Infection Prevention & Control Procedure Manual for Community Aged Residential and Long Term Care Facilities

Transcription

1 Contents Introduction... 5 Purpose... 5 Scope... 5 Associated Documents... 5 Specialist advice... 5 Outbreaks... 5 Abbreviations used in this document Infection Prevention & Control Management Organisational Support Responsibility IPC Programme IPC Committee and Personnel Policies and procedures IPC education Standard Precautions Elements of standard precautions Hand Hygiene Why hand hygiene is important Hand hygiene methods Alcohol-Based Hand Rub (ABHR) Hand washing When to perform hand hygiene How to perform hand hygiene Alcohol-based hand rub: Hand washing: Hand hygiene products Ref: Page 1 of 63 Version: 1

2 3.5.1 Figure 2. How to perform hand hygiene Hand hygiene facilities Hand care Personal Protective Equipment (PPE) Gloves Gowns/aprons Masks Eye protection and face shields Removing PPE Respiratory Hygiene / Cough Etiquette Transmission-based Precautions and Isolation Contact Precautions Droplet Precautions Airborne Precautions Common conditions requiring transmission-based precautions Use of isolation Principles of isolation Multidrug Resistant Organisms Definitions Mode of transmission Communication of MDRO MDRO Surveillance Isolation requirements and control measures General preventive measures MDRO clearance Outbreak Management Gastroenteritis Influenza Single Use Items The Safe Use and Disposal of Sharps Ref: Page 2 of 63 Version: 1

3 11. Blood and Body Fluid Exposure First aid Collecting blood samples Reporting the incident Management of Body Substance Spills Sanitising powder or granules (not carpets and soft furnishings) Hypochlorite (bleach) method (not carpets and soft furnishings) Management of Spillages on Soft Furnishing and Carpet Cleaning the Environment Cleaning responsibilities Cleaning frequencies High touch and low touch surfaces Cleaning methods Cleaning products Cleaning equipment PPE and hand hygiene Monitoring and audits Linen and Laundry Laundry separation and sorting Handling used linen Laundry areas Outbreak laundry practices Waste Management Decontamination of Shared Clinical Equipment The Spaulding classification of risk Equipment Surveillance Risk factors for infection Types of surveillance Surveillance processes Ref: Page 3 of 63 Version: 1

4 17.4 Data Collection Attributing an infection Surveillance definitions Analysing and Reporting Antimicrobial Stewardship Implementation Food Safety Legal requirements Principles of food safety Personal Hygiene Hand hygiene and glove use Food worker illness Clean - clean hands and surfaces often Separate don t cross contaminate Cook - cook to the safe internal temperature Chill refrigerate promptly Management of Urinary Devices Indwelling urinary catheters IPC principles Managing catheter bags Urine samples Measurement and Evaluation APPENDIX A Agency Outbreak Coordination Checklist Ref: Page 4 of 63 Version: 1

5 Introduction Healthcare facilities that provide 24-hour care are required to have available written policies and procedures for the prevention and control of infection (NZS34.3.3:2008). Purpose The purpose of this procedure manual is to provide a resource for aged residential and long term care facilities which reflects current accepted good practice and relevant legislative requirements procedures for infection prevention and control. Scope It is anticipated that community facilities use this resource to update their own policies and procedures. Further sections and chapters may be added to the manual in further reviews. The manual has been written by the CDHB community IPC team. Associated documents Specialist advice CDHB Community Infection Prevention & Control team Infection Control Southern Canterbury Health Laboratories Outbreaks CDHB Infection Prevention & Control IPC Checklist - Agency Outbreak Coordination Infection Prevention & Control considerations for transfer of patients with suspected or confirmed Norovirus from CDHB acute care to LTCF or ARC. Available CDHB IPC Policies and Guidelines CDHB ARC LTCF Respiratory Outbreak IPC Guidelines (2016). Available CDHB IPC Policies and Guidelines New Zealand Guidelines for the Management of Norovirus Outbreaks in Hospitals and Elderly Care Institutions (2009) Abbreviations Ref: Page 5 of 63 Version: 1

6 IPC ARC LTCF MDRO MRSA ESBL VRE CPO ABHR PPE BBFE ppm Infection prevention & control Aged residential care Long term care facility Multidrug resistant organisms Methicillin-resistant staphylococcus aureus Extended spectrum betalactamase producing organisms Vancomycin Resistant Enterococci Carbapenemase producing organisms Alcohol based hand rubs (includes alcohol hand sanitisers e.g. foam, gel, spray) Personal protective equipment Blood and body fluid exposure Parts per million e.g. 1000ppm chlorine 1. Infection Prevention & Control Management 1.1 Organisational Support Organisational support is required for effective infection prevention and control (IPC) with systems and resources in place to facilitate the implementation and compliance monitoring with IPC. There shall be an organisational culture, which promotes patient safety and quality improvement, so that the risk of infection to consumers, service providers, and visitors is minimised. 1.2 Responsibility The responsibility and accountability for IPC shall be clearly defined and understood, including relationships between management, quality and risk management, clinical governance, the IPC committee and the IPC personnel. Ref: Page 6 of 63 Version: 1

7 1.3 IPC Programme The organisation shall have an IPC programme in place, which meets the standards set out in NZS :2008 Health and Disability Services (Infection Prevention & Control) Standards: 1.3 The organisation has a clearly defined and documented infection control programme that is reviewed at least annually. 1.4 The infection control programme is developed in consultation with relevant key stakeholders, taking into account the risk assessment process, monitoring and surveillance data, trends, and relevant strategies. The governing body/senior management shall approve the programme. Key elements of an IPC programme include: Defined responsibility and accountability for IPC within the organisation Written policies and procedures An education programme for staff Surveillance and monitoring infections 1.4 IPC Committee and Personnel The organisation shall have a group of people that oversee the IPC programme, with representation from IPC stakeholders across the organisation. In a smaller facility this committee may be part of another established committee e.g. quality, health and safety. There shall be a named person whose role is to implement the programme e.g. IPC nurse, IPC officer. The person shall be allocated dedicated hours to undertake their IPC role. Ref: Page 7 of 63 Version: 1

8 1.5 Policies and procedures IPC policies and procedures shall be reviewed at least 2-3 yearly and reflect current best practice. Policies shall meet accepted standards of practice and any required legislation. Policies and procedures shall be practical and easy to implement, appropriate to the service provided and easily accessible to staff. New staff shall be familiarised with IPC policies and procedures as part of their induction programme. 1.6 IPC Education IPC education shall be delivered internally by a person who has this knowledge (usually the IPC nurse/officer) or externally by an expert IPC advisor. The person appointed this role should ensure their knowledge is current through undertaking additional learning opportunities e.g. journal articles, local study days, national conference, academic institution course, on-line learning modules in IPC. All staff shall receive IPC education and training as part of their orientation to the organisation/facility. This shall include training in The 5 Moments for Hand Hygiene All staff should receive an annual update in IPC. 2 Standard Precautions All people potentially harbour infectious agents. Standard precautions refer to those work practices that are applied to everyone, regardless of their perceived or confirmed infectious status and ensure a basic level of infection prevention and control. Implementing standard precautions is a first-line strategy to minimise cross infection. Standard precautions are used by healthcare workers to prevent or reduce the likelihood of transmission of infectious agents from recognised and unrecognised sources of infection. These sources of (potential) infection include blood and other body fluid secretions or excretions (excluding sweat), non intact skin or mucous membranes and any equipment or items in the care environment which are likely to become contaminated. Ref: Page 8 of 63 Version: 1

