulcer located in the perineal or sacral area in the presence of urinary incontinence. • Palliative care setting when pain or immobility restrict toileting.
8.4
Increased risk of UTIs with a catheter are related to: • Micro organisms pushed directly into the bladder during catheterization or operative Instrumentation(cystoscopies). • Micro organisms migrating up from the perineum on the outside of a catheter lumen once it is inserted into the bladder. • Micro organisms migrating from a contaminated urinary drainage bag into the bladder. • Biofilm (colonies of bacteria) formation on the catheter material and in the bladder (biofilms are very resistant to antibiotic penetration).
8.5
Catheter Care Best Practices to Prevent UTIs include: • Catheterization should only be done for specific medical reasons and not for healthcare provider convenience. • Consider alternatives to an indwelling catheter such as intermittent catheterization, condom drainage or incontinent products. • Remove catheter as soon as possible – assess daily.
PROCEDURE 9.1
Technique • Use aseptic technique and copious lubrication when inserting catheter. • Wash hands before and after contact with catheter. • Cleanse connections with alcohol prior to any break in this closed system. • Secure the tubing to the thigh for women and to the abdomen for men.
9.2
Patient Status • Avoid constipation. • Encourage individual to drink at least 1.5 - 2 litres of fluid/day.
9.3
Equipment • Choose the smallest suitable catheter size (12 - 16 Fr) that allows for good drainage. • Use small balloon size (5cc) and inflate balloon and channel with sterile water (NOT normal saline). • ensure drainage bag is kept below the level of the bladder • empty the drainage bag when two-thirds full • use individually assigned urine collection containers to empty drainage bag
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•
clean collection containers immediately after use – store clean and dry away from other collection containers **USE NON-LATEX CATHETERS FOR PATIENTS WITH LATEX ALLERGY
10.0
9.4
Troubleshooting / Blockage or Bypassing • Bladder irrigation is not recommended, change catheter if it is plugged or bypassing.
9.5
Maintenance and Care • Maintain a closed system and maintain unobstructed urine flow • Frequency of catheter changes are based on individual patient assessment and should be done every 8 – 12 weeks (more frequently if necessary to prevent problems with catheter). • Change catheter bags and leg bags monthly or when soiled. • If switching to a leg bag daily, night bags can be cleaned using warm soapy water or a 2:4 vinegar and water solution (odor control) – rinse well and allow bag and tubing to dry completely. Ensure all bags are labeled with residents name. • To avoid opening the system, if a leg bag will always be used, attach connection tubing between the leg bag and a night bag to allow the individual to sleep undisturbed from bag emptying.
9.6
Obtaining a Urine Specimen for Culture • A physician order is required. • For individuals with long term indwelling catheter who are suspected of having a UTI, remove existing catheter and insert a new catheter and collect specimen. • Otherwise, take specimen from sampling port on drainage tubing - clean port with alcohol swab and use sterile needle to obtain urine sample; do not obtain specimen from drainage bag.
REFERENCES 10.1
Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIs). Association for Professionals in Infection Control and Epidemiology, Inc. (APIC); 2008.
10.2
McGeer et al. Definitions of Infection for Surveillance in Long-term Care Facilities. American Journal of Infection Control, 1991; 19(1).
10.3
SHEA/APIC Guideline: Infection prevention and control in the long-term care facility. American Journal of Infection Control; September 2008; 29(9).
10.4
SHEA Position Paper: Urinary Tract Infection in Long-Term Care Facilities. Infection Control and Hospital Epid, 2001;22(3).
10.5
Godwin, L (2005) ‘Best Practice Guidelines Urinary Catheter Care’; Interior Health, Kelowna.
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IX0300:
Pneumococcal Vaccine for Residential Care
EFFECTIVE DATE: June 2009 REVISED DATE: November 2010, December 2012 REVIEWED DATE:
1.0
PURPOSE: All persons being admitted to an Extended or Intermediate Care Facility are to be assessed for their status of having received a pneumococcal vaccine in the past and this information will be recorded on the resident’s chart. If they have not had a pneumococcal vaccine, they will be offered the vaccine upon admission to the facility and this information will be recorded on the resident’s chart.
2.0
3.0
GUIDING PRINCIPLES: 2.1
Streptococcus pneumoniae (pneumococcus) can cause serious invasive disease including bacteremia, meningitis and pneumonia in people with high-risk medical conditions and the elderly. Pneumococcal infection is spread by droplet/contact from one person to another by coughing, sneezing, close face-to-face contact and direct contact through saliva.
2.2
The pneumococcal polysaccharide vaccine is offered free to seniors 65 years and older and to persons 2 years of age and older with certain medical conditions including those who have no spleen or a spleen that is not functioning properly*, sickle-cell disease*, immune systems weakened by disease or medical treatment*, chronic liver disease including cirrhosis*, chronic hepatitis B or hepatitis C*, chronic kidney disease*, chronic heart or lung disease, transplant patients, diabetes, cystic fibrosis, chronic cerebrospinal fluid leak, cochlear implant candidate or recipient, alcohol dependency, homelessness and/or illicit drug use.* People in these groups should receive a second dose of vaccine five years after the first dose and this requires a physician order.
2.3
Residents of any age living in residential care are considered an at risk population for suffering complications from pneumococcal disease and should receive the vaccine upon admission to the facility if they have not already had the vaccine previously.
2.4
Contraindications for the vaccine include anaphylaxis reaction to the vaccine or component of the vaccine in the past. Possible reactions to the vaccine may include soreness, redness and swelling at the site of injection. Headache and mild fever may also occur. These reactions are mild and generally last 1 to 2 days.
PROCEDURE 3.1
All Residential Care facilities should have pre-printed physician orders for “pneumococcal vaccine on admission if resident has not been immunized in the past”. Upon admission, staff is to seek out and document information about the resident’s pneumococcal immunization status by asking the resident and/or family, the resident’s physician (contact office) and/or the Public Health office. Document information according to facility guidelines.
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4.0
3.2
Residents who do not have a record of pneumococcal immunization with Public Health or their family physician require immunization by the facility – this should be done within two weeks of admission.
3.3
Do not delay immunization if proof of prior immunization is not available within this two week time frame - when in doubt, with no documented proof: IMMUNIZE.
3.4
It is recommended that facilities carry out yearly audits to ensure the procedure for administering and documenting pneumococcal vaccination in Residential Care Facilities is being implemented appropriately with the target being at least a 90% vaccination coverage compliance rate.
3.5
Teaching tools for residents and family: HealthLinkBC – Pneumococcal Vaccines
REFERENCE 4.1
Public Health Agency of Canada. Seventh Edition Canadian Immunization Guide 2006.
4.2
BC Centre for Disease Control. Communicable Disease Control Immunization Program, Section VII – Biological Products, January 2010.
4.3
Required Organizational Practices 2012. Accreditation Canada; pg 52.
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IX0400:
Pet Therapy and Visitation
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010 REVIEWED DATE:
1.0
PURPOSE The purpose of a pet therapy & visitation program is to provide patients with the positive aspects of stimulation, motivation and cooperation that human/animal interaction can offer in the hospital environment. This form of therapy is used successfully with people in many healthcare settings and literature supports the position that pet therapy increases cooperation with medical treatment and feelings of well-being while decreasing the stress of illness and hospitalization. Our target audience includes all eligible (as defined in this guideline) patients, with an emphasis on those patients who experience long-term hospitalization, and/or demonstrate a need for unconditional love, positive motivation and socialization while involved in their hospital experience. To allow visitation of appropriately screened therapy dogs and their screened and trained handlers to eligible patients. This guideline will cover residential pets, service, guide animals and patient owned pets as well.
2.0
DEFINITIONS Guide dog - this term shall refer to a dog which is in working harness and is certified to guide blind or hearing impaired persons by an accredited canine school that is engaged in this specific type of training. Service dog - this shall mean a dog that is certified to assist disabled people by an accredited canine school that is engaged in this specific type of training. Therapy dog - this shall refer to animals that are brought by specially trained professionals, paraprofessionals, and/or volunteers to provide opportunities for motivational, educational, recreational, and/or therapeutic benefits to enhance quality of life. Pet animal - this shall refer to any animal which belongs to a patient and whose presence in the hospital is requested by the patient and his physician.
3.0
GUIDING PRINCIPLES 3.1
Visitation of any animals to critical care areas, rooms where Additional Precautions are being implemented, medication or clean supply rooms, food storage or preparation areas, and dining rooms is prohibited.
3.2
Service/guide animals care and health is the responsibility of their owners. They will be given access to all areas in the facility except those noted in 3.1 above.
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3.3
Rodents, reptiles, and other exotic pets are prohibited without special permission of Infection Control.
3.4
All pet therapy/residential animals will have an approved handler who will be responsible for their health and well being as well as ensuring that they are in compliance with this guideline
3.5
Handlers will perform hand hygiene after all visitations. The handler will assist the patient in performing hand hygiene prior to leaving the room.
3.6
Screened and trained pet therapy animal handlers must: • Be individuals from agencies who will fully support these guidelines and any other policies of IHA that may apply to or have bearing on pet therapy programs and the general safety of our patients and families. • Have submitted an application to and have the approval of the Volunteer Coordinator. • Be a minimum of eighteen (18) years of age. • Be a certified and approved member of an approved Therapy Dogs/ Pet Program.
