INFECTION PREVENTION and CONTROL POLICY - PROCEDURE HAND HYGIENE

Transcription

1 INFECTION PREVENTION and CONTROL POLICY - PROCEDURE HAND HYGIENE Date Effective: 9/95 Revision Date: Revised with "Nail Care" made into a separate policy/procedure 11/08, 12/08, 5/10. RATIONALE: Proper hand cleaning is the single most effective deterrent to the spread of infection. SCOPE: System-wide I. POLICY: 1. All associates, licensed independent practitioners, volunteers, students, and others will clean their hands to prevent the spread of infection, as follows: 1.1. Upon entering and exiting patients' rooms or treatment areas Before applying and after removing gloves Before preparation of patient supplies or medications Before preparing or serving food During patient care, when moving from a contaminated body site to a clean body site during patient care After contact with patients' or one's own secretions/ excretions, including but not limited to urinary, fecal, nasal, oral, and wound drainage, and following such activities as using the toilet, touching the face while in patient care area, combing the hair, coughing, sneezing, and applying cosmetics Before and after eating On completion of duty. 2. All associates and independent practitioners within Lakeland will comply with the Nail Care policy/procedure.

2 II. PROCEDURE: 1. Soap and Water Handwash vs. Alcohol-based Hand Foam 1.1. Alcohol-based foam may be used before and after patient contacts, provided there has been no soilage of hands or contact with blood or body fluids Soap and water handwashing must be performed after hand contact with soil, blood or body fluids NOTE: The use of alcohol-based hand foam is not a substitute for soap and water handwashing when hands are visibly soiled or have contacted blood or body fluids. Soap and water handwashing must be performed under these circumstances C. difficile spores are not affected by alcohol-based foam. Soap and water handwashing is required after contact with patients with suspected or confirmed C. difficile or their environments. 2. Soap and Water Handwashing Technique 2.1. Turn on water and adjust water temperature to comfort Wet hands up to the wrists Apply handwashing substance, work into a lather, wash all surfaces of the hand and fingernails, between fingers and under fingernails for at least 15 seconds Per current Food Code, food handlers must wash all surfaces of the hand and fingernails for at least 20 seconds Rinse well, keeping hands pointing down Dry hands well with clean paper towels Obtain a clean paper towel. grasp the faucet with the paper towel, and turn off the faucet Dispose of paper towels properly. 3. Alcohol-based Foam Technique 3.1. Make sure hands are dry and free of soil before use Dispense a golf ball-sized amount of foam into hand Apply alcohol-based foam to all surfaces of wrists, hands, and nails, between fingers and under fingernails, then rub until dry Do not wipe off excess alcohol-based foam with a paper towel Multiple consecutive applications of the alcohol based foam within a short time interval may cause a build-up of foam that will leave the hands feeling "sticky" or "gummy" If this occurs, wash hands once with soap and water before subsequently resuming hand cleaning hygiene with the alcohol-based foam.

3 4. Hand Lotions: Hospital-approved lotion (non-petroleum based) may be used to prevent skin dryness associated with handwashing No multi-use lotion bottles may be used in any nursing unit, patient care area, or other area involved in the treatment, testing, food preparation, cleaning, or other care of the patient, the patient's supplies, or the patient's environment Lotion may not be brought in from outside the hospital and shared by the staff Personnel should carry individual bottles of hand lotion (available from General Stores) For therapeutic lotions, creams and ointments used on patients, see G. of the Infection Prevention and Control policy/procedure for Dept Specific_Rehabilitation Services. 5. See Corporate policy: Hand Sanitizer Dispenser, Installation of Alcohol Based-corp Lakeland Community Hospital Niles, Pilot Hand Hygiene Program: 6.1. Niles Hand Hygiene Pilot Program_Consequences for not washing hands in six steps Reference: CDC Guideline for Hand Hygiene in Health-Care Settings, MMWR Recommendations and Reports, October 25, 2002/Vol. 51/No. RR-16. National Patient Safety Goal. FDA Food Code.

