Winnipeg Regional Health Authority Infection Prevention & Control Manual. Original signed by B. Postl. December 2007

Transcription

1 POLICY Level: REGIONAL Applicable to all WRHA governed sites and facilities (including hospitals and personal care homes), and all funded hospitals and personal care homes. All other funded entities are excluded unless set out within a particular Service Purchase Agreement. Policy Name: Policy Number: Routine Practices for Reducing the Risk of Infection Transmission Approval Signature: Section: 1 Page: 1 of 5 Date: Original signed by B. Postl December 2007 INFECTION PREVENTION & CONTROL Supercedes: New 1.0 PURPOSE: To minimize the risk of transmission of microorganisms. 2.0 DEFINITIONS: 2.1 Alcohol Based Hand Rub: An alcohol based antiseptic with a minimum of 60% alcohol that is applied to all surfaces of the hands to reduce the number of microorganisms present on the hands. 2.2 Cleaning: The physical removal of foreign material, e.g. dust, soil, organic material such as blood, secretions, excretions and microorganisms. Cleaning physically removes rather than kills microorganisms. It is accomplished with water, detergents and mechanical action. 2.3 Disinfection: The inactivation of disease producing organisms. Disinfection does not destroy high levels of bacterial spores. Disinfectants are used on inanimate objects. Disinfection usually involves chemicals, heat or ultraviolet light. Levels of chemical disinfection vary with the type of product used. 2.4 Facility Approved Disinfectant: A disinfectant cleaner that has been approved by the facility or organization. 2.5 Hand Hygiene: A general term that applies to hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis. 2.6 Personal Protective Equipment (PPE): Gloves, gowns, masks and protective eyewear used according to risk of exposure to prevent transmission. 3.5

2 2.7 Respiratory Etiquette: Simple measures used to minimize the spread of respiratory organisms. 2.8 Routine Practices: A minimum standard of infection control precautions and practices used for all direct patient/resident/client care regardless of the patient s/resident s/client s presumed infection status or diagnosis. 2.9 Staff: All persons employed by the WRHA facilities, or WRHA funded facilities, as well as members of the medical staff, volunteers, board members, students and others associated through contracts. Level 1: All direct care staff including but not limited to Physicians, Nurses, Allied Health Care Providers (Occupational Therapy, Respiratory Therapy, Physiotherapy, Speech Language Pathologist, Dietitians, Pharmacy, Lab, EKG, DI, etc.), Support Services (Health Care Aides, Home Support Workers, Housekeeping, Porters, Transfer personnel and others as deemed appropriate by each site/area/program). Level 2: All staff who have contact with patients/residents/clients without providing direct care including, but not limited to volunteers, health records, patient registration, unit clerk, Laboratory workers and others as deemed appropriate by each site/area/program. Level 2A: All staff employed in corporate sites/areas and do not have direct daily contact with patients/residents/clients Visibly Soiled Hands: Hands showing visible dirt or visibly contaminated with proteinaceous material, blood, or other body fluids e.g. fecal material or urine Reusable: A device that has been designed by the manufacturer through the selection of material and/or components to be reused. 3.0 POLICY: 3.1 All Level 1 Direct Care Providers, Level 2 Non-Direct Care Providers and Corporate Staff shall be orientated upon employment and shall apply Routine Practices in accordance with WRHA s; and Routine Practices shall be incorporated into all patient/resident/client care to prevent the transmission infection. 3.2 All Level 1 Direct Care Providers shall receive on going education regarding Routine Practices a minimum of every 2 years of employment. 3.3 All patients/residents/clients, family members and visitors shall be provided information on Routine Practices where indicated for contact with a patient/resident/client. 3.4 Students in clinical practice who provide health services to patients/residents/clients in healthcare practice settings within the WRHA shall comply with this policy. 3.5 Artificial fingernails, gel nails, or extenders shall not be worn by any Level 1 Direct Care Providers, food handlers and anyone handling sterile preparations, linen and supplies. Refer to WRHA Dress Code Policy