3.7
Appropriately Screened Dogs for the pet therapy or residential program will: • Be a minimum of one (1) year old. • Complete the required dog history. • Require that every animal receives a health evaluation by a licensed veterinarian at least once per year and ensure that vaccinations are current, e.g.: o Distemper. o Hepatitis. o Parainfluenza. o Parvovirus. o Rabies. • Defer to the animal’s veterinarian regarding an appropriate flea, tick and enteric parasite control program which should be designed to take into the account the risks of the animal acquiring these parasites specific to its geographic location and living conditions. • For the protection of both the animal and people, prevent the animal from entering the Healthcare Facility from the onset of and until at least 1 week beyond the resolution of: o Episodes of vomiting or diarrhea. o Urinary or fecal incontinence. o Episodes of sneezing or coughing of unknown or suspected infectious origin. o Treatment with non-topical antimicrobials or with any immunosuppressive doses of medications. o Open wounds. o Ear infections. o Skin infections or ‘hot spots’ (i.e. acute moist dermatitis). o Orthopedic or other conditions that, in the opinion of the animal’s veterinarian, could result in pain or distress to the animal during handling and/or when maneuvering within the facility
3.8
Dogs that do not meet screening requirements (regarding consequences for handlers not following the above guidelines, policies or dogs that test positive for lab results): • The documents supporting these actions will be kept on file with the hospital volunteer coordinator and must be kept up to date. Those in non-compliance with the timely testing of their dogs will be immediately suspended from the program. • Dogs who test positive in the throat and/or fecal cultures will be immediately suspended from the program. • One positive Salmonella culture will permanently retire a dog from the program. • A total of three positive cultures over any period of time, for any of the above stated pathogens or parasites, will permanently retire a dog from the program. • If a dog has been removed from scheduling due to a positive test that dog will not be scheduled again until the following criteria have been met and documented:
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For treated parasite or pathogen, a first retest will be performed no sooner than seven (7) days following completion of the prescribed treatment. After two consecutive negative retests (30 days apart), the dog will be able to resume visits. Appropriately Screened Cats/Birds for the pet therapy or residential program will: o Be full grown animals and not juveniles. o Complete the required history. o Receive a yearly exam and certificate of good health with all appropriate vaccinations. o Have passed a standard temperament test. o Be groomed (bathed, nails trimmed) within 24 hours prior to visitation. o Not be in estrus (heat) when participating in therapy work. o
•
3.9
4.0
Personal Pets • Pet visitation will be restricted to special situations where the patient care team, doctor, nurses and/or social workers believe such visitation will benefit the patient. • Pets are limited to cats and dogs and must: o Be visiting a specific patient. o Be clean and well groomed prior to entering the facility. o Have a veterinarian exam and certificate of health, within the past year documenting current immunizations and being free of disease and parasites and in good health. o Not be aggressive, hyperactive or difficult to control. o Be supervised and contained with leash/cage, by the designated pet handler at all times. This supervision includes any necessary care and cleanup.
PROCEDURE 4.1
Arranging a visit: • All visits will be approved by the attending physician. • The supervising nurse and/or charge nurse will be notified that the animal visit is to occur.
4.2
Appropriate patients for visits: • Before a patient will be considered eligible for any visitation, the following requirements must be met: o Physician consent (by verbal or written order). • The following patients will not be eligible for dog visitation: o Patients on Additional Precautions due to infection. o Patients with known immunodeficiency disorders. o Patients with known animal allergies. o Patients whose physician requests that their patient not receive a visit. o Any patient or parent who expresses any concern regarding a visit will not be included in the visit.
4.3
Animal Waste • If animal waste occurs at anytime during the visit, the dog handler will be responsible for immediately cleaning the area with the approved provided clean-up kit. The handler will be provided with the following materials: o Disposable gloves. o Plastic bags. o A container of a germicidal cleaning agent (All used materials will be put in the plastic bag which will be disposed of in an appropriate waste container.)
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•
5.0
If an animal should develop symptoms of any illness following a hospital visit, the handler will immediately notify the Infection Control Department.
REFERENCE Sandra L. Lefebvre, et al. Guidelines for animals – assisted interventions in health care facilities. AJIC American Journal of Infection Control 2008; 36:2 pp 78-85
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IX0500:
Soiled Utility Rooms
EFFECTIVE DATE: March 2008 REVISED DATE: November 2010 REVIEWED DATE:
1.0
PURPOSE To minimize the risk of infection transmission in clinical areas that generate soiled equipment, soiled linen and waste.
2.0
3.0
GUIDING PRINCIPLES 2.1.
Requirements for Soiled Utility Rooms include: • Work counter with sink, gooseneck faucet and wrist blades. • Separate wall-hung hand sink for hand washing with soap and towel dispensers. • Space for waste receptacles and soiled linen receptacles; provision for storing and transporting soiled linen in covered leak proof containers. • Hospital approved equipment and products for cleaning and sanitizing bedpans, urinals, and basins. • Closed cupboards or covered bins for containing clean supplies such as bedpans, urinals, basins, incontinence supplies, and lab supplies such as urine dipsticks, specimen containers. • *If closed cupboards are not available, ensure open shelves are located away from “splash risks” around sinks, and bedpan sanitizers.
2.2.
Items that can be housed in Soiled Utility Room include: • Cleaning supplies and products readily available for non-housekeeping staff. • Soiled equipment, soiled laundry. • Personal Protective Equipment to wear while cleaning items including eye protection, surgical/procedure masks, fluid resistant apron, household gloves. • Items to be cleaned after each use such a commodes…once cleaned, they need to be stored elsewhere. • General and Biohazardous waste containers. • Specimen fridge for holding laboratory specimens.
2.3.
Items that should not be kept in a Soiled Utility room include: • Kleenex boxes. • Skin antiseptics/cleansers. • Personal hygiene supplies (soaps, mouth care products, lotions). • Sterile items such as wound dressings.
REFERENCES APIC Text 2009; http://text.apic.org/item-53/chapter-49-ambulatory-care
Infection Prevention & Control-IX10500 Note: In this document the term “patient” is inclusive of patient, resident & client.
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IX0600:
Equipment Cleaning
EFFECTIVE DATE: February 2009 REVISED DATE: November 2010 December 2012, March 2013 REVIEWED DATE:
1.0
PURPOSE: To prevent the transmission of microorganisms from soiled equipment to patients. Cleaning is a shared responsibility between multiple departments and healthcare providers.
2.0
DEFINITION See the glossary in Appendix A for definitions
3.0
GENERAL PRINCIPLES 3.1
Dedicate equipment for a single patient.
3.2
Shared equipment must be cleaned and disinfected between patient uses.
3.3
Clean soiled equipment immediately – must be cleaned prior to disinfection.
3.4
Disinfectant wipes should be used for point of care cleaning and disinfection of patient equipment; wipes must be kept wet and discarded if they become dry.
3.5
Never reuse single use equipment that is not appropriate to dedicate to single patient use (i.e. critical equipment) – discard immediately after use.
3.6
Do NOT use tape that leaves a residue on patient equipment.
3.7
Report damaged equipment to manager for replacement.
3.8
Do NOT stockpile supplies and equipment in patient room – clutter increases the risk of cross contamination in patient care areas (including hallways).
3.9
Personal care items (i.e. lotions, skin cleansers, razors) are single patient use and not to be shared between patients.
3.10
Assign responsibility for routine cleaning of equipment.
3.11
Foot care equipment must be sterilized between patient use – if the equipment is assigned as single patient use, it can be low level disinfected between use on that same patient.
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Page 1
4.0
PROCEDURE 4.1
Wear appropriate personal protective equipment (PPE) for the task.
4.2
Clean and disinfect reusable equipment in a designated area. • Clean small items in patient rooms prior to use on another patient. • Transport large items to the soiled utility room for cleaning. • Avoid performing equipment cleaning in high traffic areas like hallways or where contact with clean items may occur (clean hallway carts).
4.3
Wipe equipment thoroughly – if cloth/wipe comes away dirty, repeat until it comes away clean.
4.4
Allow equipment to air dry. • Some items may require rinsing off prior to use – ensure disinfectant has adequate contact time with the equipment/device before rinsing.
4.5
Designate a location for clean equipment (ideally, clean storage rooms or clean service rooms) where they are transported after cleaning. • Implement a process where the item is identified as clean, disinfected and ready for use on another patient.
4.6
Cardboard/paper items • Wipe laminated cardboard/paper with cloth or wipe – if not laminated, discard after use.
4.7
Fabric items • All fabric items used in patient care areas must be washable. • Washing can take one of 3 forms: o Coated Fabric (i.e. vinyl) – wiped using procedure above. o Non coated cloth – launder. o Non-washable fabrics not recommended
4.8
Electronic items • Wipe equipment thoroughly including all cables, avoiding any electrical or electronic connectors to prevent malfunction. • Use approved screen cleaners • Allow to air dry.
4.9
Toys
4.10
I.H FACILITY
REFER TO IX0700 TOY M ANAGEMENT
NON I.H. FACILITY
REFER TO IX0700 TOY M ANAGEMENT
Macerators (Vernacare) • Dispose of cardboard items immediately after use into macerator and run cycle. • Do not allow items to accumulate in macerator to avoid plugging the machine.
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5.0
4.11
Washer/Disinfector (Deko) • Place “blue ware” items used for elimination (i.e. bedpans, urinals) immediately in machine after use. • Once items are cleaned and disinfected, ensure clean items are stored to facilitate complete drying. • Items can be used for any patient after completing this process. • Establish a schedule for regular cleaning of “blue ware” (i.e. wash basins, denture cups).
4.12
Appendix B – Equipment Cleaning Table
4.13
Appendix C – information on hydrotherapy tubs and use of public pools for therapeutic interventions.
REFERENCES 5.1
Best Practices for Cleaning, Disinfection and Sterilization in all Health Care Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; February, 2010. http://www.oahpp.ca/resources/pidac-knowledge/best-practice-manuals/cleaning-disinfectionand-sterilization.html
5.2
Hand Washing, Cleaning, Disinfection and Sterilization in Health Care. Health Canada Canada Communicable Disease Report. 1998; 24 Supplement 8: i-xi, 1-55. http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/98pdf/cdr24s8e.pdf
5.3
Infection Control Guideline for the Prevention of Healthcare Associated Pneumonia. Public Health Agency of Canada; 2010. http://www.phac-aspc.gc.ca/nois-sinp/guide/pneu-gl-ld/assets/pdf/pneu-eng.pdf
5.4
Infection Prevention and Control Manual. Capital Health. Cleaning and disinfection of non-critical patient care equipment. Policy IC 08-001; July 2012.
5.5
Montana State Hospital. Policy and Procedure Manual. Cleaning of non-critical, reusable patient care equipment. Policy IC-19; March 2010.
5.6
Saskatoon Health Region. Infection Prevention and Control Manual. Non-critical Patient Care Equipment – Cleaning and Disinfection. Policy 20-80; October 2006.
5.7
Seven Oaks General Hospital. Policy and Procedure Manual. Cleaning of non-critical, reusable patient care equipment. Policy Code: 7311-07-01; December 2007.
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APPENDIX A Antiseptic An antimicrobial chemical designed for use on the skin or mucous membranes that inhibits the growth and reproduction of microorganisms (i.e.) alcohol based hand rub (ABHR) for hand hygiene. Bioburden The number and types of viable microorganisms that contaminate the equipment/device. Cleaning The physical removal of dirt, dust or foreign material. Cleaning usually involves soap and water, detergents or enzymatic cleaners. Thorough cleaning is required before disinfection or sterilization may take place. Disinfectant A product that is used on medical equipment/devices, which results in disinfection of the equipment/device. Disinfectants are applied only to inanimate objects. Some products combine a cleaner with a disinfectant. High Level Disinfection The process of using a chemical to kill all vegetative “live” bacteria, fungi, mycobacterium, and viruses. This does not necessarily kill bacterial spores. Intermediate Level Disinfection: Inactivates M. tuberculosis, vegetative bacteria, most viruses, and most fungi, but does not necessarily kill bacterial spores. Low Level Disinfection Using a chemical to kill most vegetative “live” bacteria and some fungi as well as enveloped viruses. This does not kill mycobacterium or bacterial spores. Noncritical Medical Equipment/Device Equipment/device that either touches only intact skin (but not mucous membranes) or does not directly touch the patient. Reprocessing of noncritical equipment/devices involves cleaning and may also require low-level disinfection. Personal Protective Equipment Barriers placed between the infectious source and ones own mucous membranes, airways, skin, and clothing to prevent exposure to blood and body fluids. Reprocessing The steps performed to prepare used medical equipment/devices for re-use (e.g., cleaning, disinfection, and sterilization). Sterilization The complete elimination or destruction of all forms of microbial life. Accomplished by either physical or chemical processes.
