Respiratory Infection Prevention and Control In Healthcare Facilities

Transcription

1 Respiratory Infection Prevention and Control In Healthcare Facilities Summary Guidance DRAFT Adapted from Epidemic-prone and pandemic-prone acute respiratory diseases: Infection prevention and control in healthcare facilities. Summary Guidance, published by WHO in Information on tuberculosis infection control has been added. The original document is available at:

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3 Acknowledgements This document has been produced by the World Health Organization (WHO), the United States Centers for Disease Control and Prevention (US CDC), the Regional Emerging Diseases Intervention Centre (REDI), and Jhpiego. The United States Centers for Disease Control and Prevention provided financial support for the development and publication of the source documents from which this is adapted. In addition, funding for the development and production of this reference document and the associated training materials was provided through the REDI Centre, Singapore, by US CDC under Grant Number: 1E11 CH000001, Improving Influenza Surveillance and Pandemic Preparedness for H5N1 Avian influenza. The guidance in this booklet is drawn from WHO documents entitled Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in healthcare: WHO Interim Guidelines published in , Guidelines for the prevention of tuberculosis in health care facilities in resource-limited settings published in , the associated 2006 addendum Tuberculosis infection control in the era of expanding HIV care and treatment 3 and the Plague Manual: Epidemiology, Distribution, Surveillance and Control, It also takes into account requirements of the revised International Health Regulations (IHR), For more detailed information, readers should refer to the source Guidelines and IHR documents. 1 Available at 2 Available at and 3 Available at 4 Available at 3 / Draft

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5 Table of Contents INTRODUCTION A Comprehensive Approach to Respiratory Infection Prevention and Control in Healthcare Facilities...7 SECTION 1 Application of Respiratory Infection Prevention and Control Measures in Healthcare Facilities SECTION 2 How to Organize Your Healthcare Facility to Facilitate a Comprehensive Approach to Respiratory Infection Prevention and Control Screening, Education, Separation, and Prioritizing Provision of Services Early Recognition, Isolation, and Reporting of IRDs, Including ARDs of Potential Public Health Concern Patient Areas and Patient Transportation Environmental Ventilation SECTION 3 Infection Prevention and Control Practices Standard Precautions Hand hygiene Personal protective equipment (PPE) according to Standard Precautions Source control, respiratory hygiene & cough etiquette Prevention of injuries from needles & other sharp instruments Cleaning & disinfection of respiratory equipment Cleaning the patient care environment Linen & waste management / Draft

6 3.2 Droplet Precautions Contact Precautions Airborne Precautions Selecting and Using Masks in Healthcare Post Mortem Care and Autopsy Procedures SECTION 4 A Scenario based approach to Respiratory Infection Prevention and Control Scenario 1: Patient Arrival at the Reception Scenario 2: Triage and Physical Examination Scenario 3: Patient is Transported to Another Area Scenario 4: General Nursing Care Scenario 5: Nebulized Drug Therapy Scenario 6: Collection of an Induced Sputum Specimen Scenario 7: Resuscitation, Intubation, Suctioning, and/or Extubation Scenario 8: Bronchoscopy Scenario 9: Post mortem Care of the Body Appendix / Draft

7 Introduction Background: A Comprehensive Approach to Respiratory Infection Prevention and Control in Health Care Facilities The emergence of novel respiratory diseases such as severe acute respiratory syndrome (SARS), novel influenza viruses such as A/H5N1 and A/H1N1 (with the associated threat of a pandemic), and the appearance of both multi-drug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) all highlight the need to establish effective respiratory infection prevention and control (RIPC) measures in healthcare facilities. In addition, the revised International Health Regulations (IHR 2005) define infection with a number of specific respiratory pathogens as a potential public health emergency of international concern (PHEIC) requiring urgent action, including: SARS, human influenza caused by a new subtype, pneumonic plague, and novel acute respiratory disease agents. The International Health Regulations also require signatory nations to establish a minimum core capacity to deal with such threats, including infection control measures. For all these reasons, the implementation of RIPC measures at the healthcare facility level has become critical. However, effective implementation is problematic for a number of reasons, including: 1.) individuals with infectious respiratory diseases often present with non-specific signs and symptoms, 2.) the diseases may be highly transmissible from the moment of presentation / admission (high risk of nosocomial transmission) and, 3.) rapid diagnostic tests are relatively expensive and may not be available in settings with limited resources. Despite these challenges, the experience of SARS demonstrated clearly that even when confronted with a novel infectious respiratory disease (IRD) with high epidemic potential for which there is no diagnostic test, vaccination or treatment, the systematic application of infection prevention and control measures in a healthcare facility can be effective in arresting spread and containing a potential epidemic. In this document, the broad term infectious respiratory disease (IRD) is used to refer to any transmissible respiratory illness caused by a respiratory pathogen, regardless of whether the infectious agent is a virus, bacteria or another microorganism. The term acute respiratory disease (ARD) refers to IRDs with acute onset. A subset of ARD, ARD of potential concern, refers to acute respiratory illness caused by a pathogen with epidemic potential, where early recognition is of critical importance. It is important to appreciate that microorganisms differ in the mode of transmission from the source to the susceptible host and that some respiratory pathogens may be transmitted by more than one mode. The different modes of transmission of respiratory pathogens have implications for the type of infection prevention and control measures that need to be applied. Generally speaking, previous RIPC guidance has usually focused on either ARDs, which are caused by bacteria or viruses and most commonly transmitted by large droplets and over short distances, or on Tuberculosis (TB) which is transmitted by smaller droplet nuclei that can remain infective and suspended in the air over time and distance. However, the reality is that patients do not present to a healthcare facility with a diagnosis, but with a collection of symptoms. Accordingly, this document is built on a concept that health care facilities should adopt a universal approach to managing all patients presenting with fever and respiratory symptoms 7 / Draft

8 Introduction who might be infected by any respiratory pathogen; including novel viruses for which the mode of transmission is difficult to predict. Section 1 provides a general introduction to respiratory infection prevention and control and establishes some guiding principles for their application in healthcare settings. Section 2 then outlines the organizational arrangements that healthcare facilities should establish to create an environment in which infection prevention and control measures can be applied in the most effective way possible. Next, Section 3 provides detailed and practical advice about the various elements of infection prevention and control, including standard and additional precautions, advice on the selection of masks, how to deal with contaminated linen, etc. Lastly, Section 4 considers a number of specific scenarios encountered at different stages of the patient pathway from presentation to discharge and outlines what measures need to be applied in each of these situations. In this way, Section 4 effectively integrates the recommendations on organizational arrangements with the information on IRDs and the relevant infection prevention and control practices. This document is intended to be used by government planners, healthcare facility administrators, infection control professionals, occupational health specialists, and other professionals involved in patient care as a conceptual framework to approach RIPC in healthcare facilities. Healthcare facilities are encouraged to review the guidance and recommendations and to adapt them according to local regulations, settings, needs and resources. Summary: Key Recommendations Ensure arrangements are established in the healthcare facility to create an environment in which infection control measures can be applied in the most effective way possible. Ventilate the patient environment in all areas of service delivery to reduce the risk of nosocomial transmission of airborne diseases. Screen patients at the point of entry for signs or symptoms of respiratory infection. Early recognition of an ARD of potential concern is extremely important to facilitate its containment. Similarly, early recognition of patients with TB is important because they need different infection control measures. Apply source control to the patient (ask them to wear a mask). Educate patients identified through screening with an IRD; they should be instructed on how to practice respiratory hygiene / cough etiquette. This means teaching them to cover their noses and mouths when coughing and sneezing, instructing them to practice hand hygiene and providing them with face masks or tissues to cover their mouths. Separate patients identified by screening immediately from other patients, requesting them to wait in a separate well ventilated waiting area, where face masks or tissues for cough etiquette are available. Provide priority services - patients identified by the initial screening should be triaged, i.e. moved immediately to the front of the queue to receive the services they need, thereby reducing the amount of time that others are exposed to them. This would include prioritizing patients for laboratory investigation (like sputum examination for AFB, if the patient is suspected of TB) or radiography. 8 / Draft

9 Introduction Isolate any suspected case of ARD of potential concern Report any suspected case of an ARD of potential concern immediately to the relevant public health authorities. Apply Standard Precautions when providing care to all patients regardless of their known or suspected diagnosis. Apply Additional Precautions according to the presumed or confirmed respiratory disease. Some infectious agents have multiple routes of transmission, therefore when suspecting specific pathogens more than one Additional Precaution may be needed. Apply Droplet Precautions in addition to Standard Precautions whenever providing care to a patient with a suspected or confirmed infectious ARD or pneumonic plague. Apply Contact and Droplet Precautions, in addition to Standard Precautions whenever providing care to suspected or confirmed human cases of novel influenza infection and SARS patients, as well as paediatric patients with an ARD, or when clinical symptoms strongly suggest a likely diagnosis of some specific infections such as croup, parainfluenza, acute bronchiolitis and respiratory syncytial virus (RSV). Apply Airborne Precautions when providing care to a patient infected with a pathogen that can be transmitted in the air over long distances, such as M. tuberculosis, or when performing certain procedures, such as those that may generate aerosols. Airborne precautions should also be applied as a precautionary measure (in addition to standard, and contact precautions) if an unknown ARD of potential concern is suspected after considering the epidemiological and clinical features. 9 / Draft

10 SECTION 1 Application of Respiratory Infection Prevention and Control Measures in Healthcare Facilities In many situations when an individual with respiratory symptoms presents to a healthcare facility, it may not be possible to obtain a rapid diagnosis because signs and symptoms of IRDs can be very non specific and no rapid laboratory diagnosis will be available. Therefore, it can be impossible to know exactly what infection control measures to apply. For this reason, a universal approach is needed to appropriately manage any patient arriving at a healthcare facility with fever and respiratory symptoms. These guidelines are therefore designed to encourage a universal approach to respiratory infection prevention and control as described below: Guiding principles for the application of Respiratory Infection Prevention and Control in Healthcare Facilities Because at the time of initial presentation the exact diagnosis for a patient with an IRD will not be known (but nosocomial infection can occur), a universal approach to RIPC should be employed as a minimum for all patients presenting with fever and respiratory symptoms from the first point of contact. A precautionary principle should be applied meaning that the actual RIPC measures applied should be appropriate to the highest likely level of risk. In making this risk assessment, the most critical task will be to look for any clues of an ARD of potential concern. As clinical, epidemiological and laboratory data become available, the level of risk should be regularly re assessed and infection control measures adjusted as required. Once the final diagnosis is made, RIPC measures known to be effective for that specific pathogen should be applied. 10 / Draft