3 4.0 PROCEDURE: 4.1 Hand Hygiene shall be performed in accordance with Routine Practices as outlined in WRHA IP & C Manuals and Routine Practices Educational Project Alcohol Based Hand Rub, plain soap or antimicrobial soap shall be the agents used for Hand Hygiene Hand Hygiene products shall be readily available for all Level 1 Direct Care Providers, Level 2 Non-Direct Care Providers, Corporate staff, patients/residents/clients, family members and visitors in WRHA facilities and WRHA funded facilities. 4.2 All shall provide information on Hand Hygiene to patients/residents/clients, family members and visitors and especially to patients/residents/clients before eating, after toileting and when hands are visibly soiled. 4.3 Personal Protective Equipment shall be used for the following clinical situations: Gloves shall wear clean, non-sterile gloves of appropriate size: For contact with blood, body fluids, secretions and excretions, mucous membranes, draining wounds, or non-intact skin. For handling items Visibly Soiled with blood, body fluids, secretions or excretions. When the Level 1 Direct Care Provider and Level 2 Non-Direct Care Provider have open lesions of his/her hands. Hand Hygiene shall occur after removal of gloves and before donning new gloves as gloves are not a substitute for Hand Hygiene Gowns shall wear gowns to protect uncovered skin and prevent soiling of clothing during procedures and patient/resident/client care activities likely to generate splashes or sprays of blood, body fluids, secretions or excretions Masks, Eye Protection, Face Shields shall wear standard surgical/procedure masks, eye protection and face shields where appropriate to protect the eyes and mucous membranes of the nose and mouth during procedures and patient/resident/client care activities likely to generate splashes or sprays of blood, body fluids, secretions or excretions. 3.7

4 4.4 Accommodation Single rooms shall be considered for patients in hospitals who may transmit infection, such as patients who visibly soil their environment, have draining wounds, and fecal incontinence that is not containable. If patients cannot be accommodated as suggested, contact site Infection Prevention and Control for recommendations regarding cohorting. 4.5 Patient Care Equipment Reusable equipment that has been in direct contact with a patient/resident/client or that is visibly soiled shall be cleaned and disinfected with a Facility Approved Disinfectant in accordance with WRHA Policy for Cleaning of Non-Critical Reusable Equipment/Items before use on another patient/resident/client A routine cleaning schedule should be established and documented, assigning responsibility and accountability for cleaning of the equipment (e.g. electronic thermometer) Dedicated patient care equipment may be considered for ICU and other high-risk areas Soiled patient/resident/client care equipment shall be handled in a manner preventing exposure to the Level 1 Direct Care Providers and Level 2 Non-Direct Care Providers skin and mucous membranes and contamination of clothing and the environment. 4.6 Environmental Control Procedures shall be established by facilities for routine care, Cleaning and where appropriate Disinfection of patient/resident/client furniture and environmental services with a Facility Approved Disinfectant Reusable dishware, utensils and dietary trays shall be used for patients/residents/clients for all times for any infection prevention and control purposes, e.g. disposable dishes are not required All linen and clinical waste shall be considered contaminated and handled according to facility/program policy/procedure. 4.7 Specimen Collection All clinical specimens shall be considered contaminated and handled according to Routine Practices in the WRHA Infection Prevention & Control Manuals. 4.8 Post Mortem Care All Level 1 Direct Care Providers shall use Personal Protective Equipment to prevent exposure to blood and other body fluids All Level 1 Direct Care Providers and family members shall perform Hand Hygiene after contact with a deceased individual. 3.8

5 4.9 Respiratory Etiquette All Level 1 Direct Care Providers, Level 2 Non-Direct Care Providers and Corporate Staff shall follow Respiratory Etiquette in accordance with WRHA s All patients/residents/clients, family members and visitors shall be provided information on Respiratory Etiquette information as outlined in the WRHA s. 5.0 REFERENCES: 5.1 Public Health Agency of Canada. Handwashing, Cleaning, Disinfection & Sterilization in Health Care Public Health Agency of Canada. Infection Control Guidelines Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care Infection Control Guidelines for the Management of Respiratory Infections, Winnipeg Regional Health Authority. Link Morbidity and Mortality Weekly Report. Guidelines for Hand Hygiene in Health Care Settings. October 25, 2002; Volume 51; NORR-16. Center for Disease Control and Prevention. 5.5 CHICA Canada Position Statement, Hand Hygiene (Draft), April WRHA Routine Practices Project, Link - Policy Contact Brenda Dyck, Program Director, Infection Prevention & Control Program Betty Taylor, Manager, PCH, Infection Prevention & Control Program 3.9