Approval Signature: Date of Approval: October 30, 2008 Date of Revision:

PERSONAL CARE HOME/LONG TERM CARE FACILITY INFECTION PREVENTION & CONTROL PROGRAM OPERATIONAL DIRECTIVE Cleaning and Disinfecting or Reprocessing of Non-Critical Reusable Resident Equipment/Items Page: 1 of 6 Approval Signature: Date of Approval: October 30, 2008 Date of Revision: Supercedes: WRHA PCH Program Infection Control in Housekeeping & Maintenance. December 12, 2001. 1.0 PURPOSE: 1.1 To reduce the transmission of microorganisms due to contaminated noncritical reusable resident equipment/items. 2.0 DEFINITIONS: 2.1 Cleaning: The physical removal of foreign material, e.g. dust, soil and organic material such as blood, secretions, excretions and microorganisms. Cleaning physically removes rather than kills microorganisms. Cleaning reduces or eliminates the reservoirs of potential pathogenic organisms. It is accomplished with water, detergents and mechanical action. 2.2 Contamination: The presence of microorganisms on inanimate objects (e.g. clothing, surgical instruments) or microorganisms transported transiently on body surfaces (e.g. hands), or in substances (e.g. water, food, milk). 2.3 Disinfection: The inactivation of disease producing organisms. Disinfection does not destroy high levels of bacterial spores. Disinfectants are used on inanimate objects. Disinfection usually involves chemicals, heat or ultraviolet light. Levels of chemical disinfection vary with the type of product used. 2.4 Facility Approved Disinfectant: A disinfectant cleaner that has been approved by the facility/organization (Appendix A). Operational Directive: Cleaning & Disinfecting or Reprocessing of Non Critical Reusable Resident Items (Approved October 30, 2008)

PCH/LTCFs Operational Directive: Cleaning & Disinfecting or Reprocessing of Non Critical Reusable Resident Items Pg 2 of 6 2.5 Non-Critical Reusable Equipment/Items: Equipment/items that either touch only intact skin but not mucous membranes or do not directly touch the resident. Examples of non-critical reusable equipment/items include: lifts, transfer boards, wheelchairs and items such as plastic assessment tools and call bells. 2.6 Non-Critical Reusable Wipeable Items: Non-critical equipment/items composed of non-porous material able to withstand facility approved disinfectant. Examples of non-critical reusable wipeable items include: diagnostic imaging equipment, infusion pumps, IV poles, sleep surfaces, stethoscopes, walkers and wheelchairs. 2.7 Non-Critical Reusable Hard to Clean Equipment/Items: Non-critical reusable hard to clean equipment/items are composed of porous material (e.g., fabric, cardboard/paper, foam). Some examples are wheelchair cushions, puzzles, sliders, slings, craft supplies, pencils, books, magazines and transfer belts. 2.8 Personal Protective Equipment: Gloves, gowns, masks and protective eyewear and face protection used according to risk of exposure to prevent transmission of infection. 2.9 Reprocessing: The steps performed to prepare a used medical device for reuse. The steps may include the collection and transportation of soiled devices, cleaning, inspection, disinfection, sterilization, packaging, clean transportation and storage of clean and disinfected/sterilized devices. 2.10 Reusable: A device that has been designed and tested by the manufacturer that is suitable for reprocessing prior to use on a resident. 3.0 EQUIPMENT: 3.1 Required Equipment: 3.1.1 Alcohol swabs 3.1.2 Cleaning cloths 3.1.3 Facility approved disinfectant 3.1.4 Laundry detergent 3.1.5 Personal Protective Equipment (PPE), e.g. goggles, masks, plastic apron as required for the task 3.1.6 Tap water 3.1.7 Utility or non-sterile gloves 3.2 Optional Equipment: 3.2.1 Scrub brush 3.2.2 Adhesive remover 3.2.3 70% Isopropyl alcohol 3.2.4 Ready- to- use disinfectant wipes Operational Directive: Cleaning & Disinfecting or Reprocessing of Non-Critical Reusable Resident Equipment/Items (Approved Oct 30/08)

