Guideline with MDRO or C-Diff Patient Age Group: ( ) N/A (x ) All Ages ( ) Newborns ( ) Pediatric ( ) Adult

Applies To: UNM Hospitals Responsible Department: Epidemiology Revised: 7/2012 Title: Management of Patients Infected or Colonized Guideline with MDRO or C-Diff Patient Age Group: ( ) N/A (x ) All Ages ( ) Newborns ( ) Pediatric ( ) Adult DESCRIPTION/OVERVIEW Multidrug-Resistant Organisms (MDRO) are becoming increasingly prevalent in healthcare settings. These organisms have a propensity to cause infection in patients with defects in their normal host defenses, especially those being treated with broad-spectrum antibiotics. Hospitals and long term care facilities are currently the major environment for acquisition and spread of these organisms. Infections with MDRO or C. difficile are major causes of patient morbidity, mortality, increased healthcare costs, and increased length of stay. This policy addresses Methicillin-Resistant Staphylococcus aureus (MRSA), Staphylococcus aureus with reduced susceptibility to vancomycin (VISA and VRSA), Vancomycin- Resistant Enterococcus (VRE), Multidrug-Resistant Gram-Negative Rods (MDR-GNR), carbapenemresistant Enterobacteriaceae (CRE) and Clostridium difficile infections (CDI). AREAS OF RESPONSIBILITY It is the responsibility of the University of New Mexico Health Sciences Center Infection Control Committee (UNMHSC ICC) to oversee this policy and make changes when indicated. It is the responsibility of the Epidemiology Department to provide expert advice to the UNMHSC ICC, to monitor incidence and prevalence of MDRO and CDI, and to take appropriate steps to control outbreaks. It is the responsibility of all health care workers to adhere to hand hygiene and isolation guidelines, especially given that the major mode of spread of many of these organisms is via the hands of health care workers. In addition, health care workers are encouraged to support good infection control practices in their fellow workers. It is the responsibility of all practitioners to use antibiotics judiciously as the use of broad-spectrum antibiotics is known to increase the likelihood of infection with antibiotic resistant bacteria GUIDELINE PROCEDURES 1. Surveillance: 1.1 The Infection Control Practitioner(s) will be notified by the microbiology laboratory and/or computer generated reports when an MDRO is identified. 1.2 The Infection Control Practitioner(s) will keep a record of each positive culture and determine if it is community-acquired or nosocomial. The information collected related to each positive culture will include patient s name, medical record number, hospital location. Additional information will be collected depending on the organism. 1.3 The Infection Control Practitioner(s) will ensure that the patient is placed in appropriate precautions. A note will be placed in the patient s electronic medical record noting the date, what type of culture i.e. blood, urine etc., and organism in the Problems and Diagnosis list. Once this is recorded, the Epidemiology Department should receive a notice when this patient is readmitted noting a previous history of MDRO and will notify the staff if continuing precautions are required (see criteria for continuing isolation for each type of organism below). 1.4 Increases in the incidence of MDRO will be relayed to the Hospital Epidemiologist. Rates will be reported to the Infection Control Committee. 1.5 Active surveillance testing for Methicillin Resistant Staphylococcus aureus (MRSA) is conducted in the adult intensive care units and the neonatal intensive care unit. Nares swabs are obtained on all admits to the adult ICUs and all discharges and transfers, Title: Management of Patients Infected or Colonized with MDRO or C-Diff Owner: Epidemiology Page 1 of 13