11 Table 1: Infection Control Measures for Healthcare Workers Caring for Patients with Febrile Acute Respiratory Diseases in Specific Clinical Settings. Infection Prevention and Control measures Setting or Procedure Hand hygiene Gloves Gown Medical mask for healthcare worker Particulate respirator for healthcare worker Eye Protection Respiratory hygiene/cough etiquette for patients Adequately ventilated single room ( 12ACH) a Patient coughs / Reception b sneezes & < 1m away Physical exam/triage Patient transport General nursing care Nebulization Specimen collection (induced sputum) Resuscitation, intubation, extubation suctioning and bronchoscopy Post mortem care Specimen collection (blood) Healthcare worker; ACH: Air changes per hour All spaces in the health facility should be well ventilated, not only the single rooms used for isolation purposes. Without any direct contact with patient. a b Explanatory notes No anticipated close contact with the patient Involves close contact (< 1 metre) with patient Aerosol generating procedure associated with pathogen transmission e.g. intubation; cardiopulmonary resuscitation and related procedures (e.g. manual ventilation, suction); bronchoscopy; and autopsy or surgery involving the use of high speed devices

12 SECTION 2 How to Organize Your Healthcare Facility to Facilitate a Comprehensive Approach to Respiratory Infection Prevention and Control Before a patient with a possible infectious respiratory disease arrives at a healthcare facility, it is important to ensure that arrangements are already in place to create an environment in which infection prevention and control measures can be applied in the most effective way possible. The critical elements of these organizational arrangements are summarised in the box below and considered in more detail in the text that follows. These organizational and infrastructural arrangements are sometimes referred to as administrative and environmental controls. Table 2: Key Arrangements and Working Practices for Respiratory Infection Prevention and Control Establish arrangements at the point(s) of entry to the hospital where an initial assessment of patients for the presence of an IRD can take place (one example might be a triage desk manned by appropriately trained staff) Implement a system for prioritizing a more detailed assessment of patients with IRDs (they should be able to jump the queue ). This might include prioritizing patients for laboratory investigation for ARD s of potential concern and AFB, or for radiography Ensure there is a dedicated space available away from other patients where patients with a possible IRD can be given this more detailed assessment (therefore minimising the risk of nosocomial infection to other patients) Establish a process to ensure that any patient with a possible ARD of potential public health concern is recognized and reported immediately to public health authorities Establish the most direct possible means of transporting patients to the admitting ward whilst avoiding other patient care areas wherever possible. Ideally the admitting ward should be as close as possible to the point of entry to the hospital Ensure that all areas in the healthcare facility where patients with IRDs will spend time are critically examined and structurally modified to take maximum advantages of opportunities for natural or other forms of ventilation Ensure that all staff who may encounter individuals with IRDs are appropriately trained to protect themselves and provide education to patients and other care givers Ensure access to sufficient logistic supplies at all points of delivery of care 12 / Draft

13 2 How to Organize Your Healthcare Facility to Facilitate a Comprehensive Approach to Respiratory Infection Prevention and Control In addition, to enable sustainable implementation of these arrangements, it is also important that each facility should have the following wherever possible. Established processes for coordination and communication with public health authorities. An infection control plan; which is based upon a risk assessment for that facility and which outlines the work practices and responsibilities for screening of IRDs, education, separation, provision of services and reporting. Management and administrative support for all elements of the plan. Appropriate training of staff and plans for periodic review, reinforcement, and additional training of new staff. Surveillance of nosocomial infections in patients and staff. Monitoring and assessment of infection control procedures and practices linked to a process for quality improvement. Education of patients and measures to increase community awareness. 13 / Draft

14 2.1 SCREENING, EDUCATION, SEPARATION & PRIORITIZING THE PROVISION OF SERVICES Assessing and screening patients when they arrive at a healthcare facility should be the first step of a respiratory infection prevention and control protocol; those who may have an IRD should be educated, separated from other patients and given priority in the provision of services. Screening patients for an infectious respiratory disease is the first step in an effective respiratory infection prevention and control protocol. Arrangements should be established so that a staff member is assigned to screen patients for acute febrile respiratory illness or prolonged duration of cough immediately after they arrive at the facility. One possible approach is to establish a triage desk at the point of entry. The specific screening criteria should be determined according to the local risk assessment since there will be differences in the pattern of likely diseases depending on the local setting and patient population. For example, among HIV infected persons, broader criteria may include cough of any duration, any fever, bloody sputum, weight loss, or night sweats. Staff should also be trained to be proactive in providing a mask and tissues for patients with respiratory symptoms and to educate them on respiratory hygiene & cough etiquette. To minimize the generation and spread of infectious droplets and droplet nuclei, patients should be instructed to cover their nose and mouth with a tissue when sneezing and then practice hand hygiene Therefore, if patients do not have a cloth or tissue, these should be provided by the institution. Posters emphasizing cough etiquette should be placed in waiting areas. Patients should be instructed to wash their hands after contact with respiratory secretions and arrangements established so they are able to do this. (See section 3.1.3). Patients identified in this initial screening should be moved rapidly through registration without waiting in line and requested to remain in a separate, dedicated, well ventilated waiting area. Expedited, priority services such as diagnostic investigation and delivery of care should be provided to decrease the risk of exposure to other patients and healthcare workers. A fast track system should move patients to the front of the line to quickly provide care and reduce the time that others are exposed to them. They should also be promptly evaluated for diagnosis of their respiratory condition. If diagnostic services such as TB sputum microscopy are not available, then patients should be referred to facilities where they are. Work practices immediately after patients arrive in heath care facility Screen patients for signs or symptoms of respiratory infection; think about TB and ARDs of potential concern. Educate and apply source control to patients identified during screening; including cough etiquette and hand hygiene. Separate any patient with suspected or confirmed respiratory infection. Take immediate action for suspected cases of ARDs of potential concern and TB and isolate patients in a room or move to a well ventilated waiting area away from other patients Provide priority services to move these patients to the front of the line and quickly provide care to reduce potential exposure to others. 14 / Draft

15 2.2 EARLY RECOGNITION, SEPARATION / ISOLATION, & REPORTING OF IRDs, INCLUDING TB and ARDs OF POTENTIAL PUBLIC HEALTH CONCERN Recognizing a possible ARD of potential public health concern or a case of TB is central to containing these diseases, since this allows rapid implementation of infection prevention and control measures and reporting to public health authorities. Patients with IRDs may present with a wide range of clinical symptoms. Some ARDs have the potential to spread rapidly and may have serious public health implications, including: Severe Acute Respiratory Syndrome (SARS); pandemic influenza; a novel, previously unreported ARD. Healthcare workers at the point of entry into a healthcare facility must therefore be educated to recognize and immediately report any patient with a possible ARD of potential concern. Arrangements must also be in place so that infected patients are provided with appropriate treatment and care, and infection prevention and control measures applied immediately to minimize the risk of any further transmission of the disease. Inform public health authorities immediately if a case of an ARD of potential concern is suspected. Isolate any patient with suspected or confirmed infection with an ARD of potential concern in a room or separate area away from other patients. Early indications to suspect an ARD of potential concern Although the pattern of disease on presentation may vary according to the specific infectious agent, there are some general epidemiological and clinical clues that should raise suspicion. Therefore, front line healthcare workers should be trained to recognize these clues. To help the process, they should also be aware of unusual potentially health related events occurring outside of the hospital: Epidemiological clues The patient's recent history (within the known or suspected incubation period) including: recent travel to a geographical area where there are patients known to be suffering from an ARD of potential concern; recent occupational exposure, for example to animals with symptoms of influenza, or working in a laboratory; recent contact with another patient infected with an ARD of potential concern; being part of a cluster of cases of severe respiratory infection; an unexplained outbreak of illness or mass deaths of animals in the locality; An increase in rates of severe respiratory illness in the community or in individuals attending healthcare facilities. Clinical clues Patients who present with, or who have died from: unexplained severe acute febrile respiratory illness such as fever in excess of 38 C with cough and shortness of breath; or other severe unexplained illness such as encephalopathy or diarrhoea, with an exposure history consistent with an ARD of potential concern within the known or suspected incubation period. 15 / Draft

16 2.2 Early recognition, separation / isolation, & reporting of IRDs, including TB and ARDs of potential public health concern What should you do if you suspect a patient has an ARD of potential concern (including SARS or avian influenza) Apply source control if tolerated by the patient and educate on cough etiquette and respiratory hygiene (e.g. provide tissues or medical mask to the patient) Inform public health authorities immediately Place the patient in a room or separate area away from other patients. Apply a minimum of standard, droplet, and contact precautions Ensure that all healthcare workers and others providing care to the patient are trained on standard and additional precautions and the use of personal protective equipment appropriate PPE are available for use infection control practices are monitored. Other patients presenting with an IRD may show symptoms and signs that clearly indicate infection with tuberculosis. Early identification of such patients is also important to ensure appropriate diagnostic evaluation, education, separation, contact tracing and reporting to public health authorities. Early indications to suspect pulmonary TB There are some general epidemiological and clinical clues that should raise suspicion. Epidemiological clues The patient's recent history (within the known or suspected incubation period) including: Cough for more than two weeks; Recent contact with another patient infected with tuberculosis. Clinical clues Patients who present with: Haemoptysis; Weight loss; Night sweats. 16 / Draft

17 2.2 Early recognition, separation / isolation, & reporting of IRDs, including TB and ARDs of potential public health concern What should you do if you suspect a patient has TB? Apply source control if tolerated by the patient and educate on cough etiquette and respiratory hygiene (e.g. provide tissues or medical mask to the patient) Arrange for collection of sputum for acid fast bacilli testing. Apply a minimum of standard and airborne precautions; assure effective ventilation Ensure that all healthcare workers and others that are providing care to the patient are supplied with and are using appropriate PPE. Inform public health authorities 17 / Draft

18 2.3 PATIENT AREAS AND PATIENT TRANSPORTATION A patient with an IRD must be placed in an appropriate area to ensure that the risk of nosocomial transmission of infection is kept to a minimum. Each healthcare facility should consider carefully where patient care areas are established in relation to the point of entry into the hospital / clinic, and the pathway taken in moving from one point to another. Generally speaking, journeys should be as short as possible and avoid potential contact with other patients. Factors to consider when placing patients if an inpatient stay is required In selecting the appropriate infection prevention and control strategy the healthcare worker should consider: If there are any epidemiological or clinical clues that might indicate infection with either an ARD of potential concern or TB; Whether or not an inpatient stay is required, for example many cases of tuberculosis can be managed on an outpatient basis Which recommended precautions, in addition to the Standard Precautions, are appropriate for the suspected or confirmed disease; The number of cases presenting to the hospital compared to available resources, The availability and accessibility of the necessary supplies and equipment Isolation and Cohorting Isolation refers to the process of confining a suspected or confirmed infectious patient to a designated area to prevent transmission of that infection to a susceptible person. Cohorting refers to the practice of caring for more than one patient in the same designated place and by the same designated staff using the same infection prevention and control precautions. Ideally only patients who have been laboratory confirmed with the same infectious disease should be cohorted otherwise the risk of nosocomial infection may be increased. However, special measures can be applied when limitations on resources mean that patients with the same suspected diagnosis have to be placed in the same isolation unit before the causative agent is laboratory confirmed. These measures provide the safest alternative if individual isolation rooms are not available, and include the following: A distance of at least 1 metre must be maintained between each patient. Designated staff should not provide care to other (non cohorted) patients The number of persons permitted to enter the area where cohorting is in place must be kept to a minimum. Avoid sharing of equipment, but if unavoidable, ensure that reusable equipment is appropriately disinfected between being used on different patients. Ensure regular cleaning and proper disinfection of common areas, and adequate hand hygiene by patients, visitors and caregivers. 18 / Draft Frontline healthcare workers should be trained to clearly understand the concepts of isolation and cohorting and know when to apply them by assessing the risk of transmission and by considering the resources available.