PCH/LTCFs Operational Directive: Cleaning & Disinfecting or Reprocessing of Non Critical Reusable Resident Items Pg 3 of 6 4.0 OPERATIONAL DIRECTIVES: 4.1 Refer to Cleaning of Non Critical, Reusable Items, Regional Policy # 90.00.040. 4.2. Refer to Single-use Medical Devices, Regional Policy # 90.00.010 4.3 Equipment/items dedicated to one resident are kept in the resident s room, bed space, and/or bathroom. 4.4 Clean and disinfect or reprocess all non-critical reusable equipment/items that have been in direct contact with a resident. This must be done before use in the care of another resident. 4.5 Develop and maintain a predetermined cleaning schedule according to facility/program policy for all routinely shared non-critical reusable equipment/items, which cannot be cleaned and disinfected or reprocessed between uses. 4.6 Assign responsibility and accountability for cleaning and disinfection or reprocessing according to facility/program policy. 5.0 PROCEDURE: 5.1 Gather equipment. 5.2 Inspect all non-critical reusable equipment/items for safety concerns prior to cleaning. Report any damaged items according to program policy. 5.3 Determine surface type: 5.3.1 Non-critical reusable wipeable equipment/items 5.3.2 Non-critical reusable hard to clean equipment/items Refer to Cleaning Table for Non-Critical Reusable Resident Equipment/Items in Personal Care Home/Long Term Care Facility (Appendix B) for examples to assist in determining surface type, if required. 5.4 Clean and disinfect non-critical reusable equipment/items: 5.4.1 To clean and disinfect Non-Critical Reusable Wipeable Equipment/Items: Wear PPE according to cleaning activities Use appropriate water and detergents and/or Facility Approved Disinfectant according to product directions Remove all tape. Remove any tape residue with adhesive tape remover or detergent If using reusable gloves, clean and disinfect the gloves with facility approved disinfectant after use Operational Directive: Cleaning & Disinfecting or Reprocessing of Non-Critical Reusable Resident Equipment/Items (Approved Oct 30/08)

PCH/LTCFs Operational Directive: Cleaning & Disinfecting or Reprocessing of Non Critical Reusable Resident Items Pg 4 of 6 Allow all cleaned and disinfected non-critical reusable items to air-dry prior to use in the care of another patient, following manufacturer s contact time recommendations 5.4.2 Cleaning of non-critical reusable wipeable items: Clean equipment/items with water and detergent and/or facility approved disinfectant using mechanical action Clean grooves on equipment with scrub brush Clean and disinfect scrub brush after using as per facility policy. 5.4.3 Disinfection of non-critical reusable wipeable equipment/ items After all foreign material has been removed, disinfect the equipment/items by repeating the above process with a clean cloth moistened with facility approved disinfectant or ready-touse wipe(s) Disinfection technique options: Ready-to-use disinfectant wipes Apply facility approved disinfectant to a clean cloth Avoid spraying disinfectant Avoid applying disinfectant directly onto equipment/items Allow to air-dry, following manufacturer s contact time recommendations 5.4.4 Cleaning of non-critical reusable hard-to-cleancardboard/paper items: Discard if not laminated Discard if lamination not intact Clean laminated cardboard/paper with water and detergent using mechanical action 5.4.5 Disinfection of non-critical reusable hard-to-cleancardboard/paper items: After all foreign material has been removed; disinfect the laminated cardboard/paper with a clean cloth moistened with facility approved disinfectant or ready-to-use wipe(s) Allow to air-dry, following manufacturer s contact time recommendations 5.4.6 Cleaning and disinfection of non-critical reusable hard-to-cleanfabric items: Follow manufacturer s cleaning instructions Do not add bleach unless approved by manufacturer If no manufacturer s cleaning instructions available, clean by using one of the following methods: Machine wash using gentle cycle at high temperature (>71.1 C) and machine dry if tolerated or allow to air-dry, following manufacturer s contact time recommendations Machine/hand wash at low temperatures after discussion with Infection Prevention & Control Practitioner/Professional Dry clean Discard fabric that cannot be cleaned and/or laundered Operational Directive: Cleaning & Disinfecting or Reprocessing of Non-Critical Reusable Resident Equipment/Items (Approved Oct 30/08)