including newly deceased patients, when the patient has not had a previous positive test during the current admission. Admission, transfer, and discharge swabs in adult ICUs are screened using a rapid polymerase chain reaction assay (PCR). Neonatal swabs are performed using selective agar cultures. Patients in the neonatal ICU are tested weekly during their hospitalization. When a patient is found to be colonized or infected with an MDRO, they are placed on Contact Precautions for their entire hospitalization. 2. Precautions: Patients infected or colonized with MDRO will be cared for following CDC guidelines. When a patient is infected or colonized with MDRO the following protocol will apply (additional precautions apply for patients with C. difficile infection, S. aureus with reduced susceptibility to vancomycin or carbapenem-resistant Enterobacteriaceae-see below) 2.1 Patients should be placed in Contact Precautions in a private room with a private bath whenever possible. Patient care equipment should be dedicated to this patient or properly cleaned before use on other patients. Environmental contamination is common. If a private room is not available, patients can be cohorted with other patients with the same MDRO. 2.2 Zonal care should be used in patient care areas where the patient must be housed with patients that do not have an MDRO. Patients with CDI are not to be cohorted. Precautions will be maintained until patients are shown to be free of infection or colonization of MDRO. 2.2.1 Contact Precaution requirements include: 2.2.1.1 A door sign is used to inform staff and visitors of the need to follow Contact Precautions. Contact precautions 1 (CP1) are indicated by a green sign and are used for MRSA, VRE, and MDR-GNR. Contact precautions 2 (CP2) are indicated by a tan sign. The tan sign as well as the symbols on the sign indicate the need to use soap and water for hand hygiene and for terminal room clean with hospital approved disinfectant. CP2 are only used for CDI and Norovirus. 2.2.1.2 Use gloves when entering patient rooms and during patient care. Do not wear the same pair of gloves for care of multiple patients. Remove and perform hand hygiene before exiting the patient room 2.2.1.3 Use gowns when entering patients rooms and during patient care. Do not wear the same gown for care of multiple patients. Remove gown when exiting patient room. 2.2.1.4 Use masks/goggles when patient care is likely to generate splashes of blood or body fluids, or when performing activities (e.g., suctioning) on a patient that may disperse droplet secretions. Change between patients 2.2.1.5 Visitors should be instructed on proper use of personal protective equipment and hand hygiene when visiting a patient on Contact Precautions (see Appendices). 2.2.1.6 Patients may leave their room with prior notification of staff. The patient is required to don a clean patient gown (provided by staff) and perform hand hygiene when exiting the room. Any draining wounds should be covered or reinforced. 3. Hand Hygiene 3.1 Perform hand hygiene before and after every patient contact, and after removing gloves. If hands are not visibly soiled, an alcohol based hand rub is effective. Alternatively, use soap and water to wash hands. Care of a patient with CDI requires the use of soap and water for hand hygiene as alcohol-based hand gels may not be effective against spore forming bacteria. 4. Methicillin Resistant Staphylococcus aureus (MRSA) 4.1 Patients found to be infected or colonized with MRSA will be placed on CP1 for the entire hospitalization. Patients with a previous history of MRSA colonization or infection will be placed on CP1 on readmission for a year. If it is greater than 1 year, patients will continue to require CP1 if they have a chronic history of positive MRSA cultures spanning greater than 2 years or have chronic wounds or indwelling devices (see Appendices). 4.2 Infection control will apply the above algorithm. In exceptional circumstances, infection control may advise re-screening of the patient. Screening will consist of two rapid PCR Title: Management of Patients Infected or Colonized with MDRO or C-Diff Owner: Epidemiology Page 2 of 13