19 2.3 Patient areas and patient transportation Options for placing patients with a confirmed airborne IRD including TB, measles, chickenpox or a suspected novel virus. There are two main options for placing a patient with a disease transmitted by the airborne route: patients can be placed in either: An Airborne Precaution Room (APR) (with 12 air changes per hour (ACH) plus control of airflow), or An Adequately Ventilated Room (AVR) (with 12 ACH). It is recommended that any patient infected with either a novel organism causing an ARD with potentially high public health impact or infected with an airborne transmitted disease, such as pulmonary tuberculosis, measles or chickenpox, should be placed in an APR whenever available. Patients with other ARDs of potential concern, such as SARS or human infection with novel influenza, can be placed in an AVR or in an APR. However, when considering the allocation of available space in APRs, priority should always be given to patients with airborne transmitted diseases. Other options for placing patients with TB or suspected TB If single rooms are not available, then patients should be placed in a well ventilated environment (i.e. with at least 12 ACH), with adequate space between each patient. Patients with TB, particularly those with suspected/confirmed drug resistant TB and those with sputum smears positive for AFB, should be always be cohorted separately from patients who may be immunocompromised, especially persons with HIV infection. Patients suffering from both HIV and TB should be placed carefully, recognizing that these patients are both susceptible to acquiring new forms of TB and possibly pose a risk of transmission to other patients. Other areas in which patients may have to stay, for example an area where care may be delivered or especially where a procedure may be undertaken which can result in aerosol generation must also have a minimum ventilation rate of 12 ACH. Triage areas & corridors Areas in which patients are waiting or are being triaged should also have a minimum ventilation rate of 12 ACH. Triage areas should allow for a distance of at least 1 metre to be maintained between patients. Corridors through which patients are frequently transported should be well ventilated. Key recommendations for patient areas All patient areas should be well ventilated with at least 12 air changes per hour. The distance between patient s beds should be at least 1 metre. Patients with suspected TB or an ARDs of potential concern should be placed in a separate area specifically designated for these patients, with care towards separation of infectious patients from immunocompromised patients. Patients with TB or an ARD of potential concern can be placed in either naturally or mechanically ventilated rooms. Cohorting and special measures can be applied for all ARDs but every effort should be made to isolate patients infected with a novel virus or airborne pathogens. 19 / Draft

20 2.4 ENVIRONMENTAL VENTILATION Environmental ventilation can play a critical role in helping to reduce the risk of infection. The risk of infection being transmitted through respiratory aerosols can be reduced by ensuring that patients are cared for in well designed, well ventilated rooms which allow the removal of contaminated air. Therefore every healthcare facility should critically examine all areas in the hospital where patients with IRDs may spend time to consider what structural and functional modifications may be feasible to take advantage of opportunities for natural or other forms of ventilation. Isolation rooms and other areas designated to separate IRD patients should have the recommended minimum ventilation rate of 12 air changes per hour (ACH). The rate of ventilation has a direct relationship to the speed at which infective particles in the air are removed or disappear, so the greater the ventilation, the more rapidly or efficiently the air is cleared and the risk of nosocomial infection reduced. Although environmental ventilation can reduce the risk of transmission by respiratory aerosols, it is important to recognize that if work practices or administrative controls are inadequate, then transmission of infection may still occur. It is therefore essential that these measures are always applied in combination with the additional infection control work practices described in this guide, including appropriate use of personal protective equipment. There are three different kinds of environmental ventilation: natural, mechanical and mixed mode. Natural ventilation Natural ventilation refers to fresh dilutional air that normally enters and leaves a room or other areas through openings such as windows or doors. Natural ventilation is controlled when openings are deliberately secured open to maintain air flow. Cross ventilation with unrestricted openings (i.e. that cannot be closed) on opposite sides of the room provide the most effective natural ventilation. Careful design of waiting areas and examination rooms to maximise natural ventilation can significantly reduce nosocomial spread of TB or other airborne pathogens (see Figure 1). In warm climates, this optimally means open air shelters with a roof to protect patients from sun and rain. Naturally ventilated rooms can achieve very high ventilation rates, but mosquito nets should be used in endemic areas for vector borne diseases (e.g. malaria, dengue). In naturally ventilated airborne isolation rooms the air should be directed to flow from patient care areas towards areas where no people are likely to be present (transit free areas). This ensures that contaminated air is able to mix with the air in the surrounding and external areas and become rapidly diluted without risk to other individuals in the vicinity. Mechanical ventilation Mechanical ventilation is created by the use of a fan to force air exchange and to drive air flow. It works by generating negative pressure in the room to drive airflow inward (see Figure 2). 20 / Draft

21 2.4 Environmental Ventilation To be effective in rooms designated for the isolation of infectious patients, it is essential that: the flow of air should be directed to flow from patient-care areas towards transit free areas; all doors and windows are kept closed; a minimum of 12 ACH is maintained. Mixed mode ventilation Mixed mode ventilation combines the use of mechanical and natural ventilation (see Figure 3). This type of ventilation is achieved through the installation of an exhaust fan to increase the rate of air changes in the room. It can be useful in places were natural ventilation is not suitable (e.g. very cold weather) and as an alternate to fully mechanically ventilated airborne precautions rooms. Points to remember about natural ventilation Ensure that measures are established in all patient care areas to maximise natural ventilation at all times. Keep doors and windows open to outside areas or onto well ventilated corridors with open windows. Ensure that the surrounding areas, including the corridors, are well ventilated to warrant rapid dilution of the air coming from the patient room. If the corridor is not well ventilated, the room door should be kept closed. An exhaust fan can be added to increase the air circulation out of the open windows. Locate patient beds close to the exterior walls and open windows. Figure 1. Illustration of the desired direction of air flow in a properly designed naturally ventilated isolation room (achieved by opening the windows, and the door between the isolation room and the corridor) 21 / Draft

22 2.4 Environmental Ventilation Figure 2. Schematic diagram of an ideal ventilated isolation room with a mechanical ventilation system 22 / Draft Figure 3. Illustration of different natural and mixed mode ventilation systems (courtesy of Professor Martin Liddament,)

23 SECTION 3 Infection Prevention and Control Practices 3.1 STANDARD PRECAUTIONS Standard Precautions should be applied routinely in all healthcare settings whenever providing care to patients. When applied correctly, Standard Precautions will prevent direct unprotected contact with body fluids, blood, secretions, and excretions and thus minimize spread of nosocomial infections. In healthcare settings there are two main sources of infection: people and contaminated objects. Infection can be transmitted from people through various body fluids including blood, saliva, sputum, nasal discharges, wound drainage, urine and excrement. Some people may appear well even though their blood or body fluids are capable of spreading infection, and Standard Precautions should be applied when providing care to all patients whatever their diagnosis. The organisms that cause ARDs are most often spread through droplets. When an ARD patient coughs or sneezes, small and large droplets of secretions are expelled into the air and surrounding surfaces. The large droplets gradually settle down by the action of gravity on surfaces around the patient (commonly within a distance of 1 metre from the patient). These surfaces can also become contaminated through contact with hands, used handkerchiefs/tissues or other material which has been in contact with body secretions. Other body fluids and excreta may also contain infective agents. Therefore, ARDs can be spread by droplets from the respiratory tract or through contact with contaminated surfaces. For this reason, in addition to the use of specific protection against droplets (i.e. medical masks), several elements of Standard Precautions, such as respiratory etiquette, hand hygiene, cleansing of the environment and waste management are essential to help prevent transmission of ARDs. Standard Precautions should routinely be followed in all healthcare settings and are extremely important in reducing the risk of health care associated infection transmission, including infection with an ARD of potential concern. hand hygiene; The main elements of Standard Precautions are: personal protective equipment (PPE) to avoid contact with the patient s body fluids and non intact skin; respiratory hygiene and cough etiquette; prevention of injury from needles or other sharp objects; cleaning and disinfecting respiratory equipment; cleaning the patient care environment; and linen and waste management. 23 / Draft

24 3.1 Standard Precautions HAND HYGIENE Hand hygiene before and after contact with every patient is one of the most important means of preventing the spread of infection. Points to remember when performing hand hygiene When hands are visibly dirty or contaminated with proteinaceous material, they should be washed with soap and water. If hands are NOT visibly soiled or contaminated, an alcohol based hand product for routine decontamination of hands should be used. Ensure hands are dry before starting any activity. Wash hands with soap and running water when visibly dirty or contaminated with material that may contain body secretions or fluids material. Or use an alcohol based product for routinely decontaminating hands, if hands are NOT visibly soiled (see Table 3 for in-house/local production of handrub; and Appendix A). DO NOT use alcohol based hand products when hands are visibly soiled. DO NOT use alcohol based hand products after exposure of non intact skin to blood or body fluids. In these cases, wash hands with soap and water and dry. Perform hand hygiene: Immediately On arrival at work. Before Direct contact with a patient. Putting on gloves for performing clinical and invasive procedures (e.g. administering intravenous injections). Preparing medication. Preparing, handling, serving or eating food. Feeding a patient. Leaving work. Between After Certain procedures where soiling of hands is likely. Contact with each patient. Removal of gloves. Removal of other personal protective equipment. Contact with blood, body fluids, secretions, excretions, exudates from wounds, and contaminated items. Contact with items/surfaces known or considered likely to be contaminated with blood, body substances, or excretions (e.g. bedpans, urinals, wound dressings) whether or not gloves are worn. Personal body functions such as using the toilet, wiping or blowing one's nose. 24 / Draft