9 Standard precautions should be used in the handling of: blood (including dried blood); all other body substances, secretions and excretions (excluding sweat), regardless of whether they contain visible blood; non-intact skin; and mucous membranes. Standard precautions should be applied at all times because: people may be placed at risk of infection from others who carry infectious agents people may be infectious before signs or symptoms of disease are recognised or detected, or before laboratory tests are confirmed in time to contribute to care people may be at risk from infectious agents present in the surrounding environment including environmental surfaces or from equipment there may be an increased risk of transmission associated with specific procedures and practices. 2.1 Elements of standard precautions Standard precautions consist of: hand hygiene, before and after every episode of patient contact the use of personal protective equipment respiratory hygiene and cough etiquette the safe use and disposal of sharps routine environmental cleaning reprocessing of reusable medical equipment and instruments aseptic non-touch technique waste management appropriate handling of linen Ref: Page 9 of 63 Version: 1

10 Patient-care tip Encourage residents in their role of minimising infections risk through basic hand hygiene and cough etiquette 3 Hand Hygiene Hand hygiene is the principal method of preventing the transmission of infection and is part of standard precautions used with all residents. Hand hygiene refers to any action of hand cleansing that reduces the number of microorganisms on hands. Effective hand hygiene, using soap and water, antiseptic hand wash or alcohol based hand rubs, gel, foam or wipes, has been proven to reduce the spread of infection. 3.1 Why hand hygiene is important Any pathogenic microorganism transmitted by contact or droplet can potentially be transmitted by touch. The hands of healthcare workers are a common source of transmission of these microorganisms that are acquired during patient care activities. Good hand hygiene can reduce the risk of healthcare-associated infections to residents and staff, including multi drug resistant organisms. Encouraging hand-hygiene practices among residents can decrease microorganism transfer within the facility and the risk of healthcareassociated infection. Staff need to be educated on effective hand hygiene and hand care. Gloves are not a substitute for hand hygiene. All staff shall receive training in The 5 Moments for Hand Hygiene. 3.2 Hand hygiene methods Alcohol-Based Hand Rub (ABHR) When hands are not visibly soiled, alcohol based hand rub solutions are almost always preferred over soaps for hand hygiene in healthcare settings. There are several reasons for this preference: Ref: Page 10 of 63 Version: 1

11 ABHR have greater efficacy in terms of reducing bacterial load on hands ABHR can be used repeatedly at the point of care and do not require the additional time to find and use a basin The availability of ABHR at the point of care has been repeatedly associated with improvement in hand hygiene compliance Alcohol-based hand products come in several formats, rub, gel, foam or wipe. ABHR is the preferred method for decontaminating hands. Using ABHR is better than washing hands (even with an antibacterial soap) when hands are not visibly soiled. However, hand washing with soap and running water must be performed when hands are visibly soiled. If running water is not available, use moistened towelettes to remove the visible soil, followed by alcohol-based hand rub Hand washing Most transient bacteria present on the hands are removed during the mechanical action of washing, rinsing and drying hands. Hand washing with soap and running water must be performed when hands are visibly soiled. 3.3 When to perform hand hygiene Hand hygiene should be performed before and after every episode of patient contact and after activities that may cause contamination. Appropriate opportunities and moments when hand hygiene should be performed is described in the World Health Organisation 5 Moments for Hand Hygiene, a strategy adopted by Hand Hygiene New Zealand. This strategy aims to: protect patients from transmission of infectious agents from the hands of healthcare workers help to protect patients from infectious agents (including their own) entering their bodies during procedures protect healthcare workers and the healthcare surroundings from acquiring patients infectious agents Ref: Page 11 of 63 Version: 1

12 The 5 Moments state that hand hygiene should be undertaken: 1. before touching a patient 2. before a procedure 3. after a procedure or body fluid exposure risk 4. after touching a patient 5. after touching a patient s surroundings Other opportunities for hand hygiene include: before and after eating after routine use of gloves after handling any used instruments or equipment after going to the toilet when visibly soiled or perceived to be soiled between procedures on the same resident 3.4 How to perform hand hygiene Alcohol-based hand rub: Remove hand and arm jewellery. Jewellery is very hard to clean, and hides bacteria and viruses from the antiseptic action of the alcohol. Ensure hands are visibly clean (if soiled, follow hand washing steps). Apply between 1 to 2 full pumps of product onto one palm - enough to provide full coverage of hands. Spread product over all surfaces of hands, concentrating on finger tips, between fingers, back of hands, and base of thumbs. These are the most commonly missed areas. Ref: Page 12 of 63 Version: 1

13 Hand washing: Rub hands until product is dry. This will take a minimum of 15 to 20 seconds if sufficient product is used. Remove hand and arm jewellery. Jewellery is very hard to clean, and hides bacteria and viruses from the mechanical action of the washing. Wet hands with warm (not hot) water. Hot water is hard on the skin, and will lead to dryness. Apply liquid or foam soap. Do not use bar soap in health care settings as it may harbour bacteria that can then be spread to other users. Vigorously lather all surfaces of hands for a minimum of 15 seconds. Removal of transient or acquired bacteria requires a minimum of 15 seconds mechanical action. Pay particular attention to finger tips, between fingers, backs of hands and base of the thumbs. These are the most commonly missed areas. Using a rubbing motion, thoroughly rinse soap from hands. Residual soap can lead to dryness and cracking of skin. Dry hands thoroughly by blotting hands gently with a paper towel. Rubbing vigorously with paper towels can damage the skin. Turn off taps with paper towel to avoid recontamination of your hands (NOTE: If hand air dryers are used, hands free taps are necessary). Hands need to be thoroughly dried following washing with liquid soap and water. Refer also Figure Hand hygiene products Selecting the correct hand-hygiene product is essential in ensuring the hands of staff members are adequately cleaned and disinfected if necessary. HHNZ recommends that ABHR solutions should meet the EN1500 testing standard for bactericidal effect Generally, products meeting this standard have an ethanol concentration of at least 70% volume/volume (v/v) or a 60% concentration of isopropyl alcohol. Choose a dispenser that is user friendly and can be made easily available where placed. Ref: Page 13 of 63 Version: 1

14 The ABHR should contain an emollient that prevents skin drying without leaving the hands tacky Figure 2. How to perform hand hygiene See figure 2 overleaf: Ref: Page 14 of 63 Version: 1

15 Ref: Page 15 of 63 Version: 1

16 3.6 Hand hygiene facilities Easy access to hand-hygiene facilities enables staff to clean their hands more reliably. There should be adequate hand wash basins provided in key clinical areas Hand wash basins should be of an adequate size for effective hand washing have hands free taps and paper towels. The tap spout should not issue water directly down the drain in order to minimise splashing risk. ABHR containers should be placed close to all resident rooms and in other key areas including the entrance reception area for visitors to access. 3.7 Hand care Take care of your hands by regularly using a protective hand care cream or lotion at least daily. Use your own approved (compatible with soap/alcohol rub and gloves) hand cream or a pump-action communal one. Never use tubs of cream that everyone puts their hands into they grow bacteria really well! Keep your hands and skin in good condition. Sore chapped hands will have millions more germs in the cracks that will be difficult to remove. It is not necessary, or advised, to routinely wash hands with soap and water and to also apply alcohol hand rub. Do not use hot water to rinse your hands. After hand rubbing or hand washing, let your hands dry completely before putting on gloves. 4 Personal Protective Equipment (PPE) The employer has the responsibility to provide employees, clients and visitors with protection against infectious materials. They are specifically designed for use when there is contact with blood, body fluids, secretions and excretions, draining wounds, mucous membrane and non-intact skin. Choosing products should be based on the following criteria: availability safety and reliability uniformity cost-effectiveness Ref: Page 16 of 63 Version: 1