Infection Prevention & Control-IX0600 Note: In this document the term “patient” is inclusive of patient, resident & client.
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APPENDIX B
Recommended Minimum Cleaning and Disinfection Level and Frequency for Noncritical Client/Patient/Resident Care Equipment and Environmental Items
The following chart relates to non-critical patient care equipment only, i.e., equipment that comes into contact with intact skin. This chart also includes environmental surfaces and items that do not come into contact with skin. CL = Physical removal of visible soil dust or foreign material (may use soap and water, detergent or hospital grade disinfectant with detergent properties) LLD = Soak item in or wipe surfaces with hospital grade disinfectant (wipe or cloth dampened with disinfectant), allow disinfectant to dry prior to reuse to allow item “contact time” for disinfection to occur
Item
Minimum Cleaning and Disinfection Level: CL = Clean only HLD = Clean + Highlevel Disinfection LLD = Clean + Lowlevel Disinfection
Minimum Frequency
Remarks
Airflow sensors
LLD
between patients
LLD
between patients when soiled
(Sleep Lab) Apnoea Monitor
Monitor/ Sensor Pad Arrest Cart
See Resuscitation Cart
Basin
CL
after each use between patients
between patients
LLD
Infection Prevention & Control-IX0600 Note: In this document the term “patient” is inclusive of patient, resident & client.
clean with detergent and water before disinfection
dedicated to patient dry completely before use automated process recommended
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Item
Minimum Cleaning and Disinfection Level: CL = Clean only HLD = Clean + Highlevel Disinfection LLD = Clean + Lowlevel Disinfection
Minimum Frequency
Bassinette
LLD
Remarks
weekly when soiled between newborns
Bath Seat/ Raised Toilet Seat Single patient use
LLD
▪ when soiled
Multiple patient use
LLD
▪ between patients
Bedrail and extender
LLD
▪ daily
Mattress
LLD
▪ clean between patients and when soiled
Halo bed
LLD
▪ after each patient and when soiled
Visitor cot
LLD
▪ change linen and clean between uses
▪ ideally dedicated to each patient
Bed
Bedpan and Urinal ▪ dispose immediately
Disposable
Multiple patient use
LLD
▪ between patients
▪ washer/disinfector recommended for reusable items after each use ▪ remove gross soil and fluids before automated disinfection unless machine equipped with “flush” cycle
Bladder Scanner
LLD
▪ between patients
Infection Prevention & Control-IX0600 Note: In this document the term “patient” is inclusive of patient, resident & client.
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Item
Minimum Cleaning and Disinfection Level: CL = Clean only HLD = Clean + Highlevel Disinfection LLD = Clean + Lowlevel Disinfection
Blood Pressure Cuff
LLD
Minimum Frequency
Remarks
between patients when soiled
ideally stays with patient until discharge
dedicated to patient
discard when damaged or heavily soiled
dry completely before reuse
store with patient/baby to avoid contact with other kits
Breast Pump (Hospital Grade) Pump Kits
Disposable:CL
HLD(min)
Pump Motor
between uses when soiled
between uses between different patients
LLD
Call Bell
LLD
▪ daily and between patients
Cardiac Monitor
LLD
▪ daily and between patients
CL or
▪ when soiled
dedicated to patient – washed and completely dried after each use stored with patient/baby HLD/sterilized according to Manufacturer’s instructions before use with another patient
between uses when soiled
Cast cutting Blades
disposable Saws
CL
▪ send for sterilization if contact with blood or body fluids
▪ when soiled
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Item
Minimum Cleaning and Disinfection Level: CL = Clean only HLD = Clean + Highlevel Disinfection LLD = Clean + Lowlevel Disinfection
Minimum Frequency
Chair
LLD
▪ daily and when soiled
LLD
Remarks
Includes recliners, patient chairs and shower chairs Chart Cover
when soiled
charts and clipboards should not go into rooms on Additional Precautions
replace worn binders
Binder and/ or clipboard
Clippers (handle) Surgical
LLD
▪ between patients
▪ disposable heads
LLD
▪ when soiled
▪ ideally dedicated to each patient
Commode Chairs Single patient use
▪ patients with VRE or C.difficile must have dedicated commode ▪ for C.difficile, consider cleaning with a sporicidal agent ▪ remove gross soil and fluids before cleaning and disinfection Multiple patient use
LLD
▪ when soiled ▪ between patients
Cord Clamp
Cyclers
▪ remove gross soil and fluids before cleaning and disinfection
LLD
must be single-use, disposable and discarded after use
▪ between patients
(Peritoneal Dialysis) Defibrillator
See Resuscitation Cart
Diagnostic Imaging
LLD
Portable - Machine
▪ when soiled and on leaving Contact Precautions room
Infection Prevention & Control-IX0600 Note: In this document the term “patient” is inclusive of patient, resident & client.
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Item
Portable - portable grid/
Minimum Cleaning and Disinfection Level: CL = Clean only HLD = Clean + Highlevel Disinfection LLD = Clean + Lowlevel Disinfection
Minimum Frequency
Remarks
LLD
▪ between patients if not covered
▪ ideally should be covered (e.g., pillowcase)
LLD
▪ between patients
film cassette Mammography - paddles Dopplers Transducers
LLD
Probes
LLD
Machine and Cables Electric Razor Razor body and Handle
LLD
ECG
after each use
after each use
between patients
wipe immediately after use to remove residual ultrasound gel before cleaning
probes that contact mucous membranes or non-intact skin require high-level disinfection
LLD
▪ as required
▪ must be single patient use
LLD
▪ when soiled
▪ ideally dedicated to each patient
Electronic Devices Single patient use (e.g. Bedside monitors)
▪ between patients
▪ patients with VRE or C.difficile should have device cleaned daily regardless of soilage ▪ for C.difficile, consider cleaning with a sporicidal agent ▪ remove gross soil and fluids before cleaning and disinfection ▪ consult manufacturers instructions for screen cleaning ▪ cleanable covers are highly recommended for difficult to clean components
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Item
Multiple patient use/
Minimum Cleaning and Disinfection Level: CL = Clean only HLD = Clean + Highlevel Disinfection LLD = Clean + Lowlevel Disinfection
Minimum Frequency
Remarks
LLD
▪ when soiled
▪ remove gross soil and fluids before cleaning and disinfection
▪ between patients
Personal Devices used in patient areas (i.e. Tablets)
▪ consult manufacturers instructions for screen cleaning ▪ cleanable covers are highly recommended for difficult to clean components
Glucometer
LLD
Halo Bed
See Bed
▪ after each use
Hydraulic Lift LLD Launder
▪ as required ▪ between patients and when soiled
Interior
LLD
▪ every week
Exterior
LLD
▪ every week
Interior
LLD
▪ every 6 months
Exterior
LLD
▪ every 3 days
Machine Sling
Hydrocollator
▪ dedicated to patient if possible ▪ launder if visibly soiled ▪ drain and thoroughly clean ▪ allow 10 mins contact time with disinfectant for interior surfaces then rinse well prior to refilling with water ▪ allow fresh water to reach appropriate temp prior to re-immersing packs ▪ regular temperature monitoring required as per manufacturers recommendations
Ice Machine
Infection Prevention & Control-IX0600 Note: In this document the term “patient” is inclusive of patient, resident & client.
▪ drain and thoroughly clean with a de-limer
Page 10
Item
Minimum Cleaning and Disinfection Level: CL = Clean only HLD = Clean + Highlevel Disinfection LLD = Clean + Lowlevel Disinfection
Ice Packs
LLD
Intravenous (IV)
LLD
Minimum Frequency
Remarks
between patients
▪ do not use without a cover ▪ discard if damaged
between patients when soiled
Pumps, Poles, Warmers Isolette
LLD
weekly when soiled
Laryngoscope Handle
Mattress
LLD
between patients
See Bed
Measuring Container (urine)
CL
▪ after each use
LLD
▪ after each use
Ophthalmoscope
LLD
Orthopedic Equipment
LLD
▪ between patients
LLD
between patients
between patients
between patients
Single patient use Multiple patient use
▪ one container per patient, labelled with name
between patients
Crutches, traction etc. Otoscope Handle
Ear speculum
Disposable or HLD
Otoacoustic Emission (OAE) screening tips
Disposable or HLD
Infection Prevention & Control-IX0600 Note: In this document the term “patient” is inclusive of patient, resident & client.
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Item
Minimum Cleaning and Disinfection Level: CL = Clean only HLD = Clean + Highlevel Disinfection LLD = Clean + Lowlevel Disinfection
Oxygen Delivery Systems Masks
NP/tubing
Disposable:CL
Disposable:CL
Minimum Frequency
daily when soiled
daily when soiled
Remarks
dedicated to patient
discard when damaged or heavily soiled
rinse all disinfectants from surface before reuse with same patient
dry completely before reuse with same patient
dedicated to patient
discard when damaged or heavily soiled
(externally only)
Nebulizers
after use
Disposable:CL
Oximeter Probes
LLD
▪ between patients
handle condensate carefully – remove from tubing, do not drain back towards patient dedicated to patient
discard when damaged or heavily soiled
rinse after cleaning using sterile water
dry completely before reuse with same patient
if single-use, discard after use refer to manufacturer’s instructions for cleaning discard if damaged educate users to clean after use if appropriate clean personal splints prior to immersion drain and thoroughly clean allow 10 mins contact time with disinfectant for interior surfaces then rinse well prior to refilling with water
▪ Physio/OT Equipment
LLD
▪ between patients and when soiled
▪ ▪ ▪
Splint Baths
LLD
▪ weekly
Infection Prevention & Control-IX0600 Note: In this document the term “patient” is inclusive of patient, resident & client.
▪ ▪
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Item
Minimum Cleaning and Disinfection Level: CL = Clean only HLD = Clean + Highlevel Disinfection LLD = Clean + Lowlevel Disinfection
Minimum Frequency
Remarks
▪ allow fresh water to reach appropriate temperature before reuse
Sheepskin
Launder
▪
between patients
▪ when soiled OT assessment Areas
CL ▪
(e.g. kitchen/bathroom)
after use
Wax Bath (wax)
Pillow
LLD
Reflex Hammer
LLD
Restraints
CL
Resuscitation Cart/Arrest Cart
LLD
Defibrillator
LLD
Trays
LLD
Adult
LLD
Scales
▪ between patients and when soiled between patients
between patients and when soiled
weekly and after use
after each use
after each use
daily and when soiled
Infection Prevention & Control-IX0600 Note: In this document the term “patient” is inclusive of patient, resident & client.
