Vancomycin-Resistant Enterococcus (VRE)

Transcription

1 Approved by: Vancomycin-Resistant Enterococcus (VRE) Vice President & Chief Medical Officer Corporate Policy & Procedures Manual VI-40 Date Approved July 14, 2016 August 12, 2016 Next Review (3 years from Effective Date) August 2019 Purpose To provide guidance in the management of patients colonized and/or infected with Vancomycin-Resistant Enterococcus (VRE) in healthcare facilities. Policy Statement Covenant Health Infection Prevention & Control is committed to patient/resident/client¹ safety at all levels of the organization by supporting and promoting an environment that encourages infection prevention and control best practices in the care and management of patients colonized and/or infected with VRE. Applicability This policy and procedure applies to all Covenant Health facilities, staff, members of the medical staff, volunteers, students and any other persons acting on behalf of Covenant Health. Responsibility Covenant Health health care providers* are responsible for creating and sustaining an environment that supports an infection control program that effectively prevents VRE transmission and VRE healthcare-associated infections. Principles 1. Background This organism generally colonizes the gastrointestinal tract of patients and is transmitted via stool or lack of hand hygiene following contact with items or surfaces contaminated with VRE. VRE was first identified in Europe in 1988 and has since been recognized as an important healthcare-associated pathogen. Its ability to survive on environmental surfaces makes it difficult to eradicate in healthcare facilities. It has been recognized that VRE rarely causes serious infections in most patient populations. Risk factors for acquiring VRE include admission to intensive care units, prior antimicrobial use, invasive procedures or devices, and immune deficiencies. 2. Precautions Required Acute Care: Contact precautions at all times. ¹Hereafter, all references to patients includes residents and clients. * see Definitions

2 VI-40 Page 2 of 8 Continuing Care: Use Routine Practices for all VRE positive residents (including colonization and/or infection of any body site or system, when drainage and bodily fluids (eg. sputum, feces, urine, blood) are contained and the resident is cooperative with practicing good personal hygiene and hand hygiene, unless there is an assessed higher risk of VRE transmission. Additional Precautions are recommended only when the risk of transmission to others is assessed to be high. Factors to consider in deciding when Additional Precautions are needed: o Resident s mental status, ability to cooperate, level of self-care and personal hygiene. o Ability to contain secretions, drainage and/or excretions to prevent soiling of the environment. o Clinical conditions that increase risk of transmission: VRE colonized and/or infected residents with uncontained drainage or uncontained body fluids Antibiotic Resistant Organism (ARO) colonized skin and severe nonintact skin conditions with shedding or flaking skin (eg. extensive dermatitis, psoriasis) VRE colonized and/or infected residents with symptoms of an acute respiratory tract infection (e.g., pneumonia). When a resident has been assessed as requiring Additional Precautions, follow the recommendations for the specific Additional Precaution (eg. Contact Precautions). 3. Hand Hygiene Guidelines Refer to Corporate Policy#VI-10, Hand Hygiene. 4. Patient Hygiene Acute Care: Linen must be changed daily for all patients on additional precautions. o All patients on Additional Precautions must be bathed daily using soap and water or pre-packaged rinseless bathing washcloths (eg. Sage, etc.) Continuing Care: Linen must be changed on shower/bath day and as needed. o At minimum, resident/client personal hygiene must be maintained daily, i.e., wear fresh clean clothes daily, as needed pericare, bathing with soap and water or pre-packaged rinseless bathing washcloths. Patients must have access to appropriate hand hygiene agents, in particular, following pericare/toileting, prior to meals, etc.

3 5. Personal Protective Equipment (PPE) VI-40 Page 3 of 8 Perform a Point of Care Risk Assessment (PCRA)* (see Related Documents section). Prior to every patient interaction, health care providers have a responsibility to assess the infectious risk posed to themselves, other patients, visitors and other health care providers by a patient, situation or procedure. Acute Care: Contact precautions must always be followed in addition to Routine Practices. At a minimum, non-sterile gloves and an isolation gown must be worn when entering the patient s environment. Continuing Care: When a resident has been assessed as requiring Additional Precautions, follow the recommendations for the specific Additional Precaution (i.e: Contact Precautions). PPE is single-use only. When non-sterile gloves are used, hand hygiene must be performed prior to removing a pair from the box. 6. Communication of Additional Precautions Place a contact precautions sign on the door and have personal protective equipment outside the room. Communication of VRE status should be placed on the chart and care plan, or other appropriate location (but NOT on the patient s room door), in order to alert staff of the need for contact precautions in addition to routine practices. Additional precautions must be followed by all persons entering the patient s room. Refer to sign on door for further information. Receiving unit/department/facility must be notified of the additional precautions required. 7. Accommodations Single room preferred; door may remain open. If a single room is unavailable, patients should ideally be at least two meters (i.e., 6.6 feet) apart. If unable to keep patients two meters apart, separate patients with the greatest available distance allowed within the room space. The VRE positive patient must be placed on additional precautions with their own dedicated toileting facilities, i.e., commode chair or private bathroom, if available.