17 Educational materials and in-servicing when appropriate for proper use of the purchased PPE should be considered mandatory for all personal protective equipment. The extent of the education materials and in-servicing required is dictated by the particular equipment selected. 4.1 Gloves Gloves are worn for procedures where there is a risk of exposure to blood or body substances. Types of gloves: Sterile - used for aseptic procedures where there is contact with susceptible sites (e.g. catheterisation). Non-sterile - used for procedures that involve contact with non-intact skin and mucous membranes (e.g. assisting with toileting) or potential contamination of body substances (e.g. emptying a catheter bag). Also used for aseptic non-touch technique procedures such as wound dressings. Reusable utility - used for non-care activities (e.g. general cleaning, cleaning contaminated surfaces). Gloves are not needed for every client care activity. Purchase of gloves is a major expense for any care facility. It is important to consider reliability, supply and suitability for the task. The cheapest glove is not always the most economical. Conversely, the most expensive glove is not always the highest quality. Gloves must be: Disposable, single use Approved for medical use to protect against exposure of blood, body fluids any other contaminates Available in multiple sizes: small, medium and large. Sizing must be appropriate to provide adequate protection. An ill-fitted glove can be a hazard for the health care worker resulting in impaired dexterity and possible needle stick injury Good quality (have a leakage rate of < 5%) Ref: Page 17 of 63 Version: 1

18 Appropriate for the intended use non-sterile for routine practices and sterile for invasive procedures Available in dispensers that can be wall mounted for quick and easy access by health care workers, clients and visitors Serious consideration should be given to the universal use of non-latex (vinyl or nitrile) powder- free gloves to protect patients and staff against possible anaphylactic reactions to latex. Reusable general purpose gloves that are commonly used for cleaning and disinfection of environmental surfaces or for equipment cleaning (i.e. rubber gloves) should be dedicated to individual staff members. Procedure gloves are meant to be an additional protective measure and are not a substitute for hand hygiene. Gloves need to be changed and hand hygiene practiced between clients, or when moving from one area of the body to another. Gloves should be changed based on time and usage. They are used for a task with a client and then removed immediately to prevent transmission of disease-causing organisms. The risk of not only transmission but also contamination of surfaces within the environment exists with the improper use of gloves. Gloves may also be a skin irritant in hands and should not be overused. 4.2 Gowns/aprons Fluid resistant gowns/aprons should be worn by all healthcare workers when: close contact with the patient, materials or equipment may lead to contamination of skin, uniforms or other clothing with infectious agents; or there is a risk of contamination with blood, body substances, secretions or excretions (except sweat). The type of apron or gown required depends on the degree of risk, including the anticipated degree of contact with infectious material and the potential for blood and body substances to penetrate through to clothes or skin: a clean non-sterile apron or gown is generally adequate to protect skin and prevent soiling of clothing during procedures and/or patient-care activities that are likely to generate splashing or sprays of blood or body substances; and Ref: Page 18 of 63 Version: 1

19 a fluid-resistant apron or gown should be worn when there is a risk that clothing may become contaminated with blood, body substances, secretions or excretions (except sweat). Gowns and aprons must be changed and disposed of between patients. Single-use plastic aprons are recommended for general use when there is the possibility of sprays or spills, to protect clothes that cannot be taken off. Aprons should be: impervious /fluid resistant single-use, for one procedure or episode of patient care disposable Gowns are used to protect the healthcare worker from contamination with blood, body substances, and other potentially infectious material. Gowns should be: Single-use Disposable Choice of sleeve length depends on the procedure being undertaken and the extent of risk of exposure of the healthcare worker s arms If a fluid-resistant full-body gown is required, it is always worn in combination with gloves, and with other PPE when indicated. Full coverage of the arms and body front, from neck to the mid-thigh or below, ensures that clothing and exposed upper body areas are protected. Unused gowns and aprons should be stored in an appropriate area away from potential contamination. Aprons and gowns should be removed in a manner that prevents contamination of clothing or skin. The outer, contaminated, side of the gown is turned inward and rolled into a bundle, and then discarded. Perform hand hygiene. 4.3 Masks There are a variety of healthcare masks available that offer different levels of protection to the wearer. The level of protection is usually indicated on the box; in Ref: Page 19 of 63 Version: 1

20 most circumstances in ARC a barrier level 1 surgical (droplet/procedure) mask is adequate for staff protection. A higher level of respiratory protection may be required if the facility has a resident with active pulmonary tuberculosis, measles or chicken pox. In this instance staff are required to wear a particulate respirator (N95/P2) mask when entering the room of an infectious resident. Masks and eye protection should be worn where appropriate to protect the mucous membranes of the eyes, nose and mouth during procedures and client care activities likely to generate splashes or sprays of blood, body fluids, secretions or excretions. The choice of mask must be: Manufactured to healthcare standards Large enough to cover nose and mouth with visor where appropriate (and eyes where appropriate) Available in several sizes Labelled for use as droplet, procedure or surgical. Comfortable Fluid resistant (most inclusive product) Easy to use (i.e. loops vs strings) User friendly: allows easy access to product with minimal hand contact with packaging and other contents Disposable and used only for a single-patient episode of care A variety of products may be necessary to accommodate different clinical environments. Staff shall be trained in the correct method to put on and remove a mask. If N95 respirator/p2 masks are used, staff must perform a fit-check after donning the mask and prior to entering the room. Remove the mask immediately it is not required. Handle by the straps only and perform hand hygiene after disposal. Ref: Page 20 of 63 Version: 1

21 4.4 Eye protection and face shields Eye protection and face shields are used to protect the mucous membranes of the eyes, nose and mouth during procedures and client care activities likely to generate splashes or sprays of blood, body fluids, secretions and excretions. Two types of product are generally available: goggles or eye shields which cover only the eyes and face shields which cover the entire face. Eye/face protection must be: Comfortable Easy to use Durable during regular use Must fit over prescription glasses Compatible with masks used Without visual distortion Resistant to fogging Curved around the head to prevent side splashes Of sufficient length of shield that prevents splashing/spraying into the mouth (for face shields) Available in several sizes for good fit In addition to the above, re-useable eye/face protection must: Be easily maintained/disinfected Be able to withstand the use of disinfectants without reducing visibility Have a clear protocol for cleaning and disinfection 4.5 Removing PPE Remove PPE in a manner that minimises contamination of the wearer or immediate environment. Follow these steps for removing standard PPE: Ref: Page 21 of 63 Version: 1

22 Gloves Grasp the outside of a glove with the opposite gloved hand and peel off. Hold the removed glove in the gloved hand. Slide the ungloved finger under the remaining glove at the wrist. Peel the remaining glove off over the first removed glove. Dispose of in waste bin. Perform hand hygiene Apron Unfasten or break ties at the back of the apron. Pull apron away from the neck, lifting over the head. Touching only the inside, fold or roll into a bundle Dispose of in waste bin. Mask Ref: Page 22 of 63 Version: 1 Unfasten or break ties, first from the bottom, then the top. Pull away from the face without touching front of mask. Dispose of in bin. Perform hand hygiene