▪ pour wax into disposable plastic bag or washable container for individual patient use ▪ do not reuse wax ▪ discard if cracked
launder
avoid taking cart into Contact Precautions room, have a designated clean person to pass supplies as required
all items taken into Contact Precautions room must be discarded and not returned to the cart, even if unopened
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Item
Minimum Cleaning and Disinfection Level: CL = Clean only HLD = Clean + Highlevel Disinfection LLD = Clean + Lowlevel Disinfection Diaper
LLD
Newborn
LLD
Speculum Light
LLD
Stretcher
LLD
Stethoscope
LLD
Suction Machines
LLD
Table
Minimum Frequency
after each use
after each use
after each use
after each use
after each use
Remarks
do not use phenolics
ideally use own stethoscope
if shared, disinfect ear pieces
between patients when soiled
Bedside
LLD
Over bed Telephone
when soiled between patients daily
Bedside/Nursing Station
LLD
daily when soiled between patients
Portable
LLD
Telemetry Equipment Monitor and Cables
LLD
daily when soiled between patients
between patients
Thermometer (electronic)
LLD
Tourniquet
LLD
when soiled when soiled daily between patients or disposable
Infection Prevention & Control-IX0600 Note: In this document the term “patient” is inclusive of patient, resident & client.
preferably dedicate to patient discard when soiled/ cracked
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Item
Minimum Frequency
Remarks
Transfer Belts
Minimum Cleaning and Disinfection Level: CL = Clean only HLD = Clean + Highlevel Disinfection LLD = Clean + Lowlevel Disinfection CL
Transfer Boards
LLD
between patients
when soiled
after each use
Transport Equipment Walker Wheelchair Tub Bath board/Jets/Surfaces
LLD
once weekly when soiled
use transfer belts on top of clean patient clothing/gown
LLD
after each use
Ultrasound Transducers Handle and Cable External
LLD
between patients
Urinal
See Bedpan
Urine Measuring Container
See Measuring Container
Vacutainer Holder
LLD
between patients
Iodine and chlorine products may damage tub surfaces use high-level disinfection for transducer probes if they touch mucous membranes or non-intact skin
Single patient use preferred
discard if visibly soiled
ventilation circuits used on an individual patient should not be routinely changed based on duration of use – only when visibly soiled or mechanically defective
Ventilator Machine
Ventilator Circuit
In-line monitoring devices (i.e.temp. probes)
CL
LLD
between patients
disposable or sterilized between patients
disposable or sterilized between patients
daily when soiled between patients
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Item
Minimum Cleaning Minimum Frequency and Disinfection Level: CL = Clean only HLD = Clean + Highlevel Disinfection LLD = Clean + Lowlevel Disinfection See Transport Equipment
Walker Wall-mounted Oxygen and Suction Fixtures
LLD
CL
Water Jug
CL CL
Wheelchair
See Transport Equipment
Warming Cupboard Exterior Interior
Remarks
between patients when soiled weekly
every 6 months daily
clean in dishwasher if disposable, change daily
This document /excerpt was adapted with permission from the Ontario Agency for Health Protection and Promotion (Public Health Ontario)/Provincial Infectious Diseases Advisory Committee (PIDAC). PIDAC documents contain information that requires knowledgeable interpretation and is intended primarily for use by health care workers and facilities/organizations providing health care including pharmacies, hospitals, long-term care facilities, community-based health care service providers and pre-hospital emergency services in non-pandemic settings. Public Health Ontario assumes no responsibility for the content of any publication resulting from changes /adaptation of PIDAC documents by third parties.
APPENDIX C Part 1: Infection Control Recommendations for Hydrotherapy Recommendations for Hydrotherapy are required to prevent infections to pool participants and staff, as well as to prevent contamination of the pool. 1. Contraindications: According to the BC Swimming Pool, Spray Pool and Wading Pools Regulations, it is contraindicated for residents, staff, community clients or their attendants to enter the pool with the following: • Open areas of the skin (unless covered by a waterproof bandage). • Fungal infections (i.e. Athlete’s foot, fungal infections of the groin). • Unmanaged fecal incontinence. • Fever, diarrhea or vomiting. • Any other identified infections may be a contraindication. Appropriateness of swim session for these cases will be at the discretion of the nurse, physiotherapist, doctor, health care assistant, in consultation with the lifeguard.
Infection Prevention & Control-IX0600 Note: In this document the term “patient” is inclusive of patient, resident & client.
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2. Hand Hygiene: Hand hygiene is the single most effective measure available to prevent infections. Hand hygiene should be done: • Before and after direct care with a client. • Before and after working with gloved hands. • Before and after working with open areas/dressings, urinary equipment, ostomy equipment or body fluids. • Between working with different clients. 3. Urinary Incontinence: • The bladder must be emptied before entering the pool. 4. Fecal Incontinence: • Swimmers with fecal incontinence are requested to arrange their pool time around their bowel habits. • Swimmers are requested to have a bowel movement prior to bathing. • Swimmers should wear properly fitting waterproof pants/incontinence product. 5. Ostomy Appliances: • Must be firmly secured and able to withstand pool related activities (temperature, moisture, body movements and exercises). • It is the responsibility of the client, or the client’s attendant, to ensure that the bag is secured to the body and free from seepage. • Ostomy bags must be clean before entering the pool. 6. Skin lesions and Rashes: • It is the responsibility of the client, or nurse, to check the skin for any wounds before the pool session. • If open wounds are present prior to swimming, the session should be cancelled. • If the wound is small and can be completely covered and sealed by one waterproof dressing, then the session can continue once the bandage had been properly applied. • Waterproof dressings can include various brands of waterproof bandages. Water resistant bandages will allow water to move through the bandage therefore allowing organisms to be carried to and away from the wound. • Non waterproof bandages, tape, dressings, etc… must be removed before entering the pool. Rationale: These items, if dislodged, become trapped in the pool filter system resulting in mechanical breakdown. Also, if an open area is covered by an inadequate dressing, the pool will potentially be contaminated. Part 2: Infection Control Practices for Pool Usage Pool users are required to adhere to the following practices when using the pool: 1. All pool users are required to wash their hands upon arrival and before leaving the pool facility. An antiseptic hand sanitizer solution is an option, if the hands are not visibly soiled. 2. All pool users are required to place a clean towel or other adequate barrier on the change bench to sit on as well as place their clothing on while changing. 3. All clothing and personal belongings are to be stored neatly away in either the lockers or underneath the benches after changing and while using the pool. 4. All pool users are required to take a cleansing shower using warm water and soap before entering the pool. 5. No person shall enter the pool whom: • Is obviously ill. • Has an open wound that has not been appropriately covered. • Has sore or infected eyes. Infection Prevention & Control-IX0600 Note: In this document the term “patient” is inclusive of patient, resident & client.
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• Has a discharge from the ears or nose. 6. Disinfecting wipes should be supplied in each change room and should be used to wipe benches between each use. Clients and staff are encouraged to use these wipes before and after using the benches. The wiped surface is left to air dry for effective disinfecting. 7. Disinfecting wipes are also used to wipe the grab bars and lifts after each use. 8. Disinfecting wipes are used to wipe the sling back and lift after each use. Lift slings should be washed after each use. 9. Change rooms should be cleaned and sanitized thoroughly once daily, or more often, as needed. 10. The pool deck should be cleaned and sanitized thoroughly once daily, or more often, as needed. 11. Wheelchairs that have been contaminated with body fluids are cleaned in the following manner: excess contaminant is absorbed with paper towel. The chair is then rinsed under a shower with a continuous flow of clean water. Disinfectant is then sprayed on the item and left for a minimum of 10 minutes (or per manufacturer instructions). The chair is then rinsed under clean water again, before storing it its regular location. 12. Head floats that have been contaminated with feces or blood will be thrown out. Other body fluids contaminating the head floats can be either wiped with a hospital approved disinfectant or washed in the washer. 13. Body fluid spills, (outside the pool basin) are first soaked up using paper towel. Dispose of the paper towel in the garbage. A hospital approved disinfectant is then used to wipe the area, which is left to air dry. A mop can be used for large spills after the paper towels have absorbed as much of the spill as possible. Mop head must be washed and disinfected before reuse on another surface. 14. Vomit in the pool may create a higher risk for infection.
http://www.cdc.gov/healthywater/pdf/swimming/pools/fecal-incident-responserecommendations.pdf
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Part 3: Infection Control Guidelines for Staff 1. Staff are expected to follow the same infection control guidelines set out for community clients. These include washing hands upon arriving at work, protecting open wound with waterproof dressings, putting a towel down on any bench you use to change on, ensuring your belongings are tucked away while working and having a cleansing shower before and after using the pool. 2. Staff are also expected to ensure a clean environment by doing the following: • Remind community clients to wash their hands upon arrival. • Remind community clients to take a cleansing shower before entering the pool. • Remind community clients to place their towel down upon the bench to sit on while changing. • Wipe the benches in the change room with a hospital approved disinfectant as often as time permits, preferably between each client. 3. Staff are expected to wear appropriate footwear around the pool following the footwear guidelines for pool staff. 4. Staff should encourage clients to wear appropriate footwear around the pool facility. 5. Do not allow any open wounds that are not appropriately covered in the pool. Part 4: Responding to Fecal Accidents in Rehabilitation Swimming Pools Information from the Center for Disease Control (Atlanta, Georgia) addresses fecal accidents in pools. In recent times, there have been increasing concerns about the transmission of Cryptosporidium parvum in swimming pools. While this parasite can cause self-limited diarrhea in healthy people, the diarrhea can be much more significant in those with severe immunosuppresion. The infecting dose of Cryptosporidia is quite small, and even a small visible fecal spill of liquid can contaminate an entire pool. Most bacteria are very susceptible to low concentration of free chlorine, however, Cryptosporidia are not. Chlorine (2ppm) kills Escherichia coli in less than 1 minute, while Cryptosporidia may require as long as 8 hours. Although Cryptosporidia may be found in the stool of people who have persistent diarrhea and nausea, investigators from the CDC have demonstrated Cryptosporidia are not carried as normal human enteric flora, and is not found in formed stool. In order to address the potential hazards of Cryptosporidia parvum, pool protocols have been designed to combat this organism. This has lead to the recommendation of raising chlorine concentrations for up to 8 hours, and to maintain the pool unused for 3-4 filtration cycles for 24 hours. The consequences of these policies have been significant on pools used for rehabilitation patients. Many individuals may have incompetent sphincter control, resulting in minor incontinence without diarrhea or being unwell. Small accidents, which have been totally contained within the bathing suit, are a relatively common occurrence. Unfortunately, these occurrences have been sufficient to trigger pool-closure responses, which last 24 hours. The consequence is that pools may be closed as often as they are open. This results in severe restrictions, inconvenience, and loss of valuable therapeutic pool time for many individuals. To address pools potential contaminated with feces or vomit, please refer to the “Fouled Pool Remedial Procedure”.