screening tests of the nares, and selective agar cultures of any wounds or other previously infected sites taken one week apart. If the patient meets criteria, infection control will remove the MDRO flag from the electronic record. 5. Vancomycin Resistant Enterococcus (VRE) 5.1 Patients infected with VRE will be placed on Contact Precautions 1 for entire hospitalization. Patients with a previous history of VRE infection will be placed on contact precaution on readmission for a year. 6. Multidrug-Resistant Gram-Negative Rods (MDR-GNR ) 6.1 Multidrug-Resistant Gram Negative Rods include Extended Spectrum Beta-lactamase (ESBL), Carbapenamase-producing Enterobacteriaceae (CRE) and Multi-Drug Resistant Organisms (MDRO). MDROs are bacteria with resistance to all members of at least three classes of antibiotics used for gram-negative infections. 6.1.1 No routine screening is available to determine whether a patient is colonized with MDR- GNR. 6.1.2 Patients infected with MDR-GNR will be placed on CP1 for entire hospitalization. Patients with a previous history of MDR- GNR infection will be placed on CP1 on readmission for up to a year. After one year without any positive cultures, the patient is not required to be placed on contact precautions on readmit. 6.1.3 Carbapenamase-producing Enterobacteriaceae (CRE) are an emerging MDR-GNR that is associated with high patient morbidity and mortality. In addition, the plasmid-mediated nature of the resistance creates the potential for rapid spread between species of Enterobacteriaceae (E. coli, Klebsiella pneumoniae etc). Infection control must be notified immediately if such a case is known on transfer from another facility or suspected in the Microbiology Laboratory. Patients with CRE should be placed in CP1 and will require CP1 on readmit indefinitely. 6.1.4 When a case of CRE is identified, infection control will review the case and may conduct a point prevalence survey in units with potentially exposed patients or high-risk units to identify any additional patients colonized with CRE. 7. Clostridium difficile infection (CDI) 7.1 Patients with diarrhea should be placed on CP 2 in a private room and one diarrheal stool sample should be sent for testing. If the patient tests negative, contact precautions are not required. CP2 may be discontinued when the patient no longer has diarrhea for greater than 24 hours. Patient should be moved to a clean room and the previous room should receive a terminal cleaning with a hospital approved disinfectant for C. difficile. 7.2 Patients are not to be retested after diarrhea has stopped to determine cure. 7.3 Patients with a history of CDI are not placed on CP2 on readmit unless they have symptoms that require treatment. Routine identification of asymptomatic carriers (patients or healthcare workers) for infection control purposes is not recommended. 8. Environmental Services: 8.1 Some MDRO, such as VRE, have been shown to be capable of prolonged survival on environmental surfaces and environmental contamination seems to play a role in the spread of this organism. 8.2 Patients on Contact Precautions should have all horizontal high touch surfaces in their room and toilets, sinks and horizontal surfaces in their bathroom cleaned on a daily basis. In general, cleaning vertical surfaces is not indicated unless they are soiled. 8.3 Curtains should be cleaned as indicated for soiling. Upon discharge the precaution signs should not be removed until terminal cleaning is performed on the room including changing the curtains. 8.4 Rooms that housed a patient with CDI should be cleaned with a hospital approved disinfectant for C. difficile. 9. Outbreak Management: 9.1 An outbreak is defined as a greater than usual number of cases of a specific infection and/or organism in a period of time. The expected incidence is defined by routine hospital Title: Management of Patients Infected or Colonized with MDRO or C-Diff Owner: Epidemiology Page 3 of 13

surveillance and published incidence figures from the National Healthcare Safety Network (NHSN) of the CDC. 9.2 When an outbreak has been identified by Hospital Epidemiology, nursing, involved physicians, the Chair and Infection Control Committee, hospital administration and the Associate Dean for Clinical Affairs will be notified in writing or by email. 9.3 Specific interventions will be initiated to control the outbreak. Interventions might include, but will not be limited to reinforcing infection control practices, increasing barrier precautions, cohorting and culturing of staff and patients to identify the reservoir and treat colonized individuals. 10. Treatment of MDRO: 10.1Infections with MDRO will be treated as clinically indicated. In general, attempts to eradicate colonization with MRSA are not indicated. 10.2 Preoperative and routine bathing with chlorhexidine based soap may be used to reduce the risk of infection but may not eradicate MRSA. 10.3 If a strong desire or rationale for decolonization exists, an infectious disease consult is suggested. 11. Management of Patients Colonized or Infected with Staphylococcus aureus with Reduced Susceptibility to Vancomycin (VISA and VRSA) 11.1 Vancomycin resistant S. aureus (VRSA) is used to describe S. aureus strains for which the vancomycin MIC 8µg/ml. Cultures with an MIC = 4-8µg/ml are designated as vancomycin-intermediate S. aureus (VISA). Appropriate antimicrobial prescribing by healthcare providers, adherence to recommended infection control guidelines, and, ultimately, the control of both MRSA and VRE are necessary to prevent further emergence of VRSA strains. 11.2 VISA are common and do not require public health notification. Patients with VISA should be placed in CP1 in a private room. Patients with VISA isolates may experience reversion to more susceptible MRSA isolates when vancomycin treatment is withdrawn. 11.3 VRSA: identification of VRSA requires public health notification. Due to the virulence of S. aureus and the reliance on vancomycin for the treatment of MRSA, CDC has issued specific infection control recommendations intended to prevent the transmission of VRSA even though infection continues to be a rare occurrence. A few existing factors seem to predispose case patients to VRSA infection, including: 11.3.1 Prior MRSA and Enterococcal infections or colonization 11.3.2 Underlying conditions (such as chronic skin ulcers and diabetes) 11.3.3 Previous treatment with vancomycin 11.3.4 VRSA patients require intensive isolation, risk assessment and screening of potential contacts. 11.4 Patients infected or colonized with VRSA must be: 11.4.1 Placed in a private room, with a private bath (they may be cohorted with other patients infected or colonized with the same organism), and cared for utilizing contact precautions. 11.4.2 Nursing staff caring for these patients may not simultaneously care for other patients who are not infected or colonized with the same organism. 11.4.3 Physicians involved in the care of the patient must be minimized, and limited to those essential for patient care. 11.4.4 Traffic in and out of the patient s room must be kept to a minimum. Only those persons essential for patient care should enter the patient s room. Ancillary staff entering and leaving the patient s room should also be limited. Phlebotomy should be done by the patient s primary nurse or MD. 11.4.5 Patients infected or colonized with VRSA will be taught to wash their hands with antimicrobial soap before leaving their room. They should only leave their room for essential purposes. Title: Management of Patients Infected or Colonized with MDRO or C-Diff Owner: Epidemiology Page 4 of 13