PCH/LTCFs Operational Directive: Cleaning & Disinfecting or Reprocessing of Non Critical Reusable Resident Items Pg 5 of 6 5.4 7 Cleaning of non-critical reusable hard-to-clean- foam items: Items with foam components should be covered with vinyl or impermeable material prior to use Limit uncovered foam to single resident use only Discard foam that has become contaminated if it cannot be laundered Clean impermeable surface with water and detergent or facility approved disinfectant using mechanical action to remove all foreign material 5.4.8 Disinfection of non-critical reusable hard-to-clean- foam items: Disinfect impermeable surface by using one of the disinfection techniques outlined in 5.3.4 Allow to air-dry, following manufacturer s contact time recommendations 5.4.9 Cleaning and disinfection of non-critical reusable hard-to-cleanother items: Consult an Infection Prevention and Control Practitioner/designate and/or Clinical Engineer for equipment/items for which cleaning method is undetermined Equipment/items with components falling into more than one surface type will require more than one cleaning/reprocessing method 5.5 Reassemble non-critical reusable items for use after cleaning and disinfection. 5.6 Store non-critical reusable items in a designated clean area. 6.0 REFERENCES: 6.1 Centers for Disease Control and Prevention (CDC). (2003). Guidelines for environmental infection control in health-care facilities. Atlanta, GA. Originally accessed December 13, 2007 http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/enviroguide_03.pdf 6.2 Health Canada. (1998). Hand washing, cleaning, disinfection and Sterilization in health care. Ottawa, ON. Originally accessed December 13, 2007. http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/98pdf/cdr24s8e.pdf 7.0 RESOURCES: 7.1 WRHA Infection Prevention & Control Policy, Cleaning of Non-Critical Reusable Equipment/Items. Regional Policy Number 90.00.040. 7.2 Concordia General Hospital Cleaning of Non-Critical, Reusable, Resident Care Equipment. Dec. 8, 2004. Operational Directive: Cleaning & Disinfecting or Reprocessing of Non-Critical Reusable Resident Equipment/Items (Approved Oct 30/08)

PCH/LTCFs Operational Directive: Cleaning & Disinfecting or Reprocessing of Non Critical Reusable Resident Items Pg 6 of 6 7.3 Health Sciences Centre Cleaning Guidelines for Instruments & Resident Monitoring Equipment, Infusion Pumps. April 15, 2004. 7.4 Riverview Health Centre Cleaning Schedules, 2005 7.5 WRHA PCH Program Infection Control in Housekeeping & Maintenance. December 12, 2001. 7.6 WRHA Community Stroke Care Service Guidelines for Cleaning Reusable Non-Critical Resident Care Equipment. March 24, 2006. Operational Directive Contact: Betty Taylor, Manager, PCH Infection Prevention & Control Operational Directive: Cleaning & Disinfecting or Reprocessing of Non-Critical Reusable Resident Equipment/Items (Approved Oct 30/08)

PCH/LTCF Operational Directive: Cleaning & Disinfecting or Reprocessing of Non-Critical Reusable Resident Equipment/Items Appendix A Contact Times and Dilution for Cleaning Disinfection of Equipment/Items CONTACT TIME PRODUCT CLEANING DISINFECTION Percept RTU 30 seconds* 5 minutes* Percept Concentrate 30 seconds** 5 minutes*** PerDiem 30 seconds** Not a disinfectant when diluted Dilution * When used full strength ** When diluted with water 1:64 (15ml in 1L of water) *** When diluted with water 1:16 (command centre dilution) The above dilutions and contact times are for use in equipment cleaning. Follow manufacturers directions and contact times for other types of cleaning and disinfection. Operational Directive: Cleaning & Disinfecting or Reprocessing of Non Critical Reusable Resident Items in PCH/LTCFs (Approved October 30, 2008)