23 5. Respiratory Hygiene / Cough Etiquette Respiratory hygiene and cough etiquette should be used at all times as part of standard precautions. Cough etiquette prevents the transmission of infectious diseases spread through coughing, sneezing and respiratory secretions, e.g. influenza, respiratory syncytial diseases, common cold. Staff and residents should be educated on how to use cough etiquette at all times: - cover your mouth /nose with a tissue when coughing or sneezing. Cough or sneeze into your elbow if you don t have a tissue - dispose of the tissue promptly into a waste bin - clean your hands after coughing or sneezing with soap and water or hand sanitiser The facility shall promote the use of respiratory hygiene through the provision of hand sanitiser, tissues and waste bin at the entrance. Consider posting respiratory hygiene signage for visitors during a season of high respiratory virus activity in the community and encourage visitors to not visit if they have a respiratory infection. Spatially separate residents ( one metre) who are showing signs and symptoms of respiratory infection or confine the resident to their room and implement droplet precautions. Ref: Page 23 of 63 Version: 1

24 6. Transmission-based Precautions and Isolation In some situations, standard precautions may not be sufficient to prevent transmission of an infectious disease or a multi-drug resistant organism. In these cases it may be necessary to use additional infection prevention & control precautions known as Transmission-based Precautions. Transmission-based precautions are always used in addition to standard precautions as a second tier of IPC measures. There are three types of transmission-based precautions: contact precautions (for diseases spread by direct or indirect contact), droplet precautions (for diseases spread by large particles in the air), and airborne precautions (for diseases spread by small particles suspended in the air). Each type of precautions has some unique prevention steps that should be taken, but all have standard precautions as their foundation. 6.1 Contact Precautions Used for residents that have an infection that can be spread by contact with the person s skin, mucous membranes, faeces, Ref: Page 24 of 63 Version: 1

25 vomit, urine, wound drainage, or other body fluids, or by contact with equipment or environmental surfaces that may be contaminated by the resident or by his/her secretions and excretions. Examples of infections/conditions that require contact precautions: Salmonella, scabies, some MDRO. In addition to standard precautions, wear an apron/gown and gloves when undertaking cares that involve bodily fluids, ulcers, wounds, or stoma, or touching a potentially contaminated piece of equipment or environmental surface. A single room with an ensuite is preferable, although two or more residents with the same disease may share toilet and bathroom facilities. Isolation of the resident is advised for communicable diseases e.g. gastroenteritis, scabies for infectious period, but may not be necessary for MDRO colonisation. In cases of MDRO where the resident does not require isolation but may move around freely in their home, encourage the resident to clean their hands on exiting their room. 6.2 Droplet Precautions Used for residents that have an infection that can be spread through close respiratory or mucous membrane contact with respiratory secretions. Examples of infections/conditions that require droplet precautions: influenza, N. meningitidis (one of the causes of meningitis), pertussis (also known as whooping cough ), and rhinovirus (also known as the common cold ). In addition to standard precautions, wear a mask upon room entry of a resident on droplet precautions. A single resident room is preferred. If not available, spatial separation of more than 3 metres and drawing the curtain between beds is especially important. Residents should remain in their room (isolation) while symptomatic and may exit freely when deemed non-infectious. Ref: Page 25 of 63 Version: 1

26 Residents on droplet precautions who must be transported outside of the room should wear a mask if tolerated and follow respiratory hygiene/cough etiquette. 6.3 Airborne Precautions Used for residents that have an infection that can be spread over long distances when suspended in the air. These disease particles are very small and require special respiratory protection and a single room. Examples of infections/conditions that require airborne precautions: chickenpox, measles, and pulmonary tuberculosis. In addition to standard precautions, wear a N95 mask or particulate respirator prior to room entry. Staff who are immune to measles and chickenpox are not required to wear a mask. Place the resident in an airborne infection isolation room a singleperson room that is equipped with special air handing and negative ventilation capacity. If the facility does not have a special ventilation room, place the person in a private room with the door closed. When possible, non-immune healthcare workers should not care for residents with vaccine preventable airborne diseases e.g. measles and chickenpox. 6.4 Common conditions requiring transmission-based precautions DISEASE TYPE OF PRECAUTIONS INFECTIVE MATERIAL DURATION OF PRECAUTIONS Cellulitis if Exudate Standard Pus Duration of Illness Chickenpox (varicella) Airborne & Contact Lesion exudate and cough Until lesions are crusted Clostridium difficile Contact Faeces Duration of Illness Conjunctivitis (viral) Contact Purulent Exudate Duration of Illness Gastroenteritis (bacterial) e.g. Campylobacter, Standard Faeces Duration of illness Ref: Page 26 of 63 Version: 1

27 DISEASE Salmonella, Shigella TYPE OF PRECAUTIONS Incontinent residents own toilet INFECTIVE MATERIAL DURATION OF PRECAUTIONS Head lice Contact Lice For 24 hours after start of effective antibiotics Hepatitis B & C Standard Body and Body Fluids Herpes Simplex Standard Lesion secretions from infected sites Influenza Droplet Respiratory secretions Norovirus Pertussis (Whooping cough) Pneumonia Respiratory viruses e.g. parainfluenza, rhinovirus Contact & Droplet Droplet Standard Droplet Faeces and vomitus Respiratory secretions Respiratory secretions Until lesions are crusted Duration of illness 48 hours after last symptoms Until 5 days after commencement of antibiotics Duration of illness Rotavirus Contact Faeces Duration of illness Scabies Contact Infested area For 24 hours after start of effective antibiotics Streptococcal (Group A) Standard for minor wounds Contact for large exudating wounds and sepsis Wound exudate For 24 hours after start of effective antibiotics Ref: Page 27 of 63 Version: 1

28 DISEASE TYPE OF PRECAUTIONS INFECTIVE MATERIAL DURATION OF PRECAUTIONS Tuberculosis (infective pulmonary) Airborne Respiratory secretions Until advised by Public Health Officer 6.5 Use of isolation Isolation may result in adverse psychological effects and less than optimum care for a resident. Therefore in the residential care setting, the use of isolation should be carefully considered and only limited to situations when it is necessary to prevent harm to other residents, staff and visitors. Isolation may be required to contain communicable diseases in the following situations: During an infectious outbreak For diseases spread through the droplet or airborne routes For diseases spread through faeces and vomitus where the resident is incontinent When an infectious wound exudate is unable to be contained with a dressing 6.6 Principles of isolation a) Educate the resident and their family on the reason for isolation and their own responsibilities b) Communicate isolation requirements to all staff c) Put on PPE prior to entering the room d) Remove PPE in the room and clean hands prior to exiting (exception is N95/P2 mask which is only removed outside the room) 7. Multidrug Resistant Organisms Aged residential care (ARC) facilities are an important reservoir for multidrug resistant organisms (MDRO) transmission within the community. In the ARC setting, there are frequent transfers between the acute hospital setting and back to the rest home. Although MDROs are often first introduced to ARC facilities from acute care Ref: Page 28 of 63 Version: 1