11.4.6 It is possible that health care workers who have cared for patients with VRSA may need to have nares and hand cultures performed to determine the possibility of carriage. This decision will be made at the time of occurrence and will be based on the best available information at that time. 11.4.7 The patient will only be transferred within the facility when the patient can no longer be cared for in the current location. 11.4.8 Once the patient has vacated the hospital room, all vertical and horizontal surfaces should be cleaned and the curtains changed. DEFINITIONS CDI- Clostridium difficile infection CP1- Contact Precautions 1: indicated by a green sign and used for MRSA, VRE, and MDR-GNR. CP2- Contact Precautions 2: indicated by a tan sign and used for CDI CRE- Carbapenamase-producing Enterobacteriaceae MDR-GNR- Multidrug Resistant Gram Negative Rod MDRO-Multidrug Resistant Organism MRSA-Methicillin Resistant Staphylococcus aureus VISA- Vancomycin Intermediate Staphylococcus aureus VRE- Vancomycin Resistant Enterococci VRSA- Vancomycin Resistant Staphylococcus aureus SUMMARY OF CHANGES Replaces Management of Patients Infected or Colonized with Antibiotic Resistant Bacteria, 5/29/09 11/2014; Reformatted RESOURCES/TRAINING Resource/Dept Infection Prevention & Control 272-0131 Contact Information DOCUMENT APPROVAL & TRACKING Item Contact Date Approval Owner Epidemiology Committee(s) Clinical Operations PP&G Committee, Nursing PP&G Subcommittee Y Nursing Officer Sheena Ferguson, Chief Nursing Officer Y Medical Director Meghan Brett, MD, Hospital Epidemiologist Y Official Approver Erin Doles, Administrator, Professional & Support Services Y Official Signature Date: 9/2008 Effective Date Origination Date 10/2002 Issue Date Clinical Operations Policy Coordinator ATTACHMENTS 1. MRSA algorithm 2. Transport of patients with MDRO 3. Environmental services 4. In-service sheet for MRSA Title: Management of Patients Infected or Colonized with MDRO or C-Diff Owner: Epidemiology Page 5 of 13

Positive History of MRSA For Patients with positive histories of MRSA please use this algorithm to determine if Contact Precautions are indicated. Please contact the 24/7 Epidemiology pager at 505.951.3000 if you have any questions. Last Updated 10/2010 Greater Than 1 Year Since Last Positive MRSA Culture Within Past Year (To Date) Place Patient in Contact Precautions Does Patient Have Evidence of Open Wounds or Soft Tissue Infection? Yes No Does Patient Have Chronic Wounds or Indwelling Devices (ex. Trach, Peg Tube)? Yes Does Patient Have Chronic History of Positive MRSA/VRE Cultures Spanning Greater Than 2 Years? Place Patient in Contact Precautions Patient Does Not Require Contact Precautions Place Patient in Contact Precautions Page 6 of 16