25 3.1 Standard Precautions Hand Hygiene Table 3: WHO Alcohol-based Handrub Formulations For In-house/Local production In healthcare facilities where commercially produced handrubs are unavailable, the following two WHO alcohol based handrub formulations can be prepared in house or in a local production facility, up to a maximum of 50 litres: Formulation I To produce concentrations of ethanol 80% v/v, glycerol 1.45% v/v, hydrogen peroxide 0.125% v/v. Pour into a 1000 ml graduated flask: ethanol 96% v/v ml hydrogen peroxide 3% 41.7 ml glycerol 98% 14.5 ml Top up the flask to 1000 ml with distilled or boiled and cooled water and shake the flask gently to mix the content. Formulation II To produce final concentrations of isopropyl alcohol 75% v/v, glycerol 1.45% v/v, hydrogen peroxide 0.123% v/v: isopropyl alcohol (with purity of 99.8%) ml hydrogen peroxide 3% 41.7 ml glycerol 98% 14.5 ml Top up the flask to 1000 ml with distilled or boiled and cooled water and shake the flask gently to mix the content For additional guidance on the formulation and production of alcohol based handrubs, please refer to Appendix A 25 / Draft

26 3.1 Standard Precautions Hand Hygiene HOW TO Handrub with alcohol based formulation 1a 1b Apply a palmful of the product in a cupped hand, covering all surfaces Rub hands palm to palm, right palm over left dorsum with interlaced fingers and vice versa, palm to palm with fingers interlaced, backs of fingers to opposing palms with fingers interlocked, rotational rubbing of left thumb clasped in right palm and vice versa, rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa seconds 8 Your hands are now safe. 26 / Draft

27 3.1 Standard Precautions Hand Hygiene HOW TO Handwash with soap and water Wet hands with water. Apply enough soap to cover all hand surfaces. Rub hands palm to palm, right palm over left dorsum with interlaced fingers and vice versa, palm to palm with fingers interlaced, backs of fingers to opposing palms with fingers interlocked rotational rubbing of left thumb clasped in right palm and vice versa, rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa rinse hands with water, dry hands thoroughly with a single use towel, use towel to turn off faucet seconds Your hands are now safe. 27 / Draft

28 3.1 Standard Precautions PERSONAL PROTECTIVE EQUIPMENT (PPE) USED WITH STANDARD PRECAUTIONS If the appropriate items of PPE are used correctly, they will protect healthcare workers from being exposed to certain types of infectious diseases. In order to avoid contact with blood and body fluids, in addition to hand hygiene, healthcare workers should also wear personal protective equipment that is appropriate for 1.) the type of procedure they going to perform and 2.) the level of contact with the patient that the procedure will entail. PPE used in the application of Standard Precautions consists of gloves, gowns, eye protection and medical masks. The decision to use each item depends on the potential risk of exposure to a patient with a known or suspected ARD and the procedure the healthcare worker will perform. Additional items, such as caps to cover the hair are not considered PPE, but can be used for the comfort of the healthcare worker. Likewise, boots can also be used for practical purposes, for example when resistant closed foot wear is needed and to avoid accidents with sharp objects. General PPE Guidelines Hand hygiene should always be performed after each glove change after all PPE have been removed Remove and replace any damaged or broken pieces of reusable PPE as soon as you become aware that they are not in full working order. Remove PPE in the anteroom: if there is no anteroom, avoid contaminating: the environment outside the isolation room; yourself, other healthcare workers and other patients Discard all items of PPE carefully and perform hand hygiene immediately afterwards. Choosing items of PPE Select PPE based on the assessment of risk (assessing risk should become routine practice) In particular, the healthcare worker should consider: The suspected or confirmed diagnosis and therefore the specific requirements for prevention, (e.g. whether transmission is by the airborne or droplet route) The procedure What procedure(s) will be undertaken? What is the likelihood of contact with the patient's blood or body fluids and what type of fluids might be involved? Their own risk Does the healthcare worker have any skin abrasions? The equipment and facilities Are all the items of PPE available to use? What facilities exist for putting on and taking off items of PPE? Is any external assistance required in putting on or taking off items of PPE? Where is the nearest hand hygiene facility located? Does every item of PPE fit correctly? Where are waste disposal facilities located? 28 / Draft

29 3.1 Standard Precautions Personal protective equipment (PPE) used with standard precautions General Principles when using PPE Whenever items of PPE are used, there are some general principles that always apply and which therefore should always be taken into consideration. Any damaged or broken pieces of reusable PPE must be removed and replaced immediately. All items of PPE must be removed as soon as possible after completing the healthcare procedure to avoid contaminating other surfaces. All single use items of PPE must be discarded immediately after use, using the appropriate waste management facilities. Always perform hand hygiene immediately after removing and discarding any item of PPE. Hand hygiene Gloves Gown - other types and styles are also appropriate. Medical mask - other types and styles are also appropriate. Protective eyewear - eye visors, goggles, and face shields are examples of protective eyewear Please note that the illustrations here are representative examples of PPE: Gowns, gloves, medical masks and eye/face protection may differ in style, but will perform the same protective role. 29 / Draft

30 3.1 Standard Precautions Personal protective equipment (PPE) used with standard precautions Table 4: Personal Protective Equipment (PPE) used with Standard Precautions Scenario Hand Hygiene Gloves Gown Medical Mask Eyewear Always before and after patient contact, and after contaminated environment If direct contact with blood and body fluids, secretions, excretions, mucous membranes, non intact skin If there is risk of splashes onto the health care worker s body If there is a risk of splashes onto the body and face More information about PPE items GLOVES Gloves are an essential item of PPE which prevent the healthcare worker from being exposed to direct contact with the blood or body fluids of an infected patient. It is very important that adequate supplies of gloves of different sizes are available in all areas where patients are being cared for, and in particular at the entrance to any area where patients are being kept in isolation. It should always be remembered that hand hygiene is essential for infection prevention even when using gloves. Therefore, functional and equipped hand hygiene stations or alcohol based hand rub should be available in patient care areas. Gloves 30 / Draft

31 3.1 Standard Precautions Personal protective equipment (PPE) used with standard precautions Important issues to remember about selecting and using gloves Selecting the appropriate type of gloves to use is important and should take into account the following: the gloves selected should be appropriate for the procedure that is about to be performed and the risk of the healthcare worker having direct contact with respiratory secretions or other fluids; the gloves should be the correct size for the wearer s hands; the gloves must be compatible with any chemical solutions that are being used as part of hand hygiene in the healthcare setting. Using gloves correctly includes: performing hand hygiene immediately before putting on the gloves: gloves must never be used as an alternative to hand hygiene; replacing gloves immediately if they are torn or punctured and disposing of the damaged gloves immediately using the correct facilities; removing and disposing of gloves and using new gloves between different procedures on the same patient if there is any possibility that infection could be transmitted from one part of the patient's body to another; removing and disposing of gloves immediately after contact with a patient or a potentially contaminated environmental surface and using new gloves for any subsequent contact with a different patient; and performing hand hygiene immediately after removing and disposing of gloves. Suggested sequence of procedures when only gloves are used: perform hand hygiene put on gloves perform the task remove the gloves immediately after finishing the task dispose of gloves safely perform hand hygiene Don t forget Hand hygiene is always essential - even when using gloves. Supplies of gloves and hand hygiene facilities should be available in all patient care areas 31 / Draft

32 3.1 Standard Precautions Personal protective equipment (PPE) used with standard precautions 32 / Draft GOWNS & APRONS Gowns and aprons are used to prevent the healthcare worker s clothing being exposed to blood or other body fluids. Gowns are used in addition to gloves if there is risk of fluids or blood from the patient splashing onto the healthcare worker s body. It is very important that adequate supplies of gowns and aprons are available in all areas where patients are being cared for, (especially if contact precautions are being applied), as well as surgical or special procedure areas such as a bronchoscopy room. Plastic aprons should be used in addition to gowns if the material of the gown is not fluid repellent and the task to be performed may result in splashes onto the healthcare worker s body. Some gowns are disposable and others are reusable. Reusable gowns must be laundered after every use. Supplies of gowns and aprons should be stored alongside other supplies of PPE items. Important issues to remember when selecting and using gowns and aprons The types of gowns and aprons used should be appropriate for the procedure about to be performed and the risk to the healthcare worker This should include considering: the amount of secretions to which the healthcare worker may become exposed as a result of the procedure; the types of task involved in the procedure which, if particularly labour intensive, may cause damage to the gown or apron. For example, some heavy duty tasks, such as cleaning, may warrant using a rubber apron in addition to the gown; and the size of the gown and apron to ensure coverage of any area of the wearer's body and clothes that could potentially be exposed. Using gowns or aprons correctly involves: changing and disposing of the gowns and aprons, in either the appropriate waste disposal facilities or in the relevant laundry facilities immediately after contact with a patient or a potentially contaminated environmental surface and before contact with a different patient or surface; the same gown can be used when providing care to more than one patient but only those patients in a cohort area and only if the gown does not have direct contact with a patient or the patient immediate environment. Suggested sequence of procedures when only gown and gloves are used: perform hand hygiene. put on gown. put on gloves ensuring gown cuffs are fully covered. perform the task (changing gloves and washing hands as necessary during the procedure). remove the gown and gloves immediately after finishing the task. for disposable gowns: peel off of gown and gloves together, roll inside out, and dispose of safely; and perform hand hygiene. for reusable gowns: remove gloves, perform hand hygiene remove and place gown in laundry facilities; and perform hand hygiene.