PCH/LTCF Operational Directive: Cleaning & Disinfecting or Reprocessing of Non-Critical Reusable Resident Equipment/Items Appendix B 1 of 3 Assignment for responsibility and accountability is in accordance with facility/program policy. Overall infection prevention and control cleaning principles for equipment/items: Inspect all non-critical reusable equipment/items for damage prior to each cleaning. Report any damaged items according to facility policy. Determine surface type. Clean and disinfect non-critical reusable items: When visibly soiled Prior to use by another resident Prior to sending for repair According to facility schedule Reassemble equipment/items. Store equipment/items: In resident s room while dedicated to a resident In a designated clean area if not dedicated Ambulation Aid crutches walkers Cleaning Table for Non-Critical Reusable Resident Equipment/Items in Personal Care Home/Long Term Care Facility Equipment/Item Surface Type Comments Hard-to-Clean More than one surface type Wipeable Bed side monitor bladder scanner Wipeable May have Hard-to- Clean components, Dedicate to one resident when possible Ensure cleaning between residents Examples of hard to clean components include screens and keyboards Blood glucose monitor Wipeable May be visibly soiled with blood Ensure visible soiling is cleaned prior to disinfection Cervical collar Electronic devices Continuous Positive Airway Pressure (CPAP) machine Portable continuous cardiac monitoring device More than one surface type Wipeable and Hardto-clean - Fabric Hard-to-clean - Other Ensure cleaning between residents Use caution with electronic connections Operational Directive: Cleaning & Disinfecting or Reprocessing of Non Critical Reusable Resident Items (Approved October 30, 2008)

PCH/LTCF Operational Directive: Cleaning & Disinfecting or Reprocessing of Non-Critical Reusable Resident Equipment/Items Appendix B 2 of 3 Equipment/Item Surface Type Comments Thermometer (electronic) Wipeable For rectal thermometers, ensure visible soiling is cleaned prior to disinfection High touch surfaces Wipeable E.g., bed rails, call cords, beds, over-bed table Infusion pump Wipeable Ensure cleaning between residents Intravenous Poles Wipable Ensure cleaning between residents Hygiene items basins jetted tub Wipeable Hard-to-clean Dedicate basin to one resident. Should be Cleaned after each use. Follow manufacturer s instructions for specific products Monitoring equipment Wipeable Ensure cleaning between residents Portable bedside equipment Continuous Passive Motion machine (CPM) o device o fabric lining Portable blood pressure machine Orthopedic heel boot plastic molded shell fabric lining Pulse oximeter (peripheral probe & cable) Pressure relief devices gel cushion pressure relief inflatable wheelchair cushion Splint More than one surface type Wipeable Hard-to-clean - Fabric More than one surface type Wipeable and Hardto-clean components More than one surface type Wipeable Hard-to-clean Fabric Wipeable Hard-to-clean - Other Dedicate to one resident when possible Ensure cleaning between residents Ensure blood pressure cuff is cleaned, disinfected and air-dried. If Velcro portion of cuff is visibly soiled, hand wash with dish soap and water. Clamp off hose ends to ensure water does not enter the cuff. Allow to air dry. Dedicate to one resident when possible Ensure cleaning between residents Ensure cleaning between residents Must check integrity of cover Wipeable if intact Follow manufacturer instructions Wipeable and hardto-clean Check for presence of fabric - Fabric Stethoscope Wipeable Ensure cleaning between residents Toileting device bed pans commodes urinal Wipeable Ensure crevices and/or grooves are cleaned and disinfected Where possible clean and disinfect in a designated soiled utility room Operational Directive: Cleaning & Disinfecting or Reprocessing of Non-Critical Reusable Resident Equipment/Items in PCH/LTCFs (Approved Oct 30, 2008)

PCH/LTCF Operational Directive: Cleaning & Disinfecting or Reprocessing of Non-Critical Reusable Resident Equipment/Items Appendix B 3 of 3 Equipment/Item Surface Type Comments Tourniquet Transferring/mobility device fabric (e.g., transfer belts/slings) plastic/metal Transferring/mobility device fabric (e.g., transfer belts/slings) plastic/metal Ventilator Single resident use only Hard-to-clean Fabric Wipeable Hard-to-clean Fabric Wipeable Hard-to-clean More than one surface type WRHA process requiring single resident use Ensure fabric portion is removed for laundering. Transfer belts/slings: machine dry at low temperature if tolerated or hang to air-dry. Ensure fabric portion is removed for laundering. Transfer belts/slings: machine dry at low temperature if tolerated or hang to air-dry. Responsibility of Respiratory Therapist Operational Directive: Cleaning & Disinfecting or Reprocessing of Non-Critical Reusable Resident Equipment/Items in PCH/LTCFs (Approved Oct 30, 2008)