Transport staff must do the following when transporting patients who are in Contact Precautions: 1. Get a clean patient gown to take into patient s room 2. Clean your hands (with alcohol-based hand gel or with soap and water) before entering patient s room o To wash your hands properly, first wet your hands with lukewarm water, add soap, lather and rub hands together for at least 15 seconds, rinse with lukewarm water, and completely dry your hands with paper towels. o To use the alcohol-based hand gel appropriately, use a quarter-size amount of gel and rub all surfaces of your hands together until the gel dries. o Wash with soap and water every 4 to 5 uses of alcohol-based hand gel or when build-up of product occurs. o Wash with soap and water when your hands are visibly soiled 3. Put on yellow gown and gloves before entering patient s room 4. Place clean patient gown on patient s back like a robe 5. Have patient clean his/her hands with alcohol gel or with soap and water o If patient is unable to walk, give the patient alcohol gel from the front desk or a wet washcloth with soap on it and give it to the patient 6. Help patient into the wheelchair/stretcher outside of the patient s room o If the patient is unable to walk to the clean stretcher/wheelchair located outside of the patient s room, transport staff must take the wheelchair/stretcher into the patient s room 7. Before transporting the patient, remove your yellow gown and gloves and throw them away in patient s room. o If the patient requires close contact during transport, staff may wear gowns and gloves, but at least one transporter should be not wear PPE in order to help with doors, elevators, etc. 8. Immediately after removing the yellow gown and gloves, clean your hands (with alcohol-based hand gel or with soap and water) 9. Transport staff must gown and glove again to help the patient get out of the stretcher/wheelchair at the new location (i.e. CAT scan, MRI, X-Ray, Nursing unit, etc) 10. Please remember to inform the receiving staff (i.e. CAT scan, MRI, X-Ray, nursing unit, etc) that the patient is in Contact Precautions. 11. All stretchers/wheelchairs must be wiped down with Cavi Wipes or Virex after each patient use. Page 10 of 16

o Gloves must be worn to clean equipment o Hands must be washed after each glove removal PLEASE NOTE: The patient NEVER wears yellow gown or gloves. Transport staff should NOT wear yellow gown or gloves to transport patients, except when close contact is required during transport. The following are examples of the Contact Precaution signs and the bacteria associated with them: This green Contact Precautions sign is for MRSA (Methicillin Resistant Staphylococcus aureus), VRE (Vancomycin-resistant Enterococci) and ESBL (Extended-spectrum β- lactamase). This tan Contact Precautions sign is for Clostridium difficile (C. diff) which is a bacterium that causes a diarrheal illness. The alcohol-based hand gel does NOT kill C. diff. All staff must wash their hands with soap and water after assisting a patient who has C. diff. Page 11 of 16

Terminal Cleaning Instructions The terminal cleaning is the final and complete cleaning of a hospital room when a patient has been discharged. If you are unsure about how to properly clean a patient room, please contact your supervisor. Most of the new isolation signs are printed with English on one side and Spanish on the other side. Terminal Cleaning Instructions for Tan Contact Precautions (C-Diff) Upon patient discharge, use 10% bleach solution (or other hospital approved disinfectant) and disinfect room by wiping down all horizontal surfaces, bed frames, mattresses, furniture, restrooms, showers, counter tops and sinks. Clean the floors with Virex (or other hospital approved disinfectant). Cubicle curtains will be removed and laundered. The 10% bleach solution will be provided by your supervisor. DO NOT USE BLEACH WHILE THE PATIENT IS IN THE ROOM; USE BLEACH ONLY AFTER THE PATIENT HAS BEEN DISCHARGED. Always wear gown and gloves to clean the room. Remove gown and gloves before you leave the room and wash your hands with soap and water. DO NOT USE THE ALCOHOL GEL TO CLEAN YOUR HANDS. When you are done cleaning the room, remove the sign from the door, wipe it clean and return it to the nursing station. Terminal Cleaning Instructions for Green Contact Precautions (MRSA/VRE/ESBL) Upon patient discharge, disinfect room by wiping down all horizontal surfaces, bed frames, mattresses, furniture, restrooms, showers, counter tops, sinks and floors using a Virex solution (or other hospital approved disinfectant). Cubicle curtains will be removed and laundered. Always wear gown and gloves to clean the room. Remove the gown and gloves before you leave the room and wash your hands. When you are done cleaning the room, remove the sign from the door, wipe it clean and return it to the nursing station. Page 12 of 16