4 INFECTION CONTROL POLICY - PROCEDURE STANDARD PRECAUTIONS Date Effective: 11/95 Revision: 3/98, 2/99, 2/01, 8/07, 10/07, 1/08, 10/10 Reviewed: 11/03, 7/04, 9/05 PERSONAL PROTECTIVE EQUIPMENT - RESPIRATORY HYGIENE/COUGH ETIQUETTE - DISHES, GLASSES, CUPS, AND EATING UTENSILS - ROUTINE AND TERMINAL CLEANING OCCUPATIONAL HEALTH AND BLOODBORNE PATHOGENS - SAFE INJECTION PRACTICES - PATIENT PLACEMENT PURPOSE: To provide a consistent approach to the prevention and control of the transmission of infections at a time when all persons infected with pathogens cannot reliably be identified by medical history and examination. SCOPE: POLICY: System-wide Standard Precautions will be used for the care of all patients, regardless of diagnosis or symptoms. PROCEDURE HANDWASHING & NAIL CARE (see policies Hand Hygiene and Nail Care): PERSONAL PROTECTIVE EQUIPMENT 1. GLOVES: 1) Wear gloves (clean, non-sterile gloves are adequate) when touching blood, body fluids, secretions, excretions, mucous membranes, nonintact skin, and contaminated items. Put on clean gloves just before touching mucous membranes and non-intact skin. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces and before going to another site (e.g., wound) on the same patient or another patient. Wash hands immediately to avoid transfer of microorganisms to other patients or environments. 2. MASK, EYE PROTECTION, FACE SHIELD: 1) Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. 2) Masks will also be used

5 3. GOWN: during all invasive procedures requiring Maximal Barrier Precautions (e.g. placement of central venous catheters, see IV Therapy, Infection Prevention and Control Precaution) AND to prevent droplet spread of oral flora during spinal procedures (e.g. myelogram, lumbar puncture, spinal anesthesia, epidurals) 1) Wear a non-permeable gown to protect skin and prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or cause soiling of clothing. 2). Select a gown that is appropriate for the activity and amount of fluid likely to be encountered. 3) Remove a soiled gown as promptly as possible and wash hands to avoid transfer of microorganisms to other patients or environments. Do not save a used gown for reuse, even for the same patient. Always discard gown and wash hands if leaving the patient room - do not continue to wear gown to fetch supplies. 4). Gowns are not to be worn as warm-up jackets, they are only to be worn when full barrier precautions are required, spraying and splashing are anticipated, or when going into an isolation room. RESPIRATORY HYGIENE/COUGH ETIQUETTE The following measures will be implemented to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at the point of initial encounter in a healthcare setting (e.g., triage, reception and waiting areas in emergency departments, outpatient clinics and physician offices): PATIENT-CARE EQUIPMENT: Respiratory Hygiene Cough/Etiquette Signs will be posted at entrances to point of care (e.g., emergency room, clinics, waiting rooms) within ambulatory and inpatient settings with instructions to patients and other persons with symptoms of a respiratory infection to cover their mouths/noses when coughing or sneezing, using and disposing of tissues, and perform hand hygiene after hands have been in contact with respiratory secretions. o signs and brochures will also encourage visitors with symptoms of a contagious disease to refrain from visiting their loved ones while ill. Tissues ("Kleenex") and no-touch trash receptacles will be provided for disposal of tissues. Hand hygiene stations will be provided in or near entrances and waiting areas in ambulatory and inpatient settings, providing conveniently-located dispensers of alcohol-based hand rubs. o Where sinks are available, hand hygiene supplies will be provided. Masks will be offered to coughing patients and other symptomatic persons (e.g., persons who accompany ill patients) upon entry into the facility. Educational brochures and posters will be provided which will encourage patients and visitors to maintain spatial separation, ideally a distance of at least 6 feet, from others in common waiting areas if coughing, sneezing, or otherwise expelling secretions. 1) Handle used patient-care equipment soiled with blood, body fluids, secretions and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing and transfer of microorganisms to other patients and environments.