33 3.1 Standard Precautions Personal protective equipment (PPE) used with standard precautions Different kinds of eye/face protection Illustrated are three different kinds of protective eyewear: face shield, eye visor and goggles. An example of a gown. Other styles of gowns can also be used. FACIAL MUCOSA PROTECTION Masks and eye protection, such as eyewear and goggles are used to protect the eyes, nose or oral mucosa of the healthcare worker from any risk of contact with a patient's respiratory secretions or splashes of blood, body fluids, secretions or excretions. Face shields cover mouth, nose and eyes, and if available, can be used instead of a mask plus eyewear. It is very important that adequate supplies of masks and eye protection are available in all areas where patients are being cared for, and in particular at the entrance to any area where droplet or airborne isolation precautions have been indicated. Face shield Eye visor The healthcare worker should not touch the front of the mask or the eye protection when removing these items and should remember that it is essential that hand hygiene is performed immediately following their removal. Goggles 33 / Draft

34 3.1 Standard Precautions Personal protective equipment (PPE) used with standard precautions HOW TO Put on Personal Protective Equipment (when all PPE items are needed) Step 1 Identify hazards & assess risk. Gather the necessary PPE. Plan where to put on and take off PPE (patient s room, doorway or anteroom). Do you have a friend? Mirror? Do you know how you will deal with waste? Step 2 Put on a gown. Step 3 Put on a mask. Step 4 Put on eye protection e.g. visor, face shield, goggles (consider anti-fog drops or fog resistant goggles). Caps are optional: if worn, put on after eye protection. Step 5 Put on gloves (over cuff). 34 / Draft

35 3.1 Standard Precautions Personal protective equipment (PPE) used with standard precautions HOW TO Take off Personal Protective Equipment Step 1 Avoid contamination of self, others & environment. Remove the most heavily contaminated items first. Remove gloves and gown. Peel off gown & gloves and roll inside out. Dispose of gloves and gown safely. Step 2 Perform hand hygiene. Step 3 Remove cap (if worn). Remove eye protection from behind; Put eye protection in a separate container for reprocessing. Step 4 Remove mask from behind. Step 5 Perform hand hygiene. 35 / Draft

36 3.1 Standard Precautions RESPIRATORY HYGIENE & COUGH ETIQUETTE Respiratory hygiene and cough etiquette are two key ways in which the spread of infection can be controlled at the source All patients, visitors and healthcare workers should be encouraged to adhere to cough etiquette and respiratory hygiene at all times to contain respiratory secretions. When you cough or sneeze Cover your nose and mouth In healthcare facilities Throw the used tissue away straight after Perform hand hygiene Cough etiquette and respiratory hygiene should be followed in all parts of the hospital, in community settings and even in the home. It s always the right time to take these important measures to control the source of potential infection. If you are coughing consider using a medical mask 36 / Draft

37 3.1 Standard Precautions PREVENTION OF INJURIES FROM NEEDLES & OTHER SHARP INSTRUMENTS Prevention of needle stick or other injuries from sharp instruments is another component of Standard Precautions. Although it is not the primary means of preventing and controlling TB or ARDs, this element of standard precautions is an important factor in reducing and eliminating the transmission of blood borne pathogens from infected patients to healthcare workers, other patients, and any other persons by means of injury with sharp objects. Care must be taken to prevent any injuries to the healthcare workers or the patients when using, cleaning or disposing of needles, scalpels or other sharp instruments or devices. More detailed recommendations concerning the use of safe use of needles are available from the Safe Injection Global Network (SIGN) Alliance. 4 General needle stick and sharp object guidelines Never recap used needles. Never direct the point of a needle towards any part of the body except prior to injection. Do not remove used needles from disposable syringes by hand, and do not bend, break, or otherwise manipulate used needles by hand. Dispose of syringes, needles, scalpel blades, and other sharp items in appropriate puncture resistant containers, which should be located as close as practical to the area in which the items were used. Avoid the use of reusable syringes. Do not re use needles. Familiarise yourself with the institutional/unit policy on the steps to take in event of injury / Draft

38 3.1 Standard Precautions CLEANING & DISINFECTION OF RESPIRATORY EQUIPMENT Any piece of equipment used in providing patient care must be handled with care, as it may be contaminated and have the potential to spread infection. General principles to remember when handling contaminated (used) patient care equipment. It is important to avoid any contact between a used piece of equipment and the skin, mucosa or clothing of the healthcare worker, including any handles of the equipment. The process of cleaning and disinfecting respiratory equipment frequently results in splashes which could potentially be contaminated. To avoid damage of any equipment, clean and/ or disinfect equipment following manufacturer s recommendation. When cleaning and disinfecting respiratory equipment the healthcare worker should wear: rubber gloves, a gown and a rubber apron, face protection, such as a full face shield or an eye protection, such as a visor or goggles, plus a face mask. Reusable equipment must be cleaned with soap or detergent and water until all visible signs of soiling are removed and must then be appropriately disinfected before the equipment can be used on another patient. Appropriate reprocessing always includes thorough cleaning and may also include disinfection or sterilization depending on the nature and intended use of the device or equipment. Any item designed for single use must be disposed of in an appropriate container or waste receptacle immediately after use. This is essential to prevent any accidental contamination of either another person or the environment. Disinfectant use The disinfectants available may vary from country to country. When disinfecting reusable respiratory equipment a high level of disinfection is required. Generally, bleach 5 provides a reasonable level of chemical disinfection. The use of a chemical germicide, such as bleach or a physical method such as autoclaving is usually sufficient. Cleaning should precede any high level disinfection activity. When selecting the best method to conduct high level disinfection, the following factors should be taken into consideration: the piece of equipment to be disinfected; the composition of the piece of equipment and its intended use; the level of disinfection required; and the availability and capacity of services, physical facilities, organizational resources and personnel. 38 / Draft 5 Immersion of items in bleach preparation containing 0.1%sodium hypoclorite for at least 30 minutes.

39 3.1 Standard Precautions Cleaning & disinfection of respiratory equipment The steps involved in reprocessing reusable equipment are as follows: Wash the piece of equipment with soap or detergent and water. Rinse and dry. Disinfect (see Table 5). Rinse again if using chemicals to disinfect. Dry. Store. Essential points for cleaning and disinfecting equipment Clean and disinfect all respiratory equipment between uses. Thoroughly clean respiratory and reusable equipment prior to disinfection Drying of equipment before disinfection is essential to ensure disinfection solution is not further diluted. Healthcare workers must use PPE for cleaning and disinfection of respiratory equipment. Keep clean and disinfected items dry and in individual packages. Table 5: Sodium hypochlorite - concentration and use Starting solution Most household bleach solutions contain 5% sodium hypochlorite ( ppm a available chorine). Recommended dilution 1:100 dilution of 5% sodium hypochlorite is the usual recommendation. Use 1 part bleach to 99 parts cold tap water (1:100 dilution) for disinfection of surfaces. Adjust ratio of bleach to water as needed to achieve appropriate concentration of sodium hypochlorite, e.g. for bleach preparations containing 2.5% sodium hypochlorite, use twice as much bleach (i.e. 2 parts bleach to 98 parts water). Available chlorine after dilution For bleach preparations containing 5% sodium hypochlorite, a 1:100 dilution will yield 0.05% or 500 ppm available chlorine. Bleach solutions containing other concentrations of sodium hypochlorite will contain different amounts of available chlorine when diluted. Contact times for different uses Disinfection by wiping of nonporous surfaces: a contact time of 10 min is recommended Disinfection by immersion of items: a contact time of 30 min is recommended. N.B. Surfaces must be cleaned of organic materials, such as secretions, mucus, vomit, faeces, blood, or other body fluids before disinfection or immersion. a ppm: parts per million 39 / Draft

40 3.1 Standard Precautions Cleaning & disinfection of respiratory equipment Instructions and precautions for the use of bleach: Diluted bleach should be made fresh daily, labeled, dated, and unused portions discarded 24 hours after preparation. Always keep diluted bleach covered, protected from sunlight, in a dark container, and out of the reach of children. Bleach can corrode metals and damage painted surfaces. Avoid touching the eyes. If bleach gets into the eyes, immediately rinse with water for at least 15 minutes, and consult a physician. Bleach should not be used together with, or mixed with, other household detergents because this reduces its effectiveness and can cause chemical reactions. If necessary, use detergents first, and rinse thoroughly with water before using bleach for disinfection. Table 6: Guidelines for Processing Respiratory Equipment 6 Process Cleaning removes all visible blood, body fluids and dirt. Sterilization destroys all microorganisms, including endospores. High level Disinfection destroys all viruses, bacteria, parasites, fungi and some endospores. INSTRUMENTS OR OTHER ITEMS CLEANING STERILIZATION HIGH LEVEL DISINFECTION AIRWAYS (PLASTIC) Wash with soap and water. Rinse with clean water, air or towel dry. Not necessary. Not necessary. AMBU BAGS AND CPR FACE MASKS Wash with soap and water. Rinse with clean water, air or towel dry. Not necessary. Not necessary. SUCTION CATHETERS (RUBBER OR PLASTIC) Pass soapy water through catheter three times. Rinse three times with clean water (inside and outside). Not recommended. (Heat from autoclaving or dry-heat ovens will damage plastic catheters; rubber catheters can be autoclaved.) Steam or boil for 20 minutes. (Chemical HLD is not recommended because chemical residue may remain even after repeated rinsing with boiled water.) VENTILATOR TUBING OR CIRCUITS Using a brush, wash with soap and water. Rinse with clean water and air dry. Not possible using an autoclave or dry heat oven. Acceptable Steam or boil for 20 minutes. Air dry before use. 40 / Draft 6 Adapted from: Tietjen L, Bossemeyer D and McIntosh N Infection Prevention Guidelines for Healthcare Facilities with Limited Resources. Jhpiego: Baltimore, MD.