4 VI-40 Page 4 of 8 Patients with the same strain of VRE may be grouped together (cohorted) only with direction and approval from Infection Prevention & Control. When patients are cohorted, separate additional precautions must be maintained on each patient in the same room and with each patient encounter, including separate and dedicated toileting facilities. 8. Patient/Roommate Contacts If a new VRE positive patient is identified roommate contacts do not need to be placed on contact precautions or screened. 9. Equipment and Supplies Dedicated toileting facilities are required, i.e., separate bathroom or commode chair. Use single-use items whenever possible, or dedicate non-critical patient care items (eg. blood pressure cuffs and stethoscopes) to a single patient when they are known to be colonized and/or infected with VRE. When dedicated equipment is not possible, patient items must be thoroughly cleaned and disinfected between uses with hospital-approved disinfectant. Minimize supplies taken into patient s room. 10. Waste and Laundry Acute Care: Soiled laundry bag/bin must be located inside the patient s room. Continuing Care: Soiled laundry bin/bag must be located as close to the point of use as feasible. Waste/garbage should be discarded into the general waste. Double-bagging for waste or laundry is not required unless the bag is leaking. Disposable meal trays are not required. 11. Environmental Cleaning Thorough routine cleaning is required according to Environmental Services frequency schedule with hospital-approved detergent/ disinfectant as per Covenant Health and/or facility policy / procedure. Notify facility Environmental Services to request a terminal cleaning of the room when precautions are discontinued or upon discharge or transfer of patient.

5 VI-40 Page 5 of Patient Transport and Moving Within Acute Care Site Patient should remain in room unless essential medical/diagnostic/ rehabilitative services are warranted. If patient leaves room: o does not need to wear gloves but must perform hand hygiene o should wear a clean hospital housecoat or clean clothing o must have all wounds covered. Alert receiving unit/department of patient s VRE positive status and that additional precautions are required. It is recommended that the patient be accompanied by a health care provider. Health care providers transporting the patient must wear a gown and gloves. 13. Resident Flow/Activity in Continuing Care Resident may leave room with the following stipulations: o Must perform hand hygiene o Must be wearing clean clothing o If incontinent, must be wearing an incontinence product o Must have all wounds covered. Instructions/assistance should be provided to patient and documented regarding hand hygiene following toileting and prior to leaving the room. Resident participation in group/recreational activities should not be restricted unless the resident is non-compliant with hand hygiene and/or personal hygiene, incontinent and/or wound drainage cannot be contained. 14. Patient/Resident Transport and Moving Outside Facility Information about the patient s VRE positive status and additional precautions required must be communicated directly to transport personnel and staff on the unit at the receiving site. If patient is attending an appointment, request the patient be seen promptly so minimal time is spent in public waiting areas. 15. Acute Care Screening for VRE Admission screening for VRE must be conducted as per the Covenant Health Antibiotic-Resistant Organism (ARO) Admission and Pre-Admission Screening and Testing Form (Acute Care/Acute Rehabilitation).