6 2) Reusable equipment will not be used for the care of another patient until it has been appropriately cleaned and/or reprocessed. Properly discard single use items. LINEN: 1) Handle, transport and process all used linen in a manner that prevents skin and mucous membrane exposures, contamination of clothing and transfer of microorganisms to other patients and environments, as if it is soiled with blood, body fluids, secretions and/or excretions. DISHES, GLASSES, CUPS, AND EATING UTENSILS: 1) No special precautions are needed for dishes, glasses, cups, and eating utensils. 2) Reusable dishes and utensils can be used for patients in isolation. 3) The combination of hot water and detergents used in hospital dishwashers is sufficient to decontaminate dishes, glasses and cups, and eating utensils. 4) When removing food tray from the patient room, if the tray contains sharps or appears contaminated with blood or body fluids: Contact the patient's nurse to remove the sharp and/or contaminant, Then don gloves to remove tray. ROUTINE AND TERMINAL CLEANING: 1) The room or cubicle and bedside equipment of patients in isolation are cleaned using the same procedures used for other patients, unless the infecting microorganisms(s) and the amount of environmental contamination indicates special cleaning. (See policy: Multi-Drug Resistant Pathogens) 2) For Terminal Cleaning see Contact Isolation and Environmental Services policy Cleaning Isolation Patient Room_ Discharge or Transfer. OCCUPATIONAL HEALTH AND BLOODBORNE PATHOGENS, (see also Exposure Control Plan): 1) Take care to prevent injuries when using needles, scalpels and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments and when disposing of used needles. NEVER recap used needles, or otherwise manipulate them using both hands, or any other technique that involves directing the point of a needle toward any part of the body, rather, use a mechanical device designed for holding the needle sheath. Do not remove used needles from disposable syringes by hand, and do not bend, break, or otherwise manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades and other sharp items in appropriate puncture-resistant containers located as close as practical to the area in which the items were used and place reusable sharps in a puncture-resistant container for transport to the reprocessing area. 2) Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable. 3) Wear any of the various types of masks, goggles, and face shields alone or in combination to provide barrier protection when disposing of moist body substances from suction cannisters, chest tube drainage systems, closed wound drainage systems, foley catheters, paracentesis, peritoneal dialysis, and thoracentesis.

7 SAFE INJECTION PRACTICES PATIENT PLACEMENT: Reference: Use aseptic technique to avoid contamination of sterile equipment. Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient to access a medication or solutions that might be used for a subsequent patient. o Never reinsert a used needle into a multiuse vial or use the same needle for more than one patient. o Never use a syringe more than once to draw up or deliver medications. Initial and add the expiration date whenever opening multidose vials. The expiration date for multidose vials is 28 days unless the manufacturer's recommendation is shorter. Use fluid infusion and administration sets (i.e. intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient's intravenous infusion bag. Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use. If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile. Use single-dose vials for parenteral medications whenever possible. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable. Do not use bags or bottles of intravenous solutions as a common source of supply for multiple patients. Insulin pens must never be used for more than one patient. 1) Careful consideration will be made when placing a patient who contaminates the environment. 2) If a private room is not available, consult with Infection Preventionists or nursing supervisor regarding patient placement. (Cohorting of patients must be approved through the Infection Preventionist.) 3) For Disease Specific Isolations, see: ISOLATION_TYPE AND DURATION OF PRECAUTIONS for Specific Diseases and Pathogens.pdf. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007, CDC.

8 DEPARTMENT : Policy - Procedure Human Resources Subject: Policy/Code No Submitted by: Date Effective: 04/95 Date Last Review: 01/12 Date Last Revision: Reference Distribution: Approved by: Needle Stick or Moist Body Substance Exposure Lori Dudeck, Manager Associate Health and Wellness 01/12 Corporate Norma Tirado, Vice President Human Resources and Health Information Technology PURPOSE To identify what is considered an exposure, how to report an exposure and the follow care to an exposure to blood borne pathogens. This policy assures that protocols are in place to provide timely and effective post exposure care to prevent the transmission of blood borne pathogens following needle sticks and/or other potentially infectious materials (OPIM). SCOPE This policy covers all needle sticks and other potentially infectious materials (OPIM) seeking care through Lakeland. There are two portions to this policy: 1. Lakeland Regional hospital based (Saint Joe, Niles, Berrien, and Watervliet) associates, volunteers, medical residents, physicians, first responders and Allied Health Practitioners. 2. Non-Lakeland based associates and first responders (including, but not limited to, non-lakeland based medical offices/clinics, law enforcement, contractors, medical instrument reps, students, visitors, etc.) the following procedures must be followed.