41 3.1 Standard Precautions CLEANING THE PATIENT-CARE ENVIRONMENT Environmental cleaning refers to the process of removing all or a significant amount of pathogens from contaminated surfaces and items. Cleaning the surfaces of the patient environment is important as the infectious agents that can cause ARDs are capable of surviving in the environment for many hours or even days. Cleaning can be done with water and neutral detergents. Disinfection Standard hospital disinfectants, prepared in the recommended dilutions and applied in accordance with the manufacturer s instructions can reduce the level of environmental surface contamination. Any process of disinfection must be preceded by cleaning. Only items and surfaces that have had contact with the patient s skin or mucosa or have been frequently touched by healthcare workers require disinfection after cleaning. The type of disinfectant used in a healthcare facility will depend on local availability and regulations. Some of the disinfectants that are suitable for this use include: sodium hypochlorite to be used on non metal surfaces or equipment; alcohol for use on smaller surfaces; phenolic compounds; quaternary ammonium compounds; and/ or peroxygen compounds. Key principles of environmental cleaning All horizontal surfaces in areas where care is being provided to a patient must be cleaned every day and whenever visibly soiled. They must also be cleaned whenever a patient is discharged and before a new patient arrives. If the surface has had direct contact with a patient, for example an examination couch or chair, the surface must be cleaned and disinfected before another patient come into contact with it. Cleaning solutions, cloths and mop heads should be changed regularly in accordance with local health authority policies. All cleaning equipment should be cleaned and dried after each use. Reusable mop heads should be laundered and dried after every use and before storage. Areas around the patient should be kept clear from unnecessary equipment, supplies and clutter to allow thorough daily cleaning to take place. Examination tables and surrounding equipment that have been used by patients known or suspected to be infected with an ARD of potential concern should be wiped down with disinfectants immediately after use. 41 / Draft

42 3.1 Standard Precautions Cleaning the patient-care environment PPE for cleaning the environment Cleaning is labour intensive, involving heavy duty tasks, and in certain settings it associated with a high risk of exposure to sharp objects. The healthcare worker should wear: rubber gloves; a gown and a rubber apron; resistant closed foot wear, such as boots. Cleaning of spills and splashes When cleaning any spills or splashes of body fluids or secretions, it is essential that adequate PPE is worn by the healthcare worker, including rubber gloves and gown. The stages of cleaning of spills are as follows: put on gown, apron and rubber gloves; clean the surface area with water and detergent using a disposable cleaning cloth; dispose of the cleaning cloth an appropriate leak proof container; disinfect the area. (NB sodium hypochlorite 0.5%); remove the rubber gloves and apron and dispose of both items into appropriate container for further cleaning and disinfection; remove gown and place it into appropriate container; perform hand hygiene. Key issues about cleaning and disinfection The environment used by the patient MUST be regularly cleaned. Cleaning should use proper techniques to avoid aerosolization of dust. Only surfaces that enter in contact with the patient s skin/mucosa and surfaces frequently touched by healthcare workers require disinfection after cleaning. Healthcare workers MUST use PPE for cleaning and disinfection of respiratory equipment and hand hygiene must be performed after PPE removal. PPE, including rubber gloves and gown, must be worn during cleaning and disinfecting. It is also important to note that good ventilation of the area is necessary during and immediately after the process of disinfection, regardless of the type of disinfectant used. 42 / Draft

43 3.1 Standard Precautions LINEN & WASTE MANAGEMENT Handle both waste and used linen with care, wearing appropriate PPE and practicing regular hand hygiene. The risk of being exposed to or acquiring an IRD as a result of handling waste or used linen is low. Nevertheless, it is good practice to handle both waste and used linen with care. This entails wearing the appropriate pieces of PPE and performing regular hand hygiene in line with the guiding principles of Standard Precautions. General principles All used linen and waste should be placed in bags or containers which are able to withstand transportation without being damaged. Double bagging is not needed for used linen or waste. Examples of waste classification include: general waste - such as leftover meals, administrative rubbish; clinical waste without sharp objects - such as material used during wound care; clinical waste with sharp objects - such as needles, bistouries blades; clinical waste with anatomic pieces - such as placenta. Healthcare workers should take care to avoid aerosolization of matter whenever handling and disposing of the waste. This is especially important for faeces. Healthcare workers should wear disposable gloves whenever handling waste and should perform hand hygiene immediately after removing the gloves. Linen Any solid matter on soiled linen should be removed and flushed down a toilet. The soiled linen should then be placed immediately into a laundry bag in the patient area. Used linen should be handled carefully to prevent contamination of surrounding surfaces or people. Used linen should then be washed according to normal routines. Waste Waste should be classified, handled and disposed of according to local health authority regulations and policies. Classifying waste is key to ensure it is handled correctly and disposed of down the appropriate channel. Keep bins closed. If waste is placed outside the bin, ensure the bag is tied. Managing linen & waste Handle linen and waste with care. Transport soiled linen and waste in closed containers or bags. Ensure safe handling and final treatment of waste, by classifying the waste (this is of utmost importance) and using the containers or bags specified according to its classification. Healthcare workers must use adequate PPE whenever handling soiled linen and waste. 43 / Draft

44 3.2 DROPLET PRECAUTIONS Diseases which are spread via droplets can be transmitted by an infected person when talking, coughing or sneezing. Diseases in this category include adenovirus, human influenza, severe acute respiratory syndrome (SARS) and novel influenza viruses. Typically, droplets travel only a short distance through the air but have the potential to land in the eyes, mouth or nose of an unprotected person or on an environmental surface. Droplets do not stay suspended in the air. Droplet precautions Guidelines for droplet precautions Wear a medical mask when within a 1 metre range of the patient. Put the patient in a single room or in a room that only contains other patients with the same diagnosis, or with similar risk factors, and ensure that every patient is separated by at least one metre. Ensure that the transportation of a patient to areas outside of the designated room is kept to a minimum. The patient should wear a medical mask outside their room Perform hand hygiene immediately after removing any item of PPE. Droplet Precautions should be applied in addition to Standard Precautions whenever providing care to a patient suspected or confirmed of having a disease spread by this route (see Table 9, page 48). An example of a medical mask. 44 / Draft

45 3.3 CONTACT PRECAUTIONS Transmission by contact is always a risk for healthcare workers and patients. Direct transmission by contact occurs when microorganisms are transferred from one infected person to another person without an intermediate object being involved. Indirect contact transmission occurs via a contaminated intermediate object or person, (e.g. contaminated hands of healthcare workers can transfer some respiratory viruses from an infected to a susceptible patient). Some common respiratory pathogens can be spread through the contamination of a patient's hands, the hands of a healthcare worker or an environmental surface. Key contact precautions Use clean, unsterilized gloves and a disposable or reusable gown whenever you have direct contact with a patient. Safely remove the gloves and gown immediately following any contact with a patient. Perform hand hygiene immediately after removing any item of PPE. Dedicate specific equipment for use with a single patient and ALWAYS clean and disinfect shared equipment between patient uses. Avoid touching your face, eyes or mouth with either gloved or ungloved hands as these may be contaminated. Place patients in a single occupancy room whenever possible or alternatively with other patients with the same diagnosis. Hands can transmit these diseases by having direct contact with a contaminated surface, followed by contact with either another body surface such as the conjunctival or nasal mucosa or, by contaminating another intermediate area. Contact Precautions Contact Precautions should be followed as a complement and in addition to Standard Precautions. They should be applied whenever providing care to a patient suspected or confirmed of having a disease spread by contact. Ensure that any movement of patients into areas outside of their designated room is kept to a minimum. Ensure that any contact between patients is kept to a minimum. 45 / Draft

46 3.4 AIRBORNE PRECAUTIONS Some pathogens are transmitted through inhalation of droplet nuclei that can remain infectious and suspended in the air over distances in excess of one metre. Airborne pathogens require special precautions to avoid their transmission. Diseases such as pulmonary tuberculosis, measles, and chickenpox are transmitted by this route. When a new, previously unrecognized, respiratory disease first appears, the mode of transmission may not be clear and the potential for airborne transmission should always be taken into consideration. Airborne transmission by droplet nuclei at short range may also occur with diseases that are more commonly transmitted through droplets, for example, when carrying out aerosol generating procedures. Infection may therefore occur in inadequately ventilated rooms or when individuals use inadequate PPE. Airborne precautions guidelines Patients should be kept in a well ventilated area separate from other patients, and if possible in an airborne precaution room which has 12 ACH plus control of airflow direction. Whenever entering specific high risk areas in hospitals and referral centres, such as airborne precaution rooms or patient areas in specialized treatment centres for persons with multidrug resistant TB, use a particulate respirator if available, ensuring that the seal of the respirator is checked before every use. Limit the movement of the patient and ensure that the patient is educated about respiratory etiquette / cough hygiene and wears a medical mask if outside their room. Perform hand hygiene immediately after removing any item of PPE. In such situations, if an aerosol generating procedure is indicated for the care of the patient, the healthcare worker should wear a particulate respirator instead of a medical mask, use eyewear and ensure the procedure is undertaken in an adequately ventilated room. Airborne Precautions Airborne Precautions should be followed as a complement and in addition to Standard Precautions. They should be applied whenever providing care to a patient suspected or confirmed of having a disease spread by airborne pathogens. Particulate respirator 46 / Draft

47 3.4 Airborne Precautions Table 7: Additional Precautions and Infection Prevention Requirements Infection control measures Droplet Contact Airborne Gloves Gown Eye protection Medical mask on healthcare workers and caregivers *Risk assessment Particulate respirator for room entry Particulate respirator within 1 m of patient Particulate respirator for aerosol generating procedures Medical mask on patient when outside isolation areas *Risk assessment *Risk assessment Single room if available if available if available Airborne Precaution room if available Table 8: Additional Precautions in Addition to Standard Precautions Apply Droplet Precautions whenever providing care to a patient with an acute febrile respiratory illness of unknown aetiology Apply Droplet and Contact precautions whenever providing care to a patient with possible seasonal paediatric viral outbreaks, or possible novel influenza or SARS Apply Airborne precautions whenever providing care to a patient with suspected M. tubeculosis, or suspected novel pathogens * Particulate respirators (US certified N95 or greater, EU certified FFP2 or greater, or the equivalent) should be used in specific high risk areas in hospitals and referral centres, such as airborne isolation rooms, rooms where bronchoscopy and other cough inducing procedures are performed or specialized settings where persons with multi-drug resistant TB are treated. 47 / Draft

48 3.4 Airborne Precautions Table 9: Additional precautions indicated for specific infectious respiratory diseases. Likely Disease Standard Droplet Contact Airborne No pathogen identified and no risk factor for ARD of potential concern M. tuberculosis Bacterial ARD Parainfluenza, RSV & adenovirus Influenza virus with sustained human-to-human transmission New influenza virus with no sustained human-to-human transmission SARS Yersinia Pestis, pneumonic plague Novel organisms 48 / Draft

49 3.5 SELECTING & USING MASKS IN Healthcare Masks are used to avoid the nose and mouth mucosa being exposed to splashes of the patient s body fluids. However, masks can also be used to protect against infectious respiratory aerosols. There are two main types of masks that are available to the healthcare worker: medical masks and particulate respirators. Medical masks provide protection against large particles (droplets) and particulate respirators provide protection against fine aerosols that are kept suspended in the air (droplet nuclei) as well as droplets. A particulate respirator can only be effective in protecting against infectious droplet nuclei if the seal between mask and face is intact, so there is no leak of air between the wearer s face and the device. Without appropriate work practices and environmental controls, respirators will not adequately protect the healthcare worker from infection. Since personal respirator protection may not always be affordable, it is most appropriate for use in high risk areas in the referral hospital setting. Similarly, because widespread and constant use of respirators is impractical, they should be used on a limited basis in specific high risk areas in conjunction with work practices and environmental control measures. When to use a medical mask Masks should be used by the healthcare worker when providing routine care to any patient with a disease that may be transmitted through droplets, such as: acute febrile respiratory disease; and RSV, adenovirus and influenza. Any patient displaying symptoms of respiratory infection should also be required to use a mask whenever outside of the isolation room regardless of the known or probable disease. An example of a medical mask. The type of mask to select should be appropriate for the anticipated procedures that will be performed and the level of risk the healthcare worker may face of having contact with respiratory secretions or other fluids. 49 / Draft