29 facilities, they persist more strongly in ARC facilities that lack effective infection prevention & control. This along with an over-use of antibiotics in the community can lead to a higher prevalence of MDRO in ARC. As in hospitals, prudent antibiotic use in the community setting is an essential element in the control of antibiotic resistance. Even if a resident does not usually receive antibiotics, the resident is still at risk of picking up an MDRO if a lot of antibiotics are used within the facility. Managers, nurses and carers who work in a residential care facility all have apart to play in reducing the amount of antibiotics used and minimising the increase and spread of MDRO. 7.1 Definitions MDRO: Multidrug resistant organisms (MDRO) are defined as bacteria that have become resistant to more than one class of antimicrobial agents and usually are resistant to all but one or two commercially available antimicrobial agents, complicating treatment of illnesses they cause. MRSA: multiple resistant (or methicillin resistant) Staphylococcus aureus (MRSA) ESBL: Extended beta lactamase (producing organisms) CRE/CPO: Carbapenem-resistant enterobacteriaceae / carbapenemase producing organisms VRE: Vancomycin-resistant enterococcus Colonisation: the presence of microorganism in /on the body without sign of infection Infection: The deposition and harmful multiplication of microorganism in tissues or on the surface of the body, followed by signs and symptoms of clinical illness 7.2 Mode of transmission The reservoirs for MDRO bacteria are the skin for MRSA and the gastrointestinal tract for ESBL, VRE and CRE/CPO. The transmission of MDRO s is by direct contact through transient contamination of staff members hands from one resident to another or through indirect contact with contaminated equipment or environmental surfaces. Ref: Page 29 of 63 Version: 1

30 7.3 Communication of MDRO MDRO positive results should be communicated by the laboratory or GP to the clinical manager of the facility. If the resident is admitted to the facility with a known MDRO infection or colonisation, the receiving care facility should be informed prior to the transfer or admission. Residents who are colonised with and MDRO should not be denied entry into the receiving care facility on the basis of their MDRO status. Decolonisation therapy should not be required prior to transfer 7.4 MDRO Surveillance The facility should include surveillance for MDRO cases as part of their annual IPC programme. The surveillance should be appropriate for the facility concerned. Surveillance data should be analysed monthly to identify cross-infection or crosscolonisation. A low endemic infection rate is <1 per 1000 resident days A high rate of endemic infection is > 1 per 1000 resident days An outbreak is > 3 infections in a week, or twice the number of infections in a month than has been observed in the previous three months For a high rate or MDRO outbreak consultation with an experienced IPC expert is recommended 7.5 Isolation requirements and control measures Control measures for MDRO should reflect the incidence of MDRO in the facility. For ARC facilities without infections caused by MDRO in the preceding year, and few, if any, colonised patients, no additional control measures are advocated. Residents infected or colonised with MDRO should not be placed in rooms with debilitated, non-ambulatory patients who are at greatest risk of becoming colonised or infected. Single rooms, if available, and cohorting strategies should be used judiciously to minimise dissemination of MDRO from patients shedding large numbers of organisms into the environment, such as residents with colonised Ref: Page 30 of 63 Version: 1

31 wounds not fully covered with dressings, incontinent residents with urinary or faecal carriage, or colonised residents with tracheostomies and difficulty handling respiratory secretions. Residents colonised with MDRO should not be restricted from participation in social or therapeutic group activities or be restricted for dining rooms unless there is reason to think that they are shedding large numbers of bacteria and have been implicated in the development of infection in other residents. Strict isolation and other restrictions of movement should be reserved for instances where residents may be shedding large numbers of organisms into the environment (e.g. uncontrolled faecal incontinence, large wounds not contained with dressings) and who are also linked epidemiologically with other residents who acquired infections with the same strain of MDRO. Refer also 6.5 and 6.6 for details of isolation procedures. 7.6 General preventive measures Hand hygiene is the single most effective means of preventing the spread of MDRO Standard precautions used for all residents Environmental cleaning resident s room to be cleaned last with designated cleaning cloths and mops for that resident s room. Clean down any communally shared equipment after use, including hoists, B/P cuffs etc. Laundry - communal linen such as towels and bed sheets to be washed separately using thermal and chemical disinfection process as per the NZ laundry standards (AS/NSZ 4146:200 Laundry). Residents personal clothing to be washed separately to other residents. Wound care for wounds positive for MDRO use Contact Precautions (gloves and apron/gown) for wound cares, either the resident s room or in a clean utility room. All equipment such as dressing trolley, surface work area to be cleaned down followed by a disinfection wipe down after use. 7.7 MDRO clearance Clearance of MDRO in ARC residents is not routinely recommended Ref: Page 31 of 63 Version: 1

32 There are no standardised guidelines for the clearance of MDRO that colonise the gastro-intestinal tract e.g. ESBL, CPO or VRE MRSA clearance of positive residents may be advised in the following situations: As part of the clinical care for a resident to reduce their infection risk from MRSA As part of outbreak control measures MRSA eradication in the elderly is difficult to achieve due to a number of factors: physiological changes of the skin immunosuppression due to medications occurrence of skin tears or pressure injuries intolerance to decolonisation treatment 8. Outbreak Management Residential care facilities are at risk of infectious outbreaks due to the vulnerability of residents to become ill, the increased number of residents residing within a facility and the provision of care by others who may indirectly act as a source of infection. The most common types of outbreaks reported from residential care facilities are gastroenteritis, influenza / viral respiratory illness and skin infections. Outbreak management has been defined as the process of anticipating, preventing, preparing for, detecting, responding [to] and controlling outbreaks in order that health and economic impact is minimised (ESR 2002). Please refer to the CDHB IPC Checklist - Agency Outbreak Coordination to ensure your facility have communicated to the relevant agencies for reporting and management of outbreaks. 8.1 Gastroenteritis The most common cause of gastrointestinal infection in care homes is Norovirus although other viruses such as Rotavirus and Astrovirus have also been responsible for outbreaks. Norovirus is transmitted from person-to-person via the droplet or faecal-oral route and contaminated environment or equipment. Facilities should refer to the Ministry of Health document, Guidelines for the Management of Norovirus Outbreaks in Hospitals and Elderly Care Institutions available at on the MOH website. Ref: Page 32 of 63 Version: 1

33 Facilities are required to report all gastroenteritis outbreaks to their local Public Health department. 8.2 Influenza Outbreaks of viral respiratory illness mainly occur during the winter season, with most attributed to influenza. Other respiratory pathogens have also been attributed to outbreaks in elderly institutions, including parainfluenza and the coronavirus group. Influenza can result in significant morbidity among the elderly, including pneumonia and many affected residents are admitted to acute care services. In the Canterbury region, the CDHB and SCL have developed a guideline for obtaining laboratory confirmation of a respiratory outbreak CDHB ARC LTCF Respiratory Outbreak IPC Guidelines There are no national guidelines for the management of seasonal influenza outbreaks in healthcare facilities; however the following international guidelines are good resources: 1. A Guide to the Control of Respiratory Infection Outbreaks in Long-Term Care Homes Ontario Canada, Respiratory illness in residential and aged care facilities Guidelines and information kit Updated May 2017 Victoria, Australia 9. Single Use Items Single use items shall be used in accordance with the manufacturer instructions. There are two categories of single use items: Single use: Use only once. Not to be cleaned or otherwise reprocessed for use on another resident Single resident use: to be used only by one patient, e.g. urinary collection bag. Single use items are clearly identified by the manufacturer and the packaging will display a single use symbol Ref: Page 33 of 63 Version: 1

34 10. The Safe Use and Disposal of Sharps The safe handling, use and disposal of sharps is necessary to prevent injury and the possible transmission of disease to staff, residents, visitors and other health professionals. Sharps may be contaminated by biological substances (e.g. blood, microorganisms) and other hazardous substances (e.g. medications, chemicals). All sharps, unless known to be sterile, should be considered contaminated. Sharps are best disposed of at the point of use so always take a sharps container to the resident s room or clinical are where the sharp will be generated. Patient-care tip Take a sharps container on a trolley to the resident s room when administering a sub cutaneous injection with an exposed needle Ensure that sharps are immediately placed into a sharps container after use, or placed into a kidney dish if not disposed of immediately. Don t resheath, remove or bend used needles. Most sharps injuries occur when attempting to manipulate a used needle. Don t overfill sharps containers. The practice of compacting sharps by shaking the container, or forcing more sharps into an already full container can lead to a sharps injury. Always use a sharps container that meets Australian and New Zealand standards (AS/NZS 4261:1994). Follow the local procedure for blood and body fluid exposures if a needle-stick or sharps injury occurs. Ref: Page 34 of 63 Version: 1