CONTACT ISOLATION PRECAUTION IN-SERVICE INFORMATION Updated procedure Explanation Additional information There are 2 Contact Precaution signs. The key differences: 1.) Green Contact Precaution signs are used for MRSA, VRE, ESBL, cystic fibrosis, large wounds. 2.) Tan Contact Precaution signs are used for Clostridium difficile ONLY. Place both English and Spanish versions of the Contact Precaution signs on the patient's door. Contact Precautions for C. difficile, requires conventional hand washing with soap and water after each patient/equipment contact AND requires a bleach (or other hospital approved disinfectant) terminal cleaning. There are times when both the tan and the green CP signs need to be posted on a patient's door, e.g. the patient has both MRSA and C. diff. If you need to know if a patient has a history of MRSA or VRE, look the patient up in Power chart. The menu bar will have Problems and Diagnoses. If the patient has a history of MRSA or VRE, it will be listed here. If you are sending stool to the lab for C. diff, post the tan Contact Precautions sign and do preemptive gowning and gloving. This is important for visitors/patients, but also for our Housekeeping staff. This will ensure Spanish speaking persons know how to adequately protect themselves. If you have a family who only speaks Vietnamese, we have translated signs for them as well. Please leave all isolation signs up on patient's door upon transfer or discharge. There are 2 different terminal cleanings: (disinfectant used may change with notice from EVS) 1.) The green Contact Precaution sign receives a terminal clean with Virex. 2.) The tan sign receives a terminal clean with Bleach because the Virex does NOT kill the Clostridium difficile spores. The alcohol-based gel does not kill Clostridium difficile either. Therefore, you must wash your hands with soap and water for at least 15 seconds. Some of the new signs have English on one side and Spanish on the other side. Therefore, hanging one of these doublesided signs is sufficient. Place isolation cart just outside of patient's room. MANDATORY gowning and gloving for every entry into the contact precaution room. Do NOT reuse your yellow disposable gowns. Upon leaving the patient's room, remove the gown and gloves and promptly wash your hands. DO NOT place isolation signs on carts. Instead, place them on the patient's door. The visibility of the cart is helpful in prompting staff and visitors to don gown and gloves accordingly. This is mandatory for all healthcare workers. This is based on the new CDC guidelines and its goal is to minimize transmission of certain bacteria (C. Diff, VRE, MRSA) to you or to the other patients on the unit. When Infection Control conducts the monthly Hand Hygiene Surveillance, Infection Preventionists are looking for compliance with protective measures. There is no way to reapply the yellow gown without contaminating yourself. The gowns are there to protect you, please use them appropriately. DO NOT place isolation signs on carts. Instead, place them on the patient's door. If you will be just going in the room to talk with the patient, you are still expected to gown and glove prior to entry. Page 13 of 16

CONTACT ISOLATION PRECAUTION IN-SERVICE INFORMATION - Continued Updated procedure Explanation Additional information Using disinfectant wipes, wipe down the patient's bed frame (side rails, head rest and foot rest), IV poles, ventilator, etc. once per shift. One set of wipes for one surface. Get new wipes when cleaning a different surface. Equipment entering CP rooms: - Clean all equipment before and immediately after use in CP room. Cleaning the patient's equipment will reduce the bioburden. Therefore, reducing transmissions of infectious diseases. Cleaning the equipment is also important for transporting the patients in their beds. Please change out wipes in between surfaces. For example, while wearing your gown and gloves, take several clean wipes and wipe down the headrest of the bed. Before moving onto one of the side rails, throw the used wipes in the trash and get a clean set of wipes to clean the side rail. Otherwise, the bacteria and spores are not being killed or wiped away. Rather, they are just being moved around and transmitted to new surfaces. Gown and gloves are required to enter the patient room. Upon leaving the patient's room, take equipment outside of the room, and immediately clean equipment using disinfectant wipes. Remove gown and gloves and perform hand hygiene before escorting the equipment elsewhere. - Please see below for proposed technique for Glucometer usage in CP room. Trash from a Contact Precaution room must be kept in the patient's room. When the patient is transferred or discharged, leave all Isolation Precaution signs up on the patient's door. (Droplet, Airborne, Contact) Use the same cleaning method as above (one set of disinfectant wipe per surface). Do not hang trash bags outside the patient's room or off of the isolation carts. Gown and gloves should be removed and placed in the trash before leaving the patient's room. Leaving the signs up does 2 things, it helps Housekeeping clean the rooms properly and it ensures that they take the appropriate precautions (PPE usage) when cleaning the room. Please post the isolation signs on the patient's room door. There are no "Respiratory Precautions". There are only Droplet and Airborne Precautions. If an MD orders "Respiratory Precautions", you must clarify the order. There is no "Neutropenic Precautions". Neutropenic patients are protected by standard precautions and the appropriate environment of care (no fresh fruit, vegetables, flowers, plants etc). "Immunocompromised patients" are covered in the infection control manual located on the UNMH intranet in policies and procedures. You will find the manual under patient services. Page 14 of 16