50 3.5 Selecting & using masks in healthcare When to use a particulate respirator Whenever entering specific high risk areas in hospitals and referral centres, such as airborne precaution rooms or patient areas in specialized treatment centres for persons with multidrug resistant TB. Whenever performing aerosol generating procedures associated with an increase in the risk of respiratory pathogen transmission, such as bronchoscopy; sputum induction; intubation, cardiopulmonary resuscitation and related procedures, including manual ventilation and suction; and autopsy or surgery involving the use of high speed devices. Whenever entering the room of a patient suspected of being infected with a novel or unknown organism causing an ARD, for which the main mode of transmission is completely unknown. The correct use of masks Change and dispose of a mask as soon as it becomes moist or dirty. Remove the mask when not in use: ensure it is not allowed to hang loose around the neck when not in use. Perform hand hygiene immediately after touching, removing or disposing of a mask. If using a particulate respirator, perform a seal check (see page 51 ) before every use to help assure the fit and reduce the leak of air. Particulate respirator 50 / Draft

51 3.5 Selecting & using masks in healthcare HOW TO Perform a Particulate Respirator Seal Check Step 1 Cup the respirator in your hand with the nosepiece at your fingertips allowing the headbands to hang freely below your hand. Step 2 Position the respirator under your chin with the nosepiece up. Step 3 Pull the top strap over your head resting it high at the back of your head. Pull the bottom strap over your head and position it around the neck below the ears. Step 4 Place fingers and both hands at the top of the metal nosepiece. Mould the nosepiece (USING TWO FINGERS OF EACH HAND) to the shape of your nose. Pinching the nosepiece using one hand may result in less effective respirator performance. Step 5 Cover the front of the respirator with both hands, being careful not to disturb the position of the respirator. Step 5a) Positive seal check Exhale sharply. A positive pressure inside the respirator means no leakage. If leakage, adjust the position and/or tension straps. Retest the seal Repeat the steps until the respirator is secured properly Step 5b)Negative seal check Inhale deeply. If no leakage, negative pressure will make respirator cling to your face. Leakage will result in loss of negative pressure in the respirator due to air entering through gaps in the seal. 51 / Draft

52 3.6 POST MORTEM CARE & AUTOPSY PROCEDURES Standard Precautions, including the use of PPE are just as important after the death of a patient and should always be followed by the healthcare worker. Mortuary handling In the event of the death of a patient with an ARD of potential concern, the body should be placed in a fully sealed, impermeable body bag before it is removed from the isolation room for transportation to the mortuary. This will help to avoid any leakage of body fluids. Lifting a body is a heavy duty task and healthcare workers should ensure that the items of PPE worn are of sufficient strength to withstand any potential damage. Items of PPE that should be worn by healthcare workers when handling bodies include: visors or goggles and medical mask or face shield to protect against any potential splashing of body fluids; a waterproof, disposable, long sleeved, cuffed gown and single use, unsterilized latex gloves; if duties include lifting or carrying the body, it is advisable to use an additional pair of external heavy duty rubber gloves and a resistant water proof apron. Family members who wish to view the body should be required to wear the appropriate items of PPE to avoid direct contact with body fluids. Standard Precautions should be followed during the hygienic preparation of the body to avoid direct contact with body fluids. Post-mortem examination Autopsies must be performed in a safe environment. Those involved with performing or assisting with autopsies must wear appropriate PPE including: a scrub suit comprising top and trousers, or equivalent; a single use, fluid resistant, long sleeved gown; a respirator that complies with N95 standard if there is any risk of aerosols being generated with the use of high speed devices such as saws; face shield or goggles; autopsy gloves or double pair of non sterile gloves; and boots. Use containment devices. Use vacuum shrouds for oscillating saws. Avoid using high pressure water sprays. Open intestines under water. Always use PPE How to reduce the risk of generating aerosols during autopsies Any kind of fluid from a dead body may transmit disease. It is essential to wear the appropriate PPE to avoid unprotected contact with these body fluids whenever handling dead bodies. 52 / Draft Subject to local directives, embalming can take place as long as the principles of Standard Precautions are followed to avoid direct contact with body fluids.

53 SECTION 4 A Scenario-based approach to Respiratory Infection Prevention and Control SCENARIO 1 PATIENT ARRIVAL AT THE RECEPTION Scenario: patient arrives at the healthcare facility (HCF) The following recommendations assume that the: patient s diagnosis is not known; availability of personal protective equipment (PPE) will vary between settings and countries; available space and places for patients will be different within and between settings and countries. What type of procedures will I be undertaking on this occasion? Primarily, exchange of non clinical, administrative information. Referral to clinical staff for assessment and triage. How close will I be to the patient during these procedures? No close contact i.e. expect to maintain at least 1 metre separation between self and the patient. What is the likelihood of me having contact with any blood or body fluids during the procedures? Minimal, if any. What measures should be in place to stop the patient transmitting infection? Environment Encourage the patient to maintain a distance of at least 1 metre from other patients and visitors. Limit the number of staff in patient s environment to a minimum. Keep spaces well ventilated (open windows and doors). Patient Instruct on respiratory hygiene / cough etiquette, including use of tissues, medical mask and hand hygiene. If the patient is able to tolerate it, a medical mask should be worn. Restrict patient movement. Healthcare worker If close contact, without barrier, use a medical mask. What infection control supplies should be available? Tissues, medical masks and hand hygiene products (i.e. water, soap, sink, single use towel, hand rub solution). ATTENTION! If there is any direct close contact with the patient, use a medical mask and perform hand hygiene before and after the contact. 53 / Draft

54 4 A Scenario-based approach to Respiratory Infection Prevention and Control SCENARIO 2 TRIAGE & PHYSICAL EXAMINATION Scenario: patient requires triage and physical examination The following recommendations assume that the: patient s diagnosis is not known; availability of personal protective equipment (PPE) will vary between settings and countries; available space and places for patients will be different within and between settings and countries. What type of procedures will I be undertaking on this occasion? clinical assessment. physical examination. taking history. How close will I be to the patient during these procedures? Close contact i.e. expect to be within 1 metre. What is the likelihood of me having contact with any blood or body fluids during the procedures? Possible that patient may sneeze or cough during nursing care. Healthcare workers may be exposed to patient secretions on contaminated surfaces, used equipment, tissues or linen. What measures should be in place to stop the patient transmitting infection? Environment Limit the number of staff in patient s environment to a minimum. Keep spaces well ventilated (open windows and doors). Patient Instruct on respiratory hygiene / cough etiquette, including use of tissues, medical mask and hand hygiene. If the patient is able to tolerate it, a medical mask should be worn. Healthcare worker Use a medical mask and perform hand hygiene before and after patient contact. What infection control supplies should be available? Tissues, medical masks and hand hygiene products (i.e. water, soap, single use towel, hand rub solution). ATTENTION! Contact with contaminated secretion, droplets and tiny aerosols may be increased if resuscitation, intubation, and suctioning are required. In this situation use a particulate respirator instead of medical mask, and gloves, gown and eye protection, and if possible, place patient in a well ventilated single room during such procedures. 54 / Draft

55 4 A Scenario-based approach to Respiratory Infection Prevention and Control SCENARIO 3 PATIENT IS TRANSPORTED TO ANOTHER AREA Scenario: patient is transported by a porter accompanied by a nurse The following recommendations assume that the: patient s diagnosis is not known; availability of PPE will vary between settings and countries; available space and places for patients will be different within and between settings and countries. What type of procedures will I be undertaking on this occasion? None. How close will I be to the patient during these procedures? No close contact i.e. expect to maintain at least 1 metre separation between self and the patient. What is the likelihood of me having contact with any blood or body fluids during the procedures? Minimal, but possible that patient may sneeze or cough. Healthcare workers may be exposed to patient secretions on contaminated surfaces, tissues or linen. What measures should be in place to stop the patient transmitting infection? Environment Limit the number of staff in patient s environment to a minimum. Keep corridors well ventilated (open windows and doors). Take the shortest route possible to minimise exposure to staff, other patients or visitors, or consider a route that takes you away from patient care areas (e.g. outside the healthcare facility and through a back door). Any surface area with which the patient comes into contact as a result of transportation through the healthcare facility must be cleaned and disinfected immediately following contact. Patient Instruct on respiratory hygiene / cough etiquette, including use of tissues, medical mask and hand hygiene. If the patient is able to tolerate it, a medical mask should be worn. Healthcare worker Use a medical mask and perform hand hygiene before and after patient contact. What infection control supplies should be available? Tissues, medical masks. ATTENTION! Transmission of respiratory infections can occur during patient transport. Choose the shortest route possible, try to avoid patient care areas, travel along well ventilated routes, place a medical mask on the patient and ensure cough etiquette is applied. 55 / Draft

56 4 A Scenario-based approach to Respiratory Infection Prevention and Control SCENARIO 4 GENERAL NURSING CARE Scenario: patient requires general nursing care The following recommendations assume that the: patient s diagnosis is known or suspected: risk factors are known availability of PPE will vary between settings and countries; available space and places for patients will be different within and between settings and countries. What type of procedures will I be undertaking on this occasion? General nursing care excluding aerosol generating procedures. How close will I be to the patient during these procedures? Repeated contact with the patient, their immediate care environment and equipment used in their care provision. Contact will include being within 1 metre of the patient. What is the likelihood of me having contact with any blood or body fluids during the procedures? Possible that patient may sneeze or cough during nursing care. Healthcare workers may be exposed to patient secretions on contaminated surfaces, used equipment, tissues or linen. What measures should be in place to stop the patient transmitting infection and what pieces of PPE should be available? Environment Limit the number of staff in patient s environment to a minimum. Keep spaces well ventilated (open windows and doors). Place patient in a single room if resuscitation, intubation or suctioning are undertaken. Written communication on the patient chart should inform other healthcare workers of the suspected or confirmed diagnosis. The required precautions should be posted outside the room. Patient Instruct on respiratory hygiene / cough etiquette, including use of tissues, medical mask and hand hygiene. If the patient is able to tolerate it, a medical mask should be worn. Healthcare worker Use a medical mask and perform hand hygiene before and after patient contact as part of standard precautions. Use gown, eye protection and possibly a particulate respirator if the diagnosis indicates that additional precautions are needed. Apply standard precautions + additional precautions according to the presumptive or confirmed IRD diagnosis and intended procedure Use protective gloves, gown, eye protection and particulate respirator if resuscitation, intubation or suctioning is undertaken. 56 / Draft