35 11. Blood and Body Fluid Exposure Healthcare workers are at risk of an exposure to blood or body fluids that may arise from a percutaneous injury with a contaminated sharp instrument e.g. needle-stick injury, or as a result of body fluid splash to the eyes, mouth or other mucous membranes. The recipient of the exposure (staff member) may be at risk of acquiring a bloodborne disease if the source of the body fluid is infectious. The risk will depend on the type of the exposure and the carrier status of the source person for blood borne viruses. A blood and body fluid exposure (BBFE) shall be considered an incident and reported using the organisation s incident reporting procedure. The facility should have a BBFE kit readily available in the event of a BBFE 11.1 First aid a) Encourage bleeding from the wound b) Cleanse vigorously with copious soap and water (alcohol based rinses or foams should be used if water is not available) c) Cover the wound with an adhesive water proof dressing d) If eyes, nose or mouth become contaminated, rinse thoroughly with clean running water or saline Collecting blood samples a) Both the source and the recipient should be tested for blood-borne viruses, Hepatitis B, Hepatitis C and HIV.Collect the BBFE kit if available. If no kit is available refer to the local community laboratory instructions for which blood samples to take. b) If permission is granted, take a blood sample from the source (resident or other person). c) Take a blood sample from the recipient (staff member) to test for baseline Hepatitis B immunity and other blood borne viruses. d) Complete the laboratory request forms as per the instructions and send with the blood samples urgently to the community laboratory. e) Contact an infectious diseases specialist if the source is known to be HIV or Hepatitis C or B positive or for further advice or information. Ref: Page 35 of 63 Version: 1

36 f) Staff results are generally sent to their GP not the facility management Reporting the incident All staff should be aware of the BBFE policy and who to contact/report to in the event of an exposure. The BBFE should be reported as an incident and followed up as soon as possible. Corrective actions arising from the incident shall be used to improve practice and prevent similar incidents. 12. Management of Body Substance Spills Spillages of blood and high-risk body fluids must be dealt with quickly and effectively. Disposable gloves and an apron must be worn for cleaning body fluid spillage and the contaminated debris treated as clinical waste. Chlorine-releasing agents can be a hazard especially if used in large volumes, in confined spaces or mixed with other chemicals or urine. Protective clothing must be worn and the area must be well ventilated Sanitising powder or granules (not carpets and soft furnishings) Wearing protective clothing, cover spillage with granules Leave for at least two minutes. Scoop up the debris with paper towels and/or cardboard. Wash the area with general purpose detergent and water and dry thoroughly. Dispose of all materials as per clinical waste. Clean the bucket/bowl with fresh soapy water and dry. Discard protective clothing and wash hands Hypochlorite (bleach) method (not carpets and soft furnishings) Wearing protective clothing, soak up excess fluid using disposable paper towels. Ref: Page 36 of 63 Version: 1

37 Remove organic matter using the towels and discard as clinical waste. Clean area with general purpose detergent and water and disinfect the area for example with Milton or bleach releasing agent (see dilution below) Clean the bucket/bowl in fresh soapy water and dry. Discard protective clothing and wash hands 12.3 Management of Spillages on Soft Furnishing and Carpet Detergent and water method Wearing protective clothing mop up organic matter with paper towels or disposable cloths. Clean surface thoroughly using a solution of general purpose detergent and water and paper towels or disposable cloths. Rinse the surface and dry thoroughly. Dispose of materials as clinical waste. Clean the bucket/bowl in fresh warm, soapy water and dry. Steam clean Discard protective clothing and wash hands. 13. Cleaning the Environment Regular and efficient cleaning is necessary to maintain the appearance and function of the premises. A clean environment also facilitates the prevention and control of infections and contributes to the quality and safety of residents, staff and visitors. Cleaning is a process, using general-purpose detergent and hot water (55-60 C), to physically remove contaminants, including dust, soil, large numbers of microorganisms (germs) and the organic matter (e.g. faeces, blood) that protects them. Micro-organisms are always present in the environment and all staff in care homes have a responsibility to ensure that inanimate objects (e.g. furniture, wheelchairs, commodes, shower chairs etc.) in the care home environment are decontaminated properly between residents to minimize the risk of cross infection to residents, staff and visitors. Ref: Page 37 of 63 Version: 1

38 Published cleaning standards should be used as a resource for the facility s cleaning protocols and procedures Cleaning responsibilities The facility manger or designated cleaning manager shall undertake to: Set the standard of cleanliness to be achieved Identify who has overall charge of cleaning Produce a robust cleaning schedule Formulate a cleaning schedule that must: o o o o o Have a clear breakdown of the allocation of responsibilities for cleaning all areas within the home (residents rooms, communal areas, toilets, bathrooms etc.) Clearly identify who s responsibility it is for cleaning these areas and for regularly used residential equipment items such as wheelchair, commodes, hoists, shower chairs etc. State the areas and frequency of cleaning activities e.g. daily, weekly, monthly, annually. Include clear cleaning instructions following a discharge, isolation, terminal and deep cleaning activities. Include colour coding of cleaning materials / products available for different areas Ensure routine and managerial cleaning audits take place a process through which cleaning services are checked efficiency Include a timeframe for rectification of cleaning problems and resolution Include operational and training policies and procedures (ensuring all staff have received appropriate training prior to being allocated to specific cleaning tasks) Include training for all cleaning service staff in infection control policies and procedures Record resident cleaning satisfaction evaluations to promote service user and visitors confidence Ref: Page 38 of 63 Version: 1

39 All staff have a responsibility to help keep the home clean and tidy and to identify areas which fall below acceptable or safe standards Cleaning frequencies There are several factors that influence the frequency of cleaning: Are the surfaces high touch or low touch? For example a doorknob will require more frequent cleaning than a window sill. What type of activity is taking place in the specific area and are there risks associated with that activity? For example, a hospital care area where the residents frequently receive wound care is more likely to have high-risk activities than an office area. How vulnerable are the patients/residents in the area? Patients with indwelling catheters, PEG feeding tubes etc. may be more susceptible to infection than a patient or resident in another unit. What s the likelihood that the area is going to be contaminated with body fluids under normal circumstances? This may vary depending on the setting. High and low risk areas should be identified and documented High touch and low touch surfaces High touch surfaces are those that have frequent contact with hands. Examples: doorknobs, elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards, etc. High-touch surfaces in care areas require more frequent cleaning than minimal contact surfaces. Cleaning is usually done at least daily and more frequently if the risk of environmental contamination is higher e.g. during outbreaks. Ref: Page 39 of 63 Version: 1

40 Photo shows high touch surfaces Photo shows high touch surfaces Low touch surfaces are those that have minimal contact with hands. Examples: floors, walls, ceilings, mirrors and window sills. These surfaces require cleaning on a regular (but not necessarily daily) basis, when soiling or spills occur, and when a resident is discharged from the health care setting. Ref: Page 40 of 63 Version: 1