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REFERENCES BC Health Act, “SWIMMING POOL, SPRAY POOL AND WADING POOL REGULATIONS”, B.C. Reg. 289/72,O.C. 4190/72 Responding to fecal accidents in disinfected swimming venues. CDC MMWR weekly. May 25, 2001. 50(20); 416-417. http://www.cdc.gov/mmwr/PDF/wk/mm5020.PDF Vancouver Coastal Health. Guidelines for the Stan Stronge Pool. Provincial Infection Control Network of British Columbia. Appendix 7: Pools. PICNet Antibiotic Resistant Organism Provincial Guidelines. Draft Two. April 18, 2008. Interior Health Fouled Pool Remedial Procedures
http://www.cdc.gov/healthywater/pdf/swimming/pools/fecal-incident-response-recommendations.pdf
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IX0700:
Toy Management
EFFECTIVE DATE: September 2006 REVISED DATE: November 2010 REVIEWED DATE:
1.0
PURPOSE: To prevent transmission of infections by contact routes, toys used in any department, inpatient unit or practice for therapeutic, diagnostic or entertainment purposes will be cleaned/disinfected on a routine basis and when visibly soiled .Recognizing the importance of play and education to a hospitalized child and realizing the potential of spread of infection with shared toys, hands and person-to-person contact, the following guidelines are recommended.
2.0
GENERAL PRINCIPLES 2.1.
Only toys that can be easily cleaned (plastic or non-porous) are provided.
2.2.
Stuffed toys are not permitted. If a child must have a stuffed toy, it must be labeled with the child’s name, used only by that child and sent home or discarded at discharge.
2.3.
Mobiles that contain stuffed toys are not allowed.
2.4.
No special precautions are needed for magazines or books, unless visibly soiled. Items that cannot be cleaned with hospital-approved disinfectant or soap and water should be discarded. Rooms with children on Additional Precautions will remain there throughout hospitalization. When the patient is discharged, toys should be disinfected with hospital-approved disinfectant before return to a central storage area.
2.5.
3.0
2.6.
Stuffed toys in common areas such as halls, waiting rooms, family rooms that are used to enhance the décor are not permitted.
2.7.
Communal toys including large wheel toys are cleaned weekly and when visibly soiled.
2.8.
Toys used for testing will be cleaned after each use.
PROCEDURE 3.1. Use regular soap and water for cleaning visible dirt/soil. • Wash toys with soap using friction. • Rinse with water and dry. 3.2.
Hospital approved disinfectant for cleaning toys that are mouthed or contaminated and those used with children on Additional Precautions. • Wipe toys with disinfectant. • Allow 10 minutes contact time. • Rinse with water and dry.
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4.0
REFERENCES: 4.1.
Guidelines for Isolation Precautions in Hospitals, Hospital Infections Program, Center for Infectious Diseases, Center for Disease Control, U.S. Department of Health and Human Services, Atlanta, Georgia, 1996.
4.2.
APIC Text 2009; Chapter 39 Pediatrics, Basic Principles .
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IX0800: Personal Care Supplies Best Practice Guidelines
EFFECTIVE DATE: June 2009 REVISED DATE: November 2010 REVIEWED DATE:
1.0
PURPOSE: To ensure that personal care supplies are not shared and are kept clean and prevent transmission of microorganisms to other patients and healthcare providers.
2.0
DEFINITION Personal care supplies include items used for bathing, skin care, nail care, oral hygiene, denture care, dressing care and incontinence care. Included are the following items: • Skin cleansers. • Lotions. • Creams. • Soaps. • Razors. • Toothbrush. • Toothpaste. • Denture box. • Comb and hairbrush. • Nail file and clippers. • Dressing supplies. • Any other articles needed for personal hygiene.
3.0
GENERAL PRINCIPLES: Personal care supplies should not be shared between patients. 3.1
Acute Care, Rehabilitation units, and Psychiatry units • Each patient should bring in his/her own personal care items. • Electric razors should not be shared between patients. • Personal disposable razors can be used and must be disposed of in designated waste receptacle. • Nail/foot care equipment must be sterilized between patients. • Lotions, soaps and creams - Use a ‘tongue’ depressor or separate cup to dispense to avoid contamination of the bottle and contents. • Unused products kept at the bedside should not be restocked unless they can first be appropriately cleaned and disinfected. Single-use items must not be reprocessed and must be discarded.
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4.0
3.2
Residential Care • Each resident must have his/her own personal care items. • Personal care items should be cleaned regularly.
3.3
Foot care clinics or contractors coming into Interior Health facilities • Shared foot care equipment must be sterilized between residents/clients. This includes clippers, files, and scissors.
PROCEDURE 4.1
Labeling • Each patient’s personal supplies should be identified with his/her name and kept at his/her bedside in a clean container (e.g. in a washable cosmetic bag or plastic container). Toothbrush and oral hygiene products should be kept in a separate bag or container at the bedside. • Patient’s personal care items must be sent with the patient when discharged.
4.2
Cleaning and Storage Lotions: • Preferably, use lotions in a bottle with a pump and labeled with patients name. Soaps: • Bar soap must be kept in a clean, dry soap dish that allows the bar to drain between uses. • Personal liquid body soap is preferred because it is more easily stored between uses. Wound/Skin Cleansers: • Wound and skin cleansers must not be shared. Each patient should have a personal cleanser labeled with the patient name. • Each resident should have a personal incontinence care cleanser labeled with their name. Creams: • Use a tongue depressor to dispense cream from jar to avoid contaminating the cream. Toothbrush: • Change every three months and after an illness. Keep in a plastic toothbrush container. Ensure it is stored protected from toilet aerosols. Denture box: • Label with patient name. Rinse and dry daily. Comb and Hairbrush: • Label with patient name. Clean at the same time as hair is washed. Clean in hot soapy water, rinse and allow to air dry. Hair Rollers: • Wash in hot soapy water between residents. Nail file and clipper: • Label with patient name. Clean and dry after each use.
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Razors: • Clean electric razors after each use with a personal razor brush. Don’t share. • Personal disposable razors can be used and must be disposed of in designated waste receptacles. Bedpans: • Clean and disinfect after each use. Never place on the floor. • Disposable bedpans are acceptable. Bowls for washing: • Clean with soap and water and dry after each use. 5.0
REFERENCE: 5.1
Infection Prevention and Control Best Practices For Long Term Care and Community Care Including Health Care Offices and Ambulatory Clinics. June 2007 Sponsored by Canadian Committee on Antibiotic Resistance.
5.2
Health Canada Hand Washing, Cleaning, Disinfection and Sterilization in Health Care. Canada Communicable Disease Report. Volume 24S8. December 1998
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A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page
IX0900:
Construction Projects
EFFECTIVE DATE: September 2006 REVISED DATE: September 2012 December 2012 REVIEWED DATE:
1.0
PURPOSE Construction projects, in particular renovation projects, pose potential health risks for patients, staff, visitors and construction personnel that may lead to healthcare associated infections. These risks most commonly develop when dust particles contaminated with bacteria and/or fungi are dispersed into adjacent patient care areas. The primary fungus associated with these infections is Aspergillus while the main bacterium is Legionella.
Note • • •
• • . •
CSA Z317-13-07 May 2008 shall be used to determine population risk group, construction activity type, and preventative measures. Prevention Measures will be outlined in the construction documentation prior to the construction project starting and prior to the project going to tender. Class of Preventative Measure Level I and II will be determined by the Plant Services staff in the facilities. If Plant Services staff has questions pertaining to the stratification of the risk groups, the Infection Prevention and Control Practitioner will be contacted. Infection Prevention and Control Practitioners will be involved in all discussions involving the Class of Preventative Measure Level III and IV and the ICP will sign off the Infection Control Construction permit. The Infection Control Practitioner must be given a minimum of 48 hours notice by anyone requesting a permit before the scope of work can be assessed and a permit issued. Independent contractors will communicate with the Plant Services department prior to commencing their projects to ensure the sign off form has been completed.
See: Construction and Renovation Guidelines
•
Construction-related Healthcare Associated Infections – Decreasing the Risk of Aspergillus, Legionella and Other Infections.
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See: Contractor Procedures & Information
These are the specifications that are provided to the consultants in the tender package. These documents will be included in the Request for Proposal as well as the “front end” document that Facilities Management provides to the consultants when preparing tenders.
2.0 References 2.1
CSA Standard: Canadian health care facilities. CSA Z8000-11 September 2011.
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IX1000:
Construction & Renovation Guidelines
EFFECTIVE DATE: September 2006 REVISED DATE: September 2012 December 2012, February 2013, March 2013
1.0
PURPOSE To prevent construction or renovation related infections in staff, clients and visitors. To provide guidelines to be followed during construction or renovation of health care facilities.
2.0
GUIDELINE 2.1.
Pre-Approval Assessment A well-managed multidisciplinary team with appropriate expertise will be established early in the planning stage of construction and renovation projects. The multidisciplinary team shall include: •
Infection prevention and control.
•
Administration.
•
Project management.
•
Environmental services.
•
Health care (e.g. medical and nursing staff).
•
Design (e.g. architects, engineers).
•
Operations and maintenance.
•
Construction/renovation personnel.
Assessment of the risks to occupants of the health care facility is necessary before construction or renovations begin. The Planning Department and Engineering or operations and maintenance will keep the Infection Control Service informed regarding the location of all areas of renovation and construction as soon as possible, during the planning stages. The Infection Control /Construction Form will be used by the Infection Control Practitioner, or designated person, when assessing projects.
2.2.
Approval The Infection Control Service must review all planned projects, especially those falling under the category of Class of Preventative Measure Level III and IV. All construction workers must follow the infection control procedures described in this guideline.
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Engineering or operations and maintenance and/or the Planning Department in collaboration with the Infection Control Service will determine the Class of Construction Activity for each project.
Infection Prevention and Control Measures for New Projects
Preventative measures I through IV shall apply to all new construction projects (includes construction on vacant land, facility additions, and space redevelopment) •
Prior to construction the constructor shall present an infection control plan to the multidisciplinary team including selection, design, application, specification, and assembly of construction materials to be used in the project.
•
Constructor proposed infection prevention and control measures must encompass the duration of the project and ongoing maintenance and operations.