9 POLICY All personnel, employed and other allied health practitioners, who sustain a percutaneous, mucous membrane, or open wound exposure via a needle stick or to other potentially infectious materials of a patient of LRHS are to follow the established procedures to reduce the risk of transmission of hepatitis and/or HIV. DEFINITIONS Blood = human blood, human blood components, and products made from human blood Other Potentially Infectious Materials (OPIM) = including, but not limited to, semen, vaginal secretions, amniotic fluid, cerebral spinal fluid, wound drainage, vomitus, urine, feces, etc. Percutaneous exposure = a contaminated sharp that pierces the skin (including, but not limited to needles, scalpels, broken glass) Mucous membrane exposure = exposure to eyes, mouth, or other mucous membranes to blood, or other potentially infectious materials Open wound exposure = exposure of non-intact skin (cuts, incisions, abrasions, etc.) to blood, or other potentially infectious materials ROLES AND RESPONSIBILITIES TO PREVENT EXPOSURE: 1. Protection is the key to preventing exposures. 2. All Lakeland Regional Health System (LRHS) associates, volunteers, medical residents, physicians, first responders and Allied Health Practitioners must follow Standard Precautions. 3. Hepatitis B vaccine series completion is offered free of charge and is strongly recommended for all personnel who risk of potential exposure to blood or OPIM. PROCEDURE 1. When either: A. Lakeland hospital based (Saint Joe, Niles, Berrien and Watervliet) associate, volunteer, medical resident, physician, first responder or Allied Health Practitioner sustains a percutaneous, mucous membrane or open wound exposure to the blood or other potentially infectious material of a patient, the following procedures must be followed. B. Non-Lakeland hospital based (Medical offices/clinics) associate sustains a percutaneous, mucous membrane or open wound exposure to blood or other potentially infectious material of a patient, the following procedure must be followed Immediately do one of the following: Needle sticks and cuts must be cleaned with soap and water for at least 10 seconds

10 Splashes to the nose, mouth, or skin must be flushed with water for at least 10 seconds Eyes must be irrigated with clean, tepid (16-38 C ( F) water, saline or sterile irrigate under low pressure for at least 15 minutes (ANSI Z ) Call STIK Line using Vocera immediately for information and instruction Lakeland Hospital Use Vocera and call STIK line and complete a safety call out via the Intranet Niles/Berrien Use Vocera and call Niles STIK line and complete a safety call out via the Intranet Watervliet Use Vocera to call Watervliet House Supervisor and complete the blue hard copy Associate Injury and Illness Report Form Lakeland Medical Practices Notify Supervisor who will use a landline and call the nearest site s STIK line (269) ( STIK line for SJ, Niles STIK line for Niles, and Watervliet House Supervisor for Watervliet and complete the blue Associate Injury and Illness Incident Report form The STIK responder (AH&W representative or a House Supervisor) will call laboratory for the STIK kit (including two yellow SST tubes) An exposure packet will be included in the STIK kit from the Lab. These packets are sequentially numbered and MUST be used for hospital based exposures For non-hospital based medical offices and clinics, a non-hospital based exposure follow up form MUST be used Per Michigan s First Responder law, an additional informed consent is not required from the source patient in the event of an exposure to blood or OPIM, as long as the patient remains under Lakeland s care The source patient will be tested immediately for Hepatitis B and C, and HIV per MIOSHA Standards The blood for HIV Medical Surveillance testing will be processed stat HIV (ELISA) Lab will call the HIV results to: Saint Joe STIK line using Vocera and fax order and result to Niles/Berrien Niles STIK line using Vocera and fax order and result to Watervliet Call House Supervisor using Vocera and fax order and result to Lakeland Medical Practices Notify Supervisor who will call the nearest site s STIK line and complete the blue Associate Injury and Illness Incident Report form Blood sample MUST be received in the treating laboratory within one (1) hour of original exposure If stat test is positive for HIV, the Infectious Disease physician must be contacted stat. Further confirmation testing will be done as needed If the exposure is to a known HIV contaminated source or a highrisk patient (i.e., IV drug abuser, multiple sex partners, homosexual, hemophiliac, etc.), the Infectious disease physician MUST be notified immediately of the exposure for consideration of post exposure prophylaxis.