57 4 A Scenario-based approach to Respiratory Infection Prevention and Control What infection control supplies should be available? Tissues, medical masks, and hand hygiene products (i.e. water, soap, single use towel, hand rub solution). Additional supplies depending on isolation precautions recommended. ATTENTION! Contact with contaminated secretion, droplets and tiny aerosols may be increased if resuscitation, intubation, and suctioning are required. In this situation use a particulate respirator instead of medical mask, and gloves, gown and eye protection, and if possible, place patient in a well ventilated single room during such procedures. 57 / Draft

58 4 A Scenario-based approach to Respiratory Infection Prevention and Control SCENARIO 5 NEBULIZED DRUG THERAPY Scenario: patient requires delivery of nebulized drug The following recommendations assume that the: patient s diagnosis is not known; availability of PPE will vary between settings and countries; available space and places for patients will be different within and between settings and countries. What type of procedures will I be undertaking on this occasion? Placement and adjustment of nebulizer around patient s face and nose. Contact with oxygen tank or outlet. How close will I be to the patient during these procedures? Close contact i.e. expect to be within 1 metre. What is the likelihood of me having contact with any blood or body fluids during the procedures? Possible that patient may sneeze or cough during nursing care. Healthcare workers may be exposed to patient secretions on contaminated surfaces, used equipment, tissues or linen. What measures should be in place to stop the patient transmitting infection? Environment Limit the number of staff in patient s environment to a minimum. Keep spaces well ventilated (open windows and doors). Patient Instruct on respiratory hygiene / cough etiquette, including use of tissues, medical mask and hand hygiene. If the patient is able to tolerate it, a medical mask should be worn and removed only during the nebulizer treatment. Healthcare worker Use a medical mask and perform hand hygiene before and after patient contact. What infection control supplies should be available? Tissues, medical masks and hand hygiene products (i.e. water, soap, single use towel, hand rub solution). ATTENTION! Contact with contaminated secretion, droplets and tiny aerosols may be increased if resuscitation, intubation, and suctioning are required. In this situation use a particulate respirator instead of medical mask, and gloves, gown and eye protection, and if possible, place patient in a well ventilated single room during such procedures. 58 / Draft

59 4 A Scenario-based approach to Respiratory Infection Prevention and Control SCENARIO 6 COLLECTION OF AN INDUCED SPUTUM SPECIMEN Scenario: Non intubated patient in any clinical setting The following recommendations assume that the: patient s diagnosis is UNKOWN and risk factors are known; availability of clinical equipment, resources and PPE will vary between settings and countries. What type of procedures will I be undertaking on this occasion? Chest physiotherapy and induced sputum collection. How close will I be to the patient during these procedures? Repeated close contact with the patient. Contact will include being within 1 metre of the patient and very close to their airway and respiratory secretions. What is the likelihood of me having contact with any blood or body fluids during the procedures? Likely that healthcare workers will be exposed to patient s respiratory secretions during physiotherapy or specimen collection. Healthcare workers may also be exposed to patient secretions on contaminated surfaces, used equipment, tissues or linen. What measures should be in place to stop the patient transmitting infection and what pieces of PPE should be available? Environment Limit the number of staff in patient s environment to a minimum. Place patient in a single room. Keep spaces well ventilated (open windows and doors). Healthcare worker Perform hand hygiene before and after patient contact. Use protective gloves, gown, eye protection and particulate respirator. Apply additional precautions according to the intended procedure and unknown patient diagnosis. What infection control supplies should be available? Gloves, gown, eye protection, particulate respirator and hand hygiene products (i.e. water, soap, single use towel, hand rub solution). ATTENTION! Contact with contaminated secretions, droplets and tiny aerosols is increased during suctioning. In addition to the PPE recommended above, hand hygiene must be performed carefully after PPE removal. The particulate respirator MUST be seal checked before doing the procedure! If possible, place patient in a well ventilated single room. 59 / Draft

60 4 A Scenario-based approach to Respiratory Infection Prevention and Control SCENARIO 7 RESUSCITATION, INTUBATION, SUCTIONING AND/OR EXTUBATION Scenario: Intubated patient in emergency department, intensive care unit, operating theatre or equivalent setting The following recommendations assume that the: patient s diagnosis and risk factors are known; availability of clinical equipment, resources and PPE will vary between settings and countries; where possible and available, clinicians will try and use a suction technique and/or equipment which decreases the risk for aerosolization of tracheal secretions during suction induced coughing. What type of procedures will I be undertaking on this occasion? Insertion of laryngoscope, endotracheal tube and/or suction catheter. Connection of an Ambu-bag. Normal saline lavage if thick and/or bloody secretions present. Disconnection of endotracheal tube from the ventilator. Removal of endotracheal tube. How close will I be to the patient during these procedures? Repeated close contact with the patient. Contact will include being within 1 metre of the patient and very close to their airway and respiratory secretions. What is the likelihood of me having contact with any blood or body fluids during the procedures? Likely that the patient will expel respiratory secretions and tiny aerosols during suctioning, resuscitation, intubation or extubation. Healthcare workers may also be exposed to patient secretions on contaminated surfaces, used equipment, tissues or linen. What measures should be in place to stop the patient transmitting infection and what pieces of PPE should be available? Environment The type of precautions needed to take care of the patient should be posted outside the room or area (e.g. standard + contact + droplet precautions in effect in this area) Limit the number of staff in patient s environment to a minimum. Place patient in a single room. Keep spaces well ventilated (open windows and doors) or use mechanically ventilated operating theatre for pre operative intubation. Healthcare worker Apply standard precautions + additional precautions according to the presumptive or confirmed IRD diagnosis and intended procedure Perform hand hygiene before and after patient contact. Use protective gloves, gown, eye protection and particulate respirator. 60 / Draft

61 4 A Scenario-based approach to Respiratory Infection Prevention and Control What infection control supplies should be available? Gloves, gown, eye protection, particulate respirator and hand hygiene products (i.e. water, soap, single use towel, hand rub solution). ATTENTION! Contact with contaminated secretions, droplets and tiny aerosols is increased during suctioning, resuscitation, intubation or extubation In addition to the PPE recommended above, hand hygiene must be performed carefully after PPE removal. The particulate respirator MUST be seal checked before doing the procedure! If possible, place patient in a well ventilated single room. 61 / Draft

62 4 A Scenario-based approach to Respiratory Infection Prevention and Control SCENARIO 8 BRONCHOSCOPY Scenario: Sedated patient in emergency department, intensive care unit, procedure room or equivalent setting The following recommendations assume that the: patient s diagnosis and risk factors are known; availability of clinical equipment, resources and PPE will vary between settings and countries; where possible and available, clinicians will try and use a technique and/or equipment which decreases the risk for aerosolization of tracheal secretions. What type of procedures will I be undertaking on this occasion? Insertion and removal of bronchoscope. Possibly a normal saline lavage depending on presence of thick and/or bloody secretions. Possibly biopsy or specimen collection. How close will I be to the patient during these procedures? Repeated close contact with the patient. Contact will include being within 1 metre of the patient and very close to their airway and respiratory secretions. What measures should be in place to stop the patient transmitting infection and what pieces of PPE should be available? Environment The type of precautions needed to take care of the patient should be posted outside the room or area. (e.g. standard + contact + droplet precautions in effect in this area) Limit the number of staff in patient s environment to a minimum. Place patient in a single room. Keep spaces well ventilated (open windows and doors) or use mechanically ventilated procedure room. Healthcare worker Apply standard precautions + additional precautions according to the presumptive or confirmed IRD diagnosis and intended procedure Perform hand hygiene before and after patient contact. Use protective gloves, gown, eye protection and particulate respirator. What infection control supplies should be available? Gloves, gown, eye protection, particulate respirator and hand hygiene products (i.e. water, soap, single use towel, hand rub solution). 62 / Draft What is the likelihood of me having contact with any blood or body fluids during the procedures? The patient may expel respiratory secretions and tiny aerosols during insertion or removal of the bronchoscope and/or suctioning. Healthcare workers may also be exposed to patient secretions on contaminated surfaces, used equipment, tissues or linen.

63 4 A Scenario-based approach to Respiratory Infection Prevention and Control ATTENTION! Contact with contaminated secretions, droplets and tiny aerosols is increased during suctioning, insertion or removal of the bronchoscope. The patient may expel blood stained sputum or secretions if a biopsy is taken. In addition to the PPE recommended above, hand hygiene must be performed carefully after PPE removal. The particulate respirator MUST be seal checked before doing the procedure! Place patient in a well ventilated single room. 63 / Draft

64 4 A Scenario-based approach to Respiratory Infection Prevention and Control SCENARIO 9 POST MORTEM CARE OF THE BODY Scenario: patient has died and must be handled and transported; relatives may wish to view the body The following recommendations assume that the: patients diagnosis is probably known; availability of PPE will vary between settings and countries; bodybags (or a local equivalent) are available. What type of procedures will I be undertaking on this occasion? Preparing, moving and placing the body in a sealed, impermeable body bag. How close will I be to the patient during these procedures? Direct contact with the body which may be contaminated by secretions. What is the likelihood of me having contact with any blood or body fluids during the procedures? Healthcare workers may be exposed to the body, patient secretions on contaminated surfaces, used equipment, tissues or linen. What measures should be in place to stop the transmission of infection? Environment Limit the number of staff in patient s environment to a minimum. Keep spaces well ventilated (open windows and doors). Healthcare worker Apply additional precautions according to the intended task and patient diagnosis. PPE that should be worn by healthcare workers when handling bodies includes visors or goggles and medical mask or face shield to protect against any potential splashing of body fluids, a waterproof, disposable, long sleeved, cuffed gown and single use, unsterilized latex gloves and if duties include lifting or carrying the body, it is advisable to use an additional pair of external heavy duty rubber gloves and a resistant waterproof apron. Relatives Appropriate items of PPE to avoid direct contact with body fluids. What infection control supplies should be available? Gloves, gown, eye protection, medical mask or face shield, hand care products (i.e. water, soap, single use towel, hand rub solution), a waterproof, disposable, long sleeved, cuffed gown and single use, unsterilized latex gloves and possibly an additional pair of external heavy duty rubber gloves and a resistant waterproof apron. ATTENTION! Lifting a body is a heavy duty task and healthcare workers should ensure that the items of PPE worn are of sufficient strength to withstand any potential damage. 64 / Draft

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