•
The multidisciplinary team shall communicate its policies and procedures to the constructor before construction begins.
•
The constructor should designate an individual responsible for infection control to liaise with the multidisciplinary team and monitor and coordinate the infection control procedures. The multidisciplinary team should designate a representative to communicate with the constructor and attend construction meetings as necessary.
•
On approval of the infection control plan by the multidisciplinary team, the constructor should coordinate infection control education sessions for all suppliers and subcontractors participating in the project. A copy of the infection control plan shall be provided to all subcontractors and compliance will be imposed in all subcontracts.
•
Infection Prevention and Control Practitioners will be involved in all discussions involving the Class of Preventative Measure Level III and IV and the ICP will sign off the Infection Control Construction permit.
•
The Infection Control Practitioner must be given a minimum of 48 hours notice by anyone requesting a permit before the scope of work can be assessed and a permit issued.
•
Infection prevention and control measures shall be constantly monitored and shall be reviewed at every construction and project management meeting.
•
If, during construction, events that can present infection risks occur, intervention procedures shall be implemented immediately to resolve the problems.
•
Plumbing and HVAC systems shall be supplied, installed, and commissioned in accordance with CAN/CSA-Z317.1, CAN/CSA-Z317.2, and CAN/CSA Z318.0.
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2.3.
Project Monitoring An Infection Control Practitioner will be assigned to each level III and IV project and will be the liaison with the relevant clinical areas. The ICP, after consultation and approval from IHA Project Manager (PM), will have the authority to issue a stop work order at any time during the project if, in their opinion, there are inadequate Infection Control Measures and a risk for the spread of dust particles.
3.0
REFERENCES 3.1.
Canada Communicable Disease Report: Construction-related nosocomial infections in patients in health care facilities. July 2001
3.2.
CSA Standard: Infection Control during Construction or Renovation of Health Care Facilities. CSA Z317.13 – 07 May 2008
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APPENDIX 1 Infection Control Construction Permit / Sign Off Form Location of Construction:___________________
Supervisor:____________________
Project Coordinator: ____________________
Project Start Date: ___________________
Contractor Performing Work:___________________
Estimated Duration: __________________
Supervisor:___________________
Telephone:____________________
YES
NO
CONSTRUCTION LEVEL
YES
NO
TYPE A: Inspection, non-invasive activity TYPE B: Small scale, short duration, moderate to high levels TYPE C: Activity generates moderate to high levels of dust, requires greater 1 work shift for completion TYPE D: Major duration and construction activities requiring consecutive work shifts Area Free of Hazardous Materials:
Yes
No
Population RISK GROUP GROUP 1: Least Risk GROUP 2: Medium Risk GROUP 3: Medium/High Risk GROUP 4: Highest Risk
(if No, attach description and abatement requirements).
Visual Checklist for work within existing building to check for Mold Presence completed. Mold Presence not detected Mold Detected Abatement Complete Type of Construction or Renovation: Circle
A
B
C
Population Risk Group: Circle
2
3
4
1
D
(Risk Assessment for Types of Construction Activity Table, Schedule 1)
CLASS OF PREVENTATIVE MEASURE Construction Level (Type A,B,C,D) Type A Type B
Type C
Type D
II
III/IV
II
III
IV
III
III/IV
IV
III/IV
IV
Group 1
I
Group 2
I
Group 3
I
Group 4
I - III Contact IC
III/IV
Class of Preventative Measure Required:
Level
Has the multidisciplinary team been involved; Yes
II
I
II
III
IV
No
Date: ___________________________
Date: ___________________________
________________________________ Interior Health – Infection Control Professional
________________________________ Construction Representative
Additional Requirements: Attach copy Date: ___________________________
Signature: ___________________________
Date: ___________________________
Signature: ___________________________
Infection Control Measures in Place. Work Authorized to Proceed: Date: ___________________________
Date: ___________________________
________________________________ Interior Health – Infection Control Professional
________________________________ Construction Representative
Original: Infection Control Practitioner Copy: Project Manager or Plant Manager Infection Prevention & Control-IX1000 Note: in this document the term “patient” is inclusive of patient, resident or client.
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APPENDIX 2 Schedule 1 Type of Construction Activity for Risk Assessment: (Table 3: taken from CSA Guideline Z317.13-07 May 2008) Construction Level Type A: Inspection, non-invasive activities
a)activities that require removal of not more than one ceiling tile or require wall or ceiling panels to be opened; b)painting (but not sanding) and wall covering; c)electrical trim work; d)minor plumbing work that disrupts the water supply to a localized patient care area (i.e. one room) for less than 15 min.; and e)other maintenance activities that do not generate dust or require cutting of walls or access to ceiling other than for visual inspection.
Construction Level Type B:
a) activities that require access to chase spaces;
Small scale, short duration activities that create minimal dust. These include, but are not limited to,
b) where dust migration can be controlled, cutting of walls or ceilings for installing or repairing minor electrical work, ventilation components, telephone wires, or computer cables; c) sanding or repair of a small area of a wall; and d) plumbing work that disrupts the water supply of more than one patient care area (i.e. two or more rooms) for less than thirty min.
Construction Level Type C: Activities that generate a moderate to high level of dust, require demolition, require removal of affixed facility component (e.g. sink) or assembly (e.g. countertop or cupboard), or cannot be completed in a single work shift. These include, but are not limited to,
a) activities that require sanding of a wall in preparation for painting or wall covering; b) removal of floor coverings, ceiling tiles, and case work; c) new wall construction; d) minor duct work; e)electrical work above ceilings; f) major cabling activities; and g) plumbing work that disrupts the water supply of more than one patient care area (i.e. two or more rooms) for more than 30 min but less than 1 h.
Construction Level Type D: Activities that generate high levels of dust, and major demolition and construction activities requiring consecutive work shifts to complete. These include, but are not limited to,
a) activities that involve heavy demolition or removal of a complete cabling system; b) new construction that requires consecutive work shifts to complete; and c) plumbing work that disrupts the water supply of more than one patient care area (i.e. two or more rooms) for 1 h or more.
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Border Risk Groups Assessment (Table 2: taken from CSA Guideline Z317.13-07 May 2008) Group 1
•
Office areas
Lowest Risk
•
Unoccupied wards
•
Public areas
•
Laundry and Soiled Linen cleaning areas
•
Physical Plant Workshops and housekeeping areas
Group 2
•
Patient care areas unless listed in Group 3 or 4
Medium Risk
•
Outpatient clinics (except for oncology & surgery)
•
Admission and discharge units
•
Waiting rooms
•
Autopsy and morgue
•
Occupational therapy areas remote from patient care areas
•
Physical therapy areas remote from patient care areas
Group 3
•
Emergency (except trauma rooms)
Medium to High Risk
•
Diagnostic Imaging
•
Labor & birthing rooms (non-operating)
•
Nurseries for healthy newborns
•
Nuclear medicine
•
Hydrotherapy
•
Echocardiography
•
Laboratories
•
General Medical and surgical floors
•
Pediatrics
•
Geriatrics
•
Long Term care
•
Food preparation serving and dining areas
•
Respiratory therapy
•
Clean linen handling and storage areas
•
Intensive care units (ICU’s)
•
Operating rooms (including prep, induction, post-anesthetic care unit (PACU), and scrub areas
•
Anesthesia storage areas and work rooms
•
Oncology units and outpatient clinics for cancer patients
Group 4 Highest Risk
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•
Transplant units and outpatient clinics for transplant patients
•
Wards and outpatient clinics for patients with AID’s or other immunodeficiency diseases
•
Dialysis units
•
critical care nurseries (NICU)
•
Labor and delivery operating rooms
•
Cardiac catheterization and angiography areas
•
Cardiovascular and cardiology patient areas
•
Endoscopy
•
Pharmacy admixture rooms
•
Sterile processing rooms
•
Sterile supply areas
•
Burn care units
•
Animal rooms
•
Trauma rooms
•
Protective environment isolation rooms
•
Tissue culture laboratories
•
Bronchoscopy
•
Cystoscopy
•
Pacemaker insertion rooms
•
Dental procedure rooms
•
Central processing department
Construction activity and Risk Group Matrix •
The Infection Control Service must be involved with the multidisciplinary team at the planning stage for all Class of Preventative Measure Level III and IV activities. An Infection Control Practitioner will be assigned to each project and will regularly visit the construction area.
•
Please notify the Infection Control Service when work is being done on hallways adjacent to patient care areas that fall into a Population Risk Group of 3 or 4.
•
Circumstances may necessitate changing the Class of Preventative Measure Level at any time during the project. Any changes to the scope of work, the Infection Control Practitioner assigned to the project, must review to determine if there is a further impact on infection control.
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CLASS OF PREVENTATIVE MEASURE Construction Level Type A Populations
Construction Level Type B
Construction Level Type C
Construction Level Type D
I
II
II
III/IV
I
II
III
IV
I
III
III/IV
IV
I – III
III/IV
III/IV
IV
Risk Group 1
Population Risk Group 2
Population Risk Group 3
Population Risk Group 4
• • •
*Contact infection control to ensure appropriate classification
See Table 3 for Construction Activity and Table 2 for Population Risk Group. Shaded activity areas indicate increased risks to population and implementation of stringent Infection Control precautions. Infection Control Construction Permit/Sign Off Form required for all Construction Activity. When the Class of Preventive Measure is Level III/IV, a multidisciplinary team shall determine the appropriate prevention measures required, either Level III or Level IV.
Guidelines for Dust Containment during Construction Engineering and operations or maintenance staff and/or the Planning Department in collaboration with the Infection Control Service will determine the Class of Construction Activity for each project. Please refer to the guidelines below for dust control measures for the Activity Class of the project. If the level of construction activity changes during the course of the project, please notify Engineering and operations or maintenance, and/or the Planning Department and/or the Infection Control Service before proceeding.
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APPPENDIX 3 CLASS OF PREVENTATIVE MEASURE Level I
Engineering or Operations and Maintenance Staff or Constructors • • • •
Minimize dust during construction operations. Clean the work area with a HEPA vacuum cleaner if necessary. Wipe work surfaces with a hospital approved disinfectant after the project is completed. Immediately replace any ceiling tile or access panel displaced for visual inspection.
Plumbing Activities • • • • •
Schedule water interruptions during low activity. Flush water lines prior to reuse - check for discolored water. Ensure that gaskets and items made of materials that support the growth of Legionella are not being used. Ensure faucet aerators are not installed or used. Maintain as dry an environment as possible and report any leaks that occur to walls and substructures.
Environmental Services •
Report discolored water and water leaks to Maintenance and Infection Control.
Medical/Nursing Staff • •
Minimize patients' exposure to construction/renovation area. Ensure that patient care equipment and supplies are protected from dust exposure.