41 13.3 Cleaning methods Establish a cleaning pattern that will ensure that all surfaces are being cleaned and you will know where you left off if you are interrupted during cleaning. Work from the highest point towards the lowest, from the outside to the inside and from the cleanest area toward the dirtiest area. This greatly reduces the risk of cross contamination. Highest point and work towards the lowest From the outside to the inside From the cleanest to the dirtiest 13.4 Cleaning products Cleaning remains the single most effective way of reducing the risk of infection from the environment and the routine use of a disinfectant is unnecessary except in outbreak situations or in isolation rooms. Without cleaning first, it may not be possible to disinfect properly. Use the following types of product for routine day-to-day cleaning activities: - Cream cleaner or a hard surface cleaner is usually suitable for cleaning baths, toilets and hand washbasins. - A neutral general-purpose detergent is recommended for other environmental cleaning. Detergent wipes for example, can be used for those items that cannot be immersed e.g. wheelchairs Ref: Page 41 of 63 Version: 1

42 Whilst the appropriate choice of cleaning products is important, an equal amount of importance is placed on the actual physical removal of micro-organisms and visible dirt / debris by wiping, scrubbing or brushing. In the event of an infectious outbreak or for isolation rooms, a chlorine releasing agent to a concentration of at least 1:1000ppm is generally recommended or a combined detergent and disinfectant product. All cleaning products must be accessible, prepared, stored, applied and disposed of in line with manufacturing instructions and local health and safety policy Cleaning equipment The cleaning equipment that is regularly used should be fit for purpose, easy-to-use and well-maintained. Single-use cloths shall be disposed of after use. Cleaning equipment should be thoroughly cleaned following use and the cleaner s trolley should be stored appropriately (not in the dirty utility room). Vacuum cleaners should be equipped with HEPA filters. Filters should be cleaned regularly or replaced as per equipment manufacturer instructions. Use microfibre floor mops with disposable or washable heads Colour coding cleaning equipment is good practice with mops, buckets and cloths coloured coded to reflect the different areas of the facility. An example is given below (NHS National Patient Safety Agency 2009) Ref: Page 42 of 63 Version: 1

43 13.6 PPE and hand hygiene Protective gloves and a plastic apron shall be worn by cleaning staff Hand hygiene shall be performed on removal of gloves Monitoring and audits Monitor the standard of cleanliness through regular audits by appropriately qualified staff. The audit process should encourage quality improvements and should not be punitive Audits should be conducted as a joint exercise between the staff responsible for cleanliness, infection prevention and control and management, as well as service users. Establish a regular auditing schedule using a standardised audit tool. Informal monitoring should take place in areas where standards are considered poor or where routine monitoring reveals consistent weaknesses. Auditors need to exercise discretion in judging the acceptability of any element. For example, one or two scuff marks on a floor or an isolated smudge on a window should not indicate that the element should necessarily be scored as unacceptable. 14. Linen and Laundry Used linen within healthcare settings can harbour large numbers of potentially pathogenic microorganisms. Linen should be managed correctly to minimise the risk of cross infection through handling, sorting, washing, drying and storage. The management of linen and laundry shall comply with AS/NZS 4146:2000 Laundry practice 14.1 Laundry separation and sorting All laundry and linen is sorted at point of use. Remove any resident bulk faecal matter in the resident s room and discard into the resident s ensuite toilet Place used linen in basket/trolley to transport to laundry Take used linen to the dirty side of the laundry Ref: Page 43 of 63 Version: 1

44 14.2 Handling used linen A disposable plastic apron should always be worn when handling used linen (and disposable gloves where linen is soiled/foul) e.g. during bed making. Always hold used linen away from yourself to avoid contamination of clothing from linen Hand hygiene should be performed following handling of linen and removal of apron 14.3 Laundry areas All washing of linen is in a dedicated space. The following points apply to dedicated laundry areas: staff do not consume food or beverages in laundry areas there are dirty and clean areas with a dirty-to-clean workflow floors and walls are made of durable materials that can withstand the rigors of the laundry area (i.e., water/steam resistant) where possible, the ventilation system directs the flow of air from the clean area to the contaminated/soiled area (and not vice versa) Clothes driers should be vented to the outside hand hygiene facilities are located in all laundry work areas laundry equipment is used and maintained according to manufacturers instructions gross soil is removed before washing and proper washing and drying procedures are used cloth linen bags (if used) are washed after each use and can be washed in the same cycle as the linen contained in them clean laundry is sorted, packaged, transported and stored by methods that will ensure their cleanliness and protect them from dust and soil Ref: Page 44 of 63 Version: 1

45 14.4 Outbreak laundry practices During a gastrointestinal outbreak, infectious laundry may be a source of cross infection. It is important that linen is laundered at the correct temperatures (according to AS/NSZ 4146:2000 Laundry) to ensure that any organisms are killed. Out-sourcing of linen during an outbreak is advised for the following reasons: The facility s washing machines do not have a high temperature cycle The facility s laundry environment is not designed to handle an infectious stream of line e.g. it is small, cramped, has no-where to segregate infectious linen etc. 15. Waste Management Approved containers must be available for the disposal of: Used Sharps Biological waste and contaminated martials (e.g. used dressings) Discarded single use equipment. Follow the local council waste management policy The waste management standards Waste disposal area The facility management is responsible for waste generated onsite continues until and including the actual disposal. Bins must be Weather safe and secure against animals and vermin Emptied on a needs basis at least weekly Secured for public access Waste bags Black bag for general waste Yellow for clinical waste and potentially infectious waste Ref: Page 45 of 63 Version: 1

46 Handling waste Waste bags must never be braced against the body or dragged across the floor Waste bags must not be compacted by hand or feet 16. Decontamination of Shared Clinical Equipment The level of reprocessing (decontamination) of clinical equipment is based on the risk of infection posed by reuse on subsequent residents The Spaulding classification of risk The Spaulding classification should be used as a general basis for the risk assessment. The site of use (e.g. skin, mucous membranes, and wounds) is a key determinant of level of risk to the patient. Level of risk Application Process Examples Critical Semi critical Non critical Entry or penetration into sterile tissue, cavity or bloodstream Contact with intact nonsterile mucosa or non-intact skin Contact with intact skin Sterility is required Chemical disinfection Thermal disinfection e.g. laundering Clean as necessary with detergent and water None in ARC/LTCF Wound care items such as forceps, scissors Glass thermometer Hoist sling used for showering BP cuff 16.2 Equipment Clinical equipment that is shared between residents shall be cleaned after each use. Most equipment surfaces can be adequately cleaned with warm water and detergent as per manufacturer s instructions. Cleaning may be followed by disinfection when an infection is known or suspected. Use a hospital grade disinfectant or as per manufacturer s instructions. Equipment that comes in contact with non-intact skin or likely to become contaminated with blood or body fluids should be dedicated to one resident only e.g. hoist sling for showering. Ref: Page 46 of 63 Version: 1

47 Examples of shared clinical equipment include: Thermometers Blood pressure equipment Hoists Shower chairs Commodes 17. Surveillance Surveillance is defined in the New Zealand Health and Disability Services Infection Prevention & Control Standards. Systemic surveillance refers to the regular collection, collation and analysis of information on infection events and rates, either continuously or at regular intervals, and the timely dissemination and feedback of data (NZS :2008) Surveillance activities shall be included in the organisation s IPC programme and dedicated time and resources allocated to the collection and analysis of surveillance data. All staff shall be encouraged to report infection events to the IPC nurse or person delegated to undertake infection surveillance Risk factors for infection Infections in the ARC/ LTCF population have been associated with high rates of morbidity and mortality, rehospitalisation, extended hospital stay and substantial healthcare expenses. Risk factors that predispose older adults to infections include: the presence of indwelling devices recent admission to an acute care facility functional impairment multiple comorbidities There are also specific risk factors associated with infections arising in residents in ARC/LTCFs: Ref: Page 47 of 63 Version: 1