11 All positive rapid HIV tests will be sent to the local health department for Western blot confirmation Hepatitis testing results will available within 24 business hours and will be phoned to the Exposed person per Associate Health and Wellness Any positive tests will result in baseline testing and follow up at: 6 weeks 3 months, and 6 months. Associate is responsible to follow up by contacting Associate Health and Wellness if exposure happens after office hours, to confirm that exposure has been reported If the needle stick/moist body substance exposure has resulted in an emergent injury (i.e. bleeding, laceration, etc.), the exposed person should be sent to the Emergency Department for treatment. THE Safety Call Out is NOT to be sent with the person to the Emergency Department If the exposed person wishes to have any lab work drawn, or to receive any injections, he/she should contact Associate Health and Wellness between 8 am to 5 pm and /or leave a voice message. The exposed person should NOT be sent to the Emergency department for tetanus, hepatitis injection, or any routine follow up offered by Associate Health and Wellness. 1.7 Hepatitis Vaccinations must be coordinated through AHW. Any associate who declines the vaccination must sign a declination statement that will be maintained in the personnel file. If HCW has never been vaccinated: HCW should receive first Hepatitis injection immediately and no later than seven days after exposure. If Source Patient is Hep B surface antigen positive (HBsAG) OR Unknown, the HCW should also receive hepatitis B immune globulin (HBIG) as soon as possible. 1.8 The exposed person will be notified of all of the lab results either by Associate Health and Wellness and/or the Infectious Disease Physician. 2. For non-lakeland based associates (including, but not limited to, non- Lakeland based medical offices/clinics, law enforcement, contractors, medical instrument reps, students, visitors, etc.) the following procedures must be followed Immediately do one of the following: Needle sticks and cuts must be cleaned with soap and water for at least 10 seconds Splashes to the nose, mouth, or skin must be flushed with water for at least 10 seconds Eyes must be irrigated with clean, tepid (16-38 C ( F) water, saline or sterile irrigate under low pressure for at least 15 minutes (ANSI Z ) Person is to be directed to the Emergency Department 2.3. Emergency Room staff will call STIK Line using Vocera immediately for information and instruction Saint Joe Call STIK line using Vocera Nile Call Niles STIK line using Vocera Watervliet Call Watervliet House Supervisor using Vocera Lakeland Medical Practices Notify Supervisor who will use a landline and call the nearest site s STIK line at (269) (call STIK line for SJ, call Niles STIK line for Niles, and call Watervliet House Supervisor for Watervliet) and complete the blue Associate injury report.

12 2.4. Emergency Room staff will complete the Needle stick/body Substance Exposure for Non-Lakeland based HealthCare Employees (NS ). Form located in STIK Kit and Emergency Department Requires Date/Time of exposure and physician signature Upon completion, form will be scanned into ChartMaxx and paperwork sent to employer of non-lakeland employee who had been exposed Emergency Room staff will call laboratory for the STIK kit (including two yellow SST tubes) An exposure packet will be available from the Lab. These packets are sequentially numbered, so they MUST be used Per Michigan s First Responder law, an additional informed consent is not required from the source patient in the event of an exposure to blood or OPIM, if the patient remains under Lakeland s care The source patient will be tested immediately for Hepatitis B and C, and HIV per MIOSHA Standards The blood for HIV Medical Surveillance testing will be processed stat for HIV (ELISA) Blood sample MUST be received in the treating laboratory within one (1) hour of original exposure The rapid HIV test will be phoned to the Emergency Room physician If stat test is positive for HIV, the Infectious Disease physician must be contacted stat. Further confirmation testing will be done as needed If the exposure is to a known HIV contaminated source or a highrisk patient (i.e., IV drug abuser, multiple sex partners, homosexual, hemophiliac, etc.), the Infectious Disease physician MUST be notified immediately of the exposure for consideration of post exposure prophylaxis All positive rapid HIV tests will be sent to the local health department for Western blot confirmation Hepatitis testing results will available within business hours and will be phoned to the health department, who will follow-up with the exposed person Client Services will notify supervisor of non-lakeland employee, about the exposure Non-Lakeland employee is responsible to follow-up with the primary care physician. And to determine if the care is covered under Workers Compensation. Lakeland HealthCare reserves the right to alter, amend, modify or eliminate this policy/procedure at any time without prior notice in accordance with HR Policy - Human Resources Policy Administration. Original: 04/95 Reviewed: 07/96, 10/96, 01/97, 05/97, 09/97,06/98, 04/99, 01/00, 08/02, 07/05, 01/07, 08/11, 01/12 Revised: 07/96, 10/96, 01/97, 05/97, 09/97, 04/99, 01/00, 08/02, 08/11, 01/12

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21 Contact INFORMATION for Infectious Disease PhysicianS And Infection PreventionistS To reach someone by Vocera, please dial , then give the first and last name of the person you wish to contact. Medical Director of Infectious Diseases, Infection Prevention and Control Infectious Disease Hospitalists Outpatient Infectious Disease Clinic Dr. John Froggatt Dr. Richard Douce Dr. Mark Harrison Dr. Michael Wang VOCERA PAGER OFFICE PHONE CELL FAX Occasionally Preferred Yes Yes Yes Dr. Meredith Wierman Infection Preventionists Berrien Lakeland Continuing Care Center Niles St. Joseph Watervliet Linda Helm RN CIC lhelm@lakelandregional.org Petra Woods RN pwoods@lakelandregional.org Jim Rockhill RN CIC jrockhill@lakelandregional.org Julie Langdon RN jlangdon@lakelandregional.org Sandra Daignault RN sdaignault@lakelandregional.org Theda Koshar RN CIC tkoshar@lakelandregional.org Yes Yes Associate Health and Wellness St. Joseph Office