After construction • The multidisciplinary team shall review the preventive measures that were undertaken and assess their effectiveness. Level II
Note: In addition to following preventative measure I the following measures shall be met.
Engineering or Operations and Maintenance Staff or Constructors • • • • • • • •
Seal windows and unused doors. Seal plumbing penetrations, electrical outlets, and any other sources of potential air leaks in the construction area. Seal air vents in the construction area and if possible disable until construction completed Use drop sheets to control dust. Place walk off mat outside of entrance of construction area to trap dust from the equipment and shoes of personnel leaving the area. Wet mop and /or vacuum (with HEPA filtered vacuum) at end of day as well as when the mat is visibly soiled. Walk off mats shall be of sufficient size to ensure that constructors have to place both feet on the mat at least once on exiting the construction area. Water mist work surfaces to control dust while cutting (note: caution should be exercised when such techniques are used on cellulose or fibre based materials that are intended to stay in place following construction work).
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• • • •
Contain debris in covered containers or cover with a moistened sheet before transporting it for disposal. Place supplies and equipment in covered containers during transportation through the healthcare facility to prevent contamination in other areas. Remove debris in the evening when patients are in their rooms and visitors have left. If this is not possible debris should be removed at the end of the work day. Wipe work surfaces with a hospital approved disinfectant at end of project
Plumbing Activities • •
•
Avoid collection tanks and long pipes that allow water to stagnate. Hyper chlorinate (to a minimum of 50 parts per million) or superheat (to a minimum of 70 degrees Celsius) stagnant domestic water (especially if Legionella is already present in the domestic water supply). The water lines in the construction area and adjacent patient care areas shall be flushed before reuse; and note: Preventative technologies (e.g. silver-copper ion treatments) may be considered in lieu of the techniques specified above. Be aware of the impact of techniques to remove bacterial growth and choose the approach that minimizes the risks associated with such work
Medical/Nursing Staff/Administration •
Identify high-risk patients who may need to be temporarily moved away from the construction zone.
After Construction • The multidisciplinary team shall a. Review the preventive measures that were undertaken and assess their effectiveness; and b. Conduct a final inspection to ensure that the ventilation system is functioning properly in the construction area and adjacent areas. • Infection prevention and control personnel shall ensure that the construction area has been thoroughly cleaned before building occupants are readmitted to the completed construction area. • Environmental services and healthcare staff shall a. Ensure that the construction area has been cleaned with a HEPA filter-equipped vacuum cleaner, a wet mop, or both, as necessary, and that horizontal work surfaces have been wiped with a disinfectant; and b. Report discolored water and water leaks to the maintenance and infection prevention and control departments. Level III
Note: In addition to following preventative measures I and II the following measures shall be met. Minimization of dust generation and dispersal Engineering or Operations and Maintenance Staff or Constructors •
Erect an impermeable dust barrier, from the floor to the underside of the deck (including the areas above false ceilings) consisting of two layers of 0.15mm (6 ml) fire-retardant polyethylene (or an equivalent barrier) and gypsum wall board protection approved by the multidisciplinary team. The dust barrier shall remain in place until the project is complete and the area has been cleaned thoroughly and inspected. After construction has been completed, the dust barrier shall be removed to prevent the spread of dust and other debris particles adhering to the barrier;
•
Use impermeable vessels constructed to contain contaminants. Such vessels shall have a monolithic (one-piece) exterior shell constructed of a minimum of 0.20 mm (8 ml) fibre-
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reinforced, fire-retardant polyethylene. The construction of the vessel shall allow for containment of contaminants within the vessel and have ports through which HEPA-filtered vacuum cleaners or portable construction HEPA-filtered air units can be easily attached to draw the unit under negative pressure; •
Vacuum mechanical and electrical systems and spaces above drop or false ceilings, if necessary; and
•
Remove protective clothing before entering patient care areas.
Ventilation Systems Engineering or Operations and Maintenance Staff or Constructors •
Disable the ventilation system and seal duct openings in the construction area until the project is completed;
•
Maintain a negative pressure of 7.5pa (0.03 in wc) within the construction area using portable HEPA filter-equipped air filtration units that include pressure gauges and an alarm. Filters shall be monitored and replace if clogged or functioning below the manufacturers specifications;
•
Ensure that the air is exhausted directly outside and away from intake vents and filtered through an HEPA filter. In conditions that prohibit exhausting exhaust outside, air may be recirculated in accordance with Clauses 6.6 and 7.2.3.6 (CSAZ317.13-07); and
•
Ensure that the ventilation system is functioning properly and cleaned if contaminated by soil or dust after the construction project is complete.
Portable construction HEPA-filtered air units •
Construction area exhaust shall be HEPA filtered. Filters shall be visually inspected by the constructor at least daily, condition documented, and replaced when loaded.
•
HEPA filtered air units shall be certified at the beginning of any preventative level III or IV construction activity. Units shall be recertified at least every 12 months and the recertification shall be documented.
•
Construction, maintenance, and repair area exhaust air shall not be discharged to areas occupied by Population risk group 3 or 4. Measures related to recirculated air shall require approval from the multidisciplinary team.
•
The relative space pressures between areas occupied by Population risk group 3 or 4 shall be continuously monitored.
Impact on the facility HVAC system •
Portable air filtration units may affect a facility’s HVAC system; therefore,
•
The main facility system shall be verified for operation in accordance with design during construction work.
•
The healthcare facility and constructor shall verify the pressure relationships for critical areas near the construction area.
Construction air handling •
Permanent air handling systems should not be used for exhausting air from construction or renovation work areas. Temporary duct work may be installed for such purposes. However, it shall not connect to the facility’s HVAC system.
•
In cases where air cannot be directly exhausted outside(not tying into another system), exhaust air may be piped to the building exhaust system if an engineering analysis has been performed by qualified personnel to ensure that the exhaust air will not be re entrained into the occupied
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building and the multidisciplinary team approves piping to the exhaust system. •
Where air cannot be directly exhausted outside or piped through the building exhaust system, it may be recirculated into areas of the building occupied by Risk Group 1 or 2 if multidisciplinary team approval is granted. Construction exhaust air shall not be recirculated into building areas occupied by Risk Group 3 or 4.
Cleaning and Maintenance •
Engineering or operations and maintenance staff in the construction area shall clean outside the work area with a HEPA filter-equipped vacuum cleaner every day or more frequently if necessary.
•
Environmental services staff shall a. Increase the frequency of cleaning adjacent to the construction area. b. Wet mop and vacuum the area with a HEPA filter-equipped vacuum cleaner as necessary and when the work is complete; and c.
Wipe exposed surfaces with a hospital grade disinfectant.
Role of infection prevention and control personnel •
To collaborate with the environmental services staff to ensure the construction area is thoroughly cleaned when work is complete;
•
Inspect the integrity of dust barriers; and
•
In collaboration with the facility program manager, designating a traffic pattern for constructors that avoids patient care areas and a traffic pattern for clean or sterile supplies and equipment that avoids the construction area.
Role of healthcare staff Healthcare staff shall •
Ensure that patient care equipment and supplies are protected from dust exposure;
•
Ensure that patients do not go near the construction area;
•
Ensure that staff do not visit the construction area; and
•
Report discolored water and water leaks to maintenance and infection prevention and control personnel.
After Construction • The multidisciplinary team shall c. Review the preventive measures that were under taken and assess their effectiveness; and d. Conduct a final inspection to ensure that the ventilation system is functioning properly in the construction area and adjacent areas. • Infection prevention and control personnel shall ensure that the construction area has been thoroughly cleaned before building occupants are readmitted to the completed construction area. • Environmental services and healthcare staff shall c. Ensure that the construction area has been cleaned with a HEPA filter-equipped vacuum cleaner, a wet mop, or both, as necessary, and that horizontal work surfaces have been wiped with a disinfectant; and d. Report discolored water and water leaks to the maintenance and infection prevention and control departments. Infection Prevention & Control-IX1000 Note: in this document the term “patient” is inclusive of patient, resident or client.
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Level IV
Note: In addition to following preventative measures I, II, and III the following measures shall be met. Engineering or Operations and Maintenance Staff or Constructors •
Ensure that all access shall be from outside the occupied areas of the healthcare facility, or construct anterooms at access points to the construction area if access is from within the healthcare facility;
•
Place a walk-off mat outside and inside the anteroom to trap dust from equipment, debris, and the shoes of personnel leaving the construction area. Walk off mats shall be of sufficient size to ensure that constructors have to place both feet on the mat at least once on exiting the construction area;
•
Ensure that the constructors a. Leave the construction area through the anteroom so that they can be vacuumed with a HEPA filter-equipped vacuum cleaner before leaving; or b. Wear protective clothing that is to be removed each time they leave the construction area and before going into patient care areas; c.
Repair holes in walls within 8 hours or seal them temporarily;
d. Ensure that ventilation systems are working properly in adjacent areas; and e. Carefully remove barrier walls and use short term protection to minimize environmental contamination during removal. •
Environmental services staff shall ensure that the construction area is thoroughly cleaned when work is complete.
•
Infection prevention and control personnel shall regularly visit the construction area to ensure that preventative measures are followed. The frequency of their visits shall be determined by the multidisciplinary team
•
Infection prevention and control measures shall be constantly monitored and shall be reviewed at every construction and project management meeting
•
If, during construction, events that can present infection risks occur, intervention procedures shall be implemented immediately to resolve the problems
•
Plumbing and HVAC systems shall be supplied, installed, and commissioned in accordance with CAN/CSA-Z317.1, CAN/CSA-Z317.2, and CAN/CSA Z318.0
•
Before substantial completion and occupancy, the constructor shall have satisfied all infection control measures. Detailed inspections shall be performed by the multidisciplinary team
After construction •
In addition to preventative measures II and IIl before the completed construction area is occupied any portions of the infection control plan still in effect shall be reviewed by the multidisciplinary team.
•
If necessary such portions shall be incorporated into the healthcare facilities ongoing operating policies and procedures.