48 residents are clustered in a confined living arrangement daily activities often take place in groups some residents are cognitively impaired and unable to follow basic hygiene precautions caregivers are often inadequately trained and may have little knowledge of the fundamental principles of infection prevention and control understaffing is a common problem in ARC It is often difficult to diagnose infections in the elderly 17.2 Types of surveillance The facility shall choose the type of surveillance that is appropriate for the organisation including: Size Types of services provided Acuity, risk factors and needs of residents Risk factors Surveillance should be performed for infections for which there are clear strategies that can be implemented for prevention and control of transmission. Surveillance activities may need to target those infections in a facility that have the most potential for prevention. Monitoring should also include infections that are associated with a high likelihood of transmission and development of outbreaks (e.g., norovirus, influenza, Group A Streptococcus, acute viral hepatitis). Specific infection events or all events facility-wide are usually chosen by ARC/LTCF. The infections described within the McGeer criteria are suitable for ARC/LTCF surveillance; however the following infections are commonly monitored: Respiratory tract infections Skin and soft tissue infections Urinary tract infections Eye infections Multidrug resistant organisms both colonisation and infection Ref: Page 48 of 63 Version: 1

49 Outbreaks o Gastro-intestinal o Influenza and other upper respiratory tract infections o MDRO Unusual organism e.g. toxigenic Group A Streptococcus 17.3 Surveillance processes Surveillance activities include: Collecting relevant data Managing data Analysing and interpreting data Communicating results Data should be regularly collected, at least monthly. Analysis and calculation of rates should occur annually or more frequently if an increase is noted. Surveillance should form part of an organisation s quality improvement process with timely follow up of any corrective actions Data Collection Methods for collecting data are varied: Paper forms - may be organisational e.g. same forms for a group of ARC facilities Electronic data entry Computerised surveillance using surveillance software o There are some private organisations that provide an electronic surveillance service for ARC/LTCF. These have the capability to benchmark Attributing an infection For infection surveillance purposes, infections should be attributed to a LTCF onset if: Ref: Page 49 of 63 Version: 1

50 (a) there is no evidence of an incubating infection at the time of admission to the facility (on the basis of clinical documentation of appropriate signs) (b) onset of clinical manifestation occurs >2 calendar days after admission Surveillance definitions Standardised definitions should be applied at all times. It is recommended that the McGeer Criteria are applied for ARC HAI. As outlined in the McGeer Criteria, three important conditions should be met when applying these surveillance definitions: All symptoms must be new or acutely worse. Many residents have chronic symptoms, such as cough or urinary urgency, which are not associated with infection; however, a new symptom or a change from baseline may be an indication that an infection is developing. Alternative non-infectious causes of signs and symptoms (e.g., dehydration, medications) should generally be considered and evaluated before an event is deemed an infection. Identification of infection should not be based on a single piece of evidence but should always consider the clinical presentation and any microbiologic or radiologic information that is available. Microbiologic and radiologic findings should not be the sole criteria for defining an event as an infection. Similarly, diagnosis by a physician alone is not sufficient for a surveillance definition of infection and must be accompanied by documentation of compatible signs and symptoms. Refer to the McGeer Criteria for detailed definitions for specific infections Analysing and Reporting Infections in ARC/ LTCF are usually reported as rates and shall be documented as the rate of infection per 1,000 resident/occupied bed days. The formulary for this is: Number of infections x 1,000 = Rate of infection per 1,000 Numbers of occupied bed days 1 resident/occupied bed days. Ref: Page 50 of 63 Version: 1

51 Outbreak surveillance In the event of an outbreak the figures from this are not included in the monthly surveillance numbers. It is recommended that a separate report be done detailing the course of the outbreak together with the number of resident/staff affected. These figures shall be further broken down separately into residents and staff and presented as a percentage. The formulary for this is: Number of infections x 100 = % affected Number of residents/staff 1 The collated information and analyses together with the action/recommendations resulting from this shall be reported to infection control and management personnel in a timely manner. A surveillance report should be presented to the IPC committee annually. 18. Antimicrobial Stewardship Improving the use of antibiotics in healthcare protects patients and reduces the threat of antibiotic resistance. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Antibiotics are among the most frequently prescribed medications in nursing homes with many antibiotics prescribed as unnecessary or inappropriate. Antibiotic overuse may cause harm for the frail and older adults receiving care in nursing homes, including risk of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions, and colonisation and/or infection with antibiotic-resistant organisms Implementation Management should demonstrate support and commitment to safe and appropriate antibiotic use in the facility. They should create a culture, through messaging, education, and celebrating improvement, which promotes antibiotic stewardship. The infection prevention and control coordinator has access to data to inform strategies to improve antibiotic use. This includes tracking of antibiotic courses, the management of treated infections, and reviewing antibiotic resistance patterns in the Ref: Page 51 of 63 Version: 1

52 facility. When infection prevention coordinators have training, dedicated time, and resources to collect and analyse infection surveillance data, this information can be used to monitor and support antibiotic stewardship activities. Identify clinical situations which may be driving inappropriate courses of antibiotics such as asymptomatic bacteriuria or urinary tract infection prophylaxis and implement specific interventions to improve use. Monitor clinical outcomes such as rates of C. difficile infections, antibiotic-resistant organisms or adverse drug events to demonstrate that antibiotic stewardship activities are successful in improving patient outcomes. Engage residents and their family members in antibiotic use and stewardship education to ensure clinicians have their support to make appropriate antibiotic use decisions. Working with residents and families will reduce the perception that their expectations may be a barrier to improving antibiotic use in nursing homes. 19. Food Safety Older people are more likely to suffer from food poisoning and become ill because aging weakens the immune system s ability to fight infection. So it is important to take extra care when dealing with food intended for people in residential care Legal requirements On 1 st March 2016 the laws around food safety changed with the introduction of the Food Act Under this Act anyone who provides food as part of a service must comply with the law this includes healthcare facilities which provide food services. The facility must register with their local council or the Ministry of Primary Industries (MPI) and produce a written food control plan. MPI provides a template for the plan which helps you to identify and manage food safety risks on a day to day basis. More information on food control plans and meeting the legal requirements can be found on the MPI website Principles of food safety Underpinning these principles are four core practices within the kitchen environment. Clean, Separate, Cook and Chill Ref: Page 52 of 63 Version: 1

53 There are three basic principles that food handlers are required to have training in: Personal hygiene for food handlers Time & temperature control Prevention of cross contamination 19.3 Personal Hygiene Food workers must observe the highest possible standards of personal hygiene to make certain that food does not become contaminated by pathogenic microorganisms, physical or chemical hazards. Things to consider for personal hygiene include the following: Hand hygiene and hand washing facilities Glove use Food worker illness policy Hair and jewellery Sticking plasters Uniform/clothing wear clean outer clothing Protective clothing Personal cleanliness Eating, drinking, smoking, or spitting habits Staff toilets / changing room Hand hygiene and glove use Hand hygiene is the best way for food handlers to get rid of illness-causing bacteria and viruses, so they are not transferred from hands to food. Hand hygiene may be performed using soap and water or an alcohol based hand rub/gel/foam. The correct method for hand hygiene shall be performed Refer Section 3- Hand Hygiene. Food handlers are expected to wash their hands whenever their hands are likely to contaminate food. This includes washing their hands: Ref: Page 53 of 63 Version: 1