6 VI-40 Page 6 of 8 Do not screen for VRE with unit-to-unit transfers. Exception: Transfers in or out of ICU/CCU that meet screening criteria as per Covenant Health Antibiotic-Resistant Organism (ARO) Admission and Pre-Admission Screening and Testing Form (Acute Care/Acute Rehabilitation). Screening for VRE may also be conducted at the discretion of care providers or when advised by Infection Prevention & Control. 16. Continuing Care Screening for VRE No routine admission screening required. Screening for VRE may be conducted at the discretion of care providers or when advised by Infection Prevention & Control. 17. Frequency of Screening for VRE Positive Cases Acute Care: VRE screening as per Infection Prevention & Control request of rectal swab or stool sample Continuing Care: Screening may be required if identified by IPC. Edmonton Zone Continuing Care only: No screening required. 18. Documentation Communication of VRE positive status should be placed on the chart and care plan, or other appropriate location (but NOT on the patient s room door), in order to alert staff to use additional precautions, along with routine practices. Document all education provided to the patient and family regarding VRE, hand hygiene and personal protective equipment. 19. Discontinuation of Precautions Acute Care: In consultation with Infection Control Professional, contact precautions may be discontinued once THREE negative cultures have been obtained from all previously positive sites, and in the absence of effective antimicrobial exposure Continuing Care: Additional precautions for VRE may be discontinued when the resident is cooperative with hygiene practices, and drainage and body fluids are contained.

7 20. Patient Teaching VI-40 Page 7 of 8 Patients are required to perform hand hygiene. If patients are unable to mobilize to a sink, hand washing may be accomplished with a soapy wash cloth or alcoholbased hand rub (ABHR). All education regarding VRE, hand hygiene and personal protective equipment provided to the patient/family must be documented in the patient record. Definitions Health care professional means an individual who is a member of a regulated health discipline, as defined by the Health Disciplines Act [Alberta] or the Health Professions Act [Alberta], and who practices within scope and role. Health care provider means any person who provides goods or services to a patient, inclusive of health care professionals, staff, students, volunteers and other persons acting on behalf of or in conjunction with Covenant Health. Point of Care Risk Assessment (PCRA) an evaluation of the risk factors related to the interaction between the health care provider, the patient, and the patient s environment to assess and analyze potential for exposure to infectious agents and identify risks for transmission. Related Documents The following resources are Covenant Health Corporate Policy #VI-10, Hand Hygiene. Covenant Health Infection Prevention & Control Posters: Personal Protective Equipment Putting on (Donning) Personal Protective Equipment Detailed Taking off (Doffing) Personal Protective Equipment Detailed Covenant Health Infection Prevention & Control Patient/Resident/Visitor Teaching Materials: FAQs about MRSA and VRE FAQs about isolation precautions Covenant Health Infection Prevention & Control Staff Information: Management of Vancomycin-Resistant Enterococci Acute Care Quick Reference for Charge Nurses Covenant Health Infection Prevention & Control Outbreak Toolkits: Acute Care VRE Toolkit Covenant Health Infection Prevention & Control Additional Precaution Toolkits: Acute Care VRE Toolkit

8 VI-40 Page 8 of 8 Covenant Health Infection Prevention & Control Routine Practices: Point of Care Risk Assessment Covenant Health IPC Diseases & Conditions Table: Recommendations for Management of Acute Care Recommendations for Management of Continuing Care Covenant Health Infection Prevention & Control Continuing Care Resource Manual: Clinical Care Admission Screening for ARO s Clinical Care ARO s Covenant Health Antibiotic Resistant Organism Admission and Preadmission Screening and Testing Form Acute Care/Acute Rehabilitation Covenant Health Infection Prevention & Control Best Practice Guidelines: Patients/Residents on Additional Precautions Participation in Group Therapies: Occupational, Physical and Recreational References 1. Alberta Health Services IPC Surveillance Committee (2015). Provincial Surveillance of Vancomycin Resistant Enterococcus (VRE) Surveillance Protocol. 2. Archibald, L. K. (2014). Enterococci. In R. Carico (Ed.), APIC Text of Infection Control and Epidemiology. Retrieved August 18, 2015 from: enterococci 3. Provincial Infectious Diseases Advisory Committee (PIDAC) (2012). Review of literature for evidence-based practices for VRE control. Retrieved August 17, 2015 from: 4. Provincial Infectious Diseases Advisory Committee (PIDAC) (2012). Routine practices and additional precautions. Retrieved August 17, 2015 from: pdf 5. Provincial Infectious Diseases Advisory Committee (PIDAC) (2013). Annex A: Screening, testing and surveillance for antibiotic-resistant organisms (AROs) in all health care settings. Retrieved August 17, 2015 from: IPC_Annex_A_Screening_Testing_Surveillance_AROs_2013.pdf 6. Public Health Agency of Canada (PHAC) (2013). Routine practices and additional precautions for preventing the transmission of infection in healthcare settings. Retrieved August 17, 2015 from: Revisions March 11, 2016 May 15, 2012 February 6, 2012 November 1, 2011 November 3, 2010