CONTACT ISOLATION PRECAUTION IN-SERVICE INFORMATION - Continued Updated procedure Explanation Additional information Ambulating patients in CP Patients: - Before leaving room, perform hand hygiene and dons a clean hospital gown as a robe - Before returning to the room, remove robe, place in dirty linen and performs hand hygiene Healthcare workers: - Cover any dripping, draining wounds patient may have - Wear yellow gown and gloves to ambulate patient - Only touch the patient while ambulating (to reduce environmental contamination) Patients in CP are to be restricted to their rooms as much as possible especially if they have open wounds, uncontrolled cough or diarrhea. Please do not ambulate patients in the hall who have drippy/draining wounds or diarrhea. First contain wounds and/or cover infected sites. Patient to perform hand hygiene upon coming back to his/her room and removes gown. Gown is now considered dirty, so it goes into laundry. The patient never wears the disposable yellow gown or gloves. Physical Therapists have been instructed to wear gown and gloves when ambulating patients in the halls because PT anticipates heavy contact with the patient. RN's and tech's also ambulate patients, please follow the same procedure. If you, the healthcare worker, are wearing gown and gloves outside the patient's room, please do not touch anything but the patient or the patient's equipment. Transporting patients in contact precautions using a wheelchair or stretcher: Patients: - Perform hand hygiene and don a hospital gown as a robe Healthcare workers: - Gown and glove to assist patient into the wheelchair or stretcher - Remove gown and gloves and perform hand hygiene prior to transport - At destination, perform hand hygiene and don gown and gloves to assist patient - Using disinfectant wipes, wipe down stretcher/wheelchair after transport complete Personnel transporting a patient in CP (for tests/procedures that can not be performed at the bedside) should NOT routinely need to wear PPE during transportation. If you are anticipating contact with the patient during transport, you should wear gown and gloves. However, someone who is not wearing gown and gloves and has clean hands should accompany you to open doors etc. Staff from the Transporting office has been asked NOT to wear gown or gloves when transporting patients. Departments like CT, MRI, and X-ray have PPE in their depts. Remember, the patient never wears yellow gown or gloves. Pressing buttons with your elbows is helpful. Inpatient units: If you are a sending patients to X- ray, CT Scan, MRI, Cath lab, etc., please be sure you are communicating the patient's isolation status to the receiving area, whether it is Airborne, Droplet, or Contact Precautions. Departments (CT Scan, MRI, IR or receiving inpatient units): If you will be receiving the patient, please be sure you are asking what the patient's isolation status is. Page 15 of 16

CONTACT ISOLATION PRECAUTION IN-SERVICE INFORMATION - Continued Updated procedure Explanation Additional information Transporting patients in contact precautions using a patient bed: Patients: - Perform hand hygiene and don a hospital gown as a robe (if able) Healthcare workers (there should be at least 2 healthcare workers transporting patients in a bed): - Gown and glove to enter patient's room to ready patient for transport - At least one of the transporters will remove gown and gloves and perform hand hygiene prior to transport (this transporter will be considered clean and will be responsible for contacting clean surfaces, e.g. door, elevator, etc.) - At destination, the "clean" transporter will perform hand hygiene and don gown and gloves to assist patient Disinfectant wipes may be used to clean those parts of the bed and equipment handled during patient transport. Remember healthcare workers should be wiping down the patient's bed and equipment at least once per shift. Cleaning the patient's equipment will reduce the bioburden and enables the "clean" transporter to help with transporting. Visitors - must perform hand hygiene before and after leaving the patient's room. Visitors must wear a yellow, disposable gown while in patient's room. Visitors sleeping in the CP room over night are expected to wear the yellow, disposable gown. Visitors do not need to wear gloves unless they will be performing a nurselike activity such as dressing a wound etc. Upon leaving the room, they discard their gowns and wash their hands. PSCU, PICU, Carrie Tingley inpatient and GPU are unique in that the parents of their patients live on their units until the patient goes home. The parents may be expected to gown in a different manner than other units. However, CP are still maintained. Page 16 of 16