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APPENDIX 4
Quick Reference Guide for CSA Z8000-11 Guidelines Infection Prevention and Control & Facility Infrastructure Requirements Infection Prevention & Control shall be involved from the design phase through to commissioning in both new construction and renovations of existing facilities. Canadian Standards Association (CSA) Standards shall be incorporated into all construction/renovation projects. With renovations every effort shall be taken to follow the latest CSA standards. This includes: 1. CSA Z317.2 – 10: Special requirements for heating, ventilation, and air conditioning (HVAC) systems in health care facilities, 2010. 2. CSA Z8000 – 11: Canadian health care facilities, 2011. The need for facility renovations shall be identified by the mandatory use of the biennial audit tool Best Practices for Hand Hygiene in all Healthcare Settings: Supplementary checklist for facilities and infrastructure needed to support healthcare providers; Provincial Hand Hygiene Working Group – Facilities/Infrastructure Team (2012)
Quick Reference Guide for CSA Z8000-11 Guidelines Item Airborne isolation rooms (AIR)
Explanation Each acute care facility shall have a minimum of one AIR per inpatient unit unless a risk assessment demonstrates otherwise
Allied Health Services
For complete information see pages >
Page Page 94 (also see page 26-27 of CSA Z317.210) Page 244-247
Ambulatory Care
For complete information see pages >
Page 174-183
Ceilings
For complete information see pages >
Clause 11
Table of common requirements
Page 354, Page 361-362 Page 327-353
Clean supply/utility room
• •
Page 329
Dialysis
Clean and soiled utility rooms shall be separate Supplies shall be stored in mobile shelving that is cleanable, smooth, non porous, and tolerant of hospital disinfectants; or automated dispensers • Equipment and supplies shall not be exposed to direct HVAC air flow, or stored by windows • See section on floors/walls/ceilings For complete information see pages >
Dining Room
For complete information see pages >
Page 333
Electrodiagnostic Services
For complete information see pages >
Page 267-273
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Page 184-191
Page 14
Emergency Examination/procedure/tr eatment room
For complete information see pages > • • •
A wall mounted hand hygiene sink shall be located adjacent to the door along with a hand hygiene station Soiled linen hamper and soiled garbage container shall be provided Storage of supplies should be provided in closed cupboards
Page 209-223 Page 333-335
Floors
For complete information see pages >
Page 359-361
Hand hygiene sinks
Dedicated hand hygiene sinks shall be provided A hand hygiene sink is required: • In each inpatient bedroom • Where treatments/exams/assessments are provided • Locations designed for one patient: one sink • Locations designed for three or more patients: one sink per three patients, with 6 m. or less between any patient and sink • Inside(if plastic pipes used), or adjacent to each diagnostic MRI room • Stainless steel hand hygiene sinks shall be used in areas handling radioactive materials • In each soiled utility/soiled holding room • In any food prep area • Inside or within 6 m. of each nursing station • Inside or within 6 m. of each staff lounge • In medication preparation areas • Within 6 m. of each laboratory work station and within each work room • Where soiled linen is handled • Any area where hands are likely to be contaminated • In each airborne isolation room and each anteroom • For complete information on materials, size, construction, location, controls, backsplash, dispensers and hand dryers see pages > • Sinks must have water supply & drainage separate from hemodialysis piping For complete information see pages >
Page 96-97
For complete information see pages >
Page 21-24, 9194 Page 22, 340342
Housekeeping closet Infection Control general information Inpatient room
•
• Inpatient isolation rooms
Shall be single bedded rooms, unless the functional program, with supporting documentation, demonstrates the necessity of a two-bed arrangement Shall have one washroom per patient
For complete information see pages >
Infection Prevention & Control-IX1000 Note: in this document the term “patient” is inclusive of patient, resident or client.
Page 337-339
Page 186 Page 339
Page 343-344 Page 15
Inpatient washrooms
For complete information see pages >
Page 342-343
Laboratory
For complete information see pages >
Page 248-266
Laundry for Rehab and LTC Maternal and Newborn
For complete information see pages >
Page 344
For complete information see pages >
Page 128-135
MDR
• • • • • • •
Stainless steel is preferred for surface materials Open hoppers shall be located away from staff work areas and traffic areas Ceilings shall be resistant to humidity, non porous, non shedding, and shall be constructed without fissures, open joints or crevices Solid walls shall have a hard, smooth finish and may be sealed in epoxy or spray painted Flooring shall have integral coved base Shelving shall be non porous, non shedding, and easily cleanable The top and bottom of storage carts shall be solid
Page 311-325
Medical Imaging
For complete information see pages >
Page 278-284
Medication Room
For complete information see pages >
Page 345
Oncology
For complete information see pages >
Page 192-208
Operating Rooms and Procedure Rooms Pharmacy
For complete information see pages >
Page 224-243
The mixing of parenteral therapy solutions requires special work stations and air handling • Chemo prep requires negative pressure • Sterile medication prep requires positive pressure • Anterooms are recommended • Satellite pharmacy
Page 285-290
Respiratory
Cough inducing procedures require special room requirements and air handling
Page 274-277, 347
Scrub sinks
Shall be provided where operative procedures are performed including ORs, delivery rooms, endoscopy suites, interventional radiology, and cardiac catheterization suites
Page 97
Soiled utility room
• • • • •
Shall be separate from clean utility room Separate hand hygiene sink shall be provided No storage of clean equipment May store patient waste disposal equipment and stool/urine/vomit specimen supplies Shall have human waste management system
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Page 348-349
Page 16
• • •
Surfaces – ceilings, floors, walls, doors, window, furniture Tub/Shower room
Shall be smooth, non porous, seamless, resilient and impact resistant, cleanable and compatible with facility approved disinfectants, water impermeable • •
Waiting rooms
• •
Walls Washroom - public
•
•
•
Waterless hand hygiene stations
Window treatments
Page 351-352
Zones shall be created so that the more infectious persons are in a separate area Public washrooms shall be provided in close proximity
Page 352
Page 360-361
Toilet, sink, and paper towel dispensers shall be hands free Toilets with tanks shall not be used, due to risk of condensation
Page 352
One washroom with toilet and sink for each inpatient. A closed waste management mechanism with hand hygiene sink shall be installed where toilet not required (e.g. ICU, NICU or nursery) Each inpatient service shall be equipped with at least one closed waste management system
Page 94-95
Waterless hand hygiene station shall be provided in each of the following locations: • All entrances and exits to the healthcare facility • Immediately adjacent to the entrance of each patient bedroom • Immediately adjacent to the entrance of each patient care area (e.g. exam or procedure room) • Adjacent to the bedside at point of care unless risk to patient • Where Personal Protective Equipment (PPE) is donned or doffed Shall be mounted approximately 1 m. from floor and shall be in compliance with fire regulation guidelines • •
Page 86 - 89
Shall have a hand hygiene sink at the entrance/exit just inside room Each room shall have storage space for supplies and PPE
For complete information see pages >
•
Waste management
Splash protection shall be provided on walls near water supply, sinks, or human waste management system PPE should be available Shall provide storage for soiled linen, garbage, and biohazard carts
Shall be durable and easy to clean Blinds to external windows should be installed between double glazing
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Page 97 Page 339
Page 356-357
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EFFECTIVE DATE: September 2006
IX1100 Contractor Procedures & Information
REVISED DATE: January 2010 December 2012
DIVISION 01 – GENERAL REQUIREMENTS SECTION 01550 – Infection Control Measures CONTRACTOR PROCEDURES AND INFORMATION 1. BACKGROUND The scope of work for this project will include the requirement of dust control during the construction process. It is the responsibility of the Contractor to ensure critical and strict measures are taken to control dust throughout the construction process. Refer to Construction-Related Healthcare associated Infections. The Infection Prevention and Control Practitioner will be involved in all discussions involving Risk Group 3 and 4 populations. 2. CLASS OF CONSTRUCTION ACTIVITY LEVEL Class of Preventative Measure Level I and II will be determined based on guidelines by IHA’s Project Manager and/or Plant Services’ staff in the facilities. The Infection Control Construction Permit/Sign Off Form will be filled out by either the IHA Project Manager, Contractor’s Superintendent, or Plant Services manager and sent, to the Infection Control Practitioner responsible for that area. For all Class of Preventative Measure Level III and IV, the Owner’s Infection Control Practitioner will sign off the permit. The Infection Control Practitioner must be given a minimum of 48 hours notice by anyone requesting a permit before the scope of work can be assessed and a permit issued. All work in the Construction Scope is to be as per contract documents and the enclosed drawings, SK1 to SK4 for Class Preventative Measures III and IV. If there is a discrepancy between the contract documents and SK1 to SK4, contact the Architect for written clarification. 3. DURATION The required measures of this section are to be implemented prior to the start of any work on site and are to be maintained until Substantial Completion of the Project. 4. FAMILIARIZATION MEETING Prior to starting work on site, the Prime Consultant and/or the Project Manager shall convene a meeting to review Infection Control Measures and ensure that all parties are familiar with all requirements. This meeting should be held in conjunction with the Start-up Meeting required elsewhere in Division 1. Attendance by the Site Superintendent for the Prime Contractor and at least one representative of each major sub-trade is mandatory. The IH’s Infection Control Practitioner, Owner’s Project Manager and the Prime Consultant will be in attendance.
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5. ACCESS TO ADJACENT OCCUPIED AREAS In the event that some aspects of the work require access into an adjacent space within the facility (occupied or not), the Contractor shall inform the Interior Health Project Manager and/or designate no less than 5 working days prior to the start of the work in the adjacent space. The Contractor is to specify the location, duration and work to be completed in the adjacent space. The Contractor must communicate with the Owner’s Project Manager and/or designate prior to commencing their projects to ensure that the sign off form has been completed. The Contractor shall not enter a Patient Room to begin construction until the patient has been relocated. The Contractor will follow the Class of Preventative Measure noted in this document for all work within adjacent areas. 6. VACCINATIONS It is recommended that all persons working within the hospital ensure that their vaccinations are up to date for Hepatitis B, Tetanus and Diphtheria. 7. REMOVAL OF HOARDING AND DUST CONTROL Prior to removal of hoarding, the construction zone should be thoroughly cleaned, including all horizontal surfaces. Remove all hoarding and dust control that was erected, installed for the project, or installed for that phase prior to moving on to the next phase and repair any damage. Removal of hoarding should occur in a fashion that will minimize the spread of dust and bacteria. During the removal, the hoarding and area surrounding should be spray misted with water to minimize dust. 8. HEPAFILTER UNITS Interior Health will provide 1 (one) HEPA-filter unit for the project, if required; however, the contractor is responsible to return the unit with new primary and HEPA filters and in a clean and operable condition. HEPA-filter unit is to be certified prior to construction III or IV and recertified annually. This includes labeling and dating the items. The Contractor is responsible to provide and maintain negative pressure of 7.5 pa (0.03 in wc) in the construction area. The use of the HEPA-filter will be determined by the Interior Health Project Manager and Infection Control Practitioner. The contractor is to maintain the HEPA-filter and change out filters to ensure the sound operation of equipment. The Contractor will replace the 1 (one) HEPA-filter of equal quality at the end of each project or as required to maintain the machine as per manufacturer’s recommendations.
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MATERIAL MANAGEMENT Shipping, handling and storage of all susceptible materials are to be stored in a manner that avoids exposure to contaminants and moisture. Damaged material is to be decontaminated or replaced at the discretion of the multidisciplinary team.
Please review diagrams as they may not fit current regulations………………p. 33- 37 of binder
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