Personal Care Home/Long Term Care Facility Infection Prevention and Control Program Operational Directive Management of Clostridium Difficile Associated Diseases Approval Signature: Supercedes: Page 1 of 9 Date of Approval: December 6, 2007 Review Date: Management of Clostridium Difficile (November 2003) 1.0 PURPOSE: 1.1 To prevent and/or minimize the transmission of Clostridium difficile from person to person both within the personal care home/ long term care facility and between facilities/sites within the Winnipeg Regional Health Authority (WRHA). 1.2 To ensure consistent Infection Prevention and Control practices are followed for the management of Clostridium difficile Associated Diseases (CDAD) within the WRHA personal care homes/long term care facilities. 2.0 DEFINITIONS: 2.1 Additional Precautions: Infection control precautions and practices required in addition to Routine Practices. They are determined by the mode of transmission of selected microorganisms or clinical presentation. 2.2 Cleaning: The physical removal of foreign material, e.g. dust, soil, organic material such as blood, secretions, excretions and microorganisms. Cleaning physically removes rather than kills microorganisms. It is accomplished with water, detergents and mechanical action. 2.3 Clostridium difficile (C. difficile): A gram-positive spore-forming anaerobic bacillus microorganism of the gastrointestinal tract. 2.4 C.difficile-Associated Diseases (CDAD): Illnesses include diarrhea, colitis, toxic megacolon, sepsis-like picture and death caused by C. difficile and its toxin expression. Operational Directive: Management of Clostridium Difficile Associated Diseases (Approved Dec 2007)

PCH/LTCF Operational Directive: Management of Clostridium Difficile Associated Diseases. Page 2 of 9 2.5 Clostridium difficile Associated Disease (CDAD) case definition: Acute onset of diarrhea (3 or more loose stool that takes the shape of the container that holds it, within a 24 hour period) without another etiology; and laboratory confirmation (positive Clostridium difficile toxin, culture with evidence of toxin production or histological/pathological diagnosis of CDAD); or diagnosis of typical pseudo-membranes on endoscopy (sigmoidoscopy or colonoscopy); or diagnosis of toxic megacolon supported by diagnostic imaging. 2.6 Clostridium difficile Associated Disease (CDAD) Nosocomial Case (current facility): Resident s initial symptoms occur greater than 48 hours (2 or more days) after admission; or a resident who has been discharged from the current healthcare facility within the preceding four weeks, who develops an onset of CDAD which requires readmission to the same healthcare facility. 2.7 Clostridium difficile Associated Disease (CDAD) Nosocomial Case (imported from different facility): The resident s initial signs of diarrhea occur within 48 hours post-admission to a health care facility or attendance in out-patient; and the resident has been discharged from or has been in ambulatory care in a different health care facility in the preceding four weeks. 2.8 Clostridium difficile Associated Disease (CDAD) Community Acquired Case: The resident does not meet either Nosocomial definition. 2.9 Clostridium difficile Associated Disease (CDAD) Recurrent Case: Residents who have a second confirmed episode of CDAD between the end of treatment and eight weeks from the end of treatment of the first episode. 2.9.1 If the second episode is greater than eight weeks from the end of the treatment date, it is no longer considered a recurrence. It is classified as a new case. 2.9.2 If two C-difficile toxin positive specimens are separated by under two weeks, the second specimen is described as an additional test result of the original specimen and not counted as a recurrence. Operational Directive: Management of Clostridium Difficile Associated Diseases (Approved Dec 2007)

PCH/LTCF Operational Directive: Management of Clostridium Difficile Associated Diseases. Page 3 of 9 2.10 Cohorting: Two or more residents infected with Clostridium difficile Associated Disease (CDAD) placed/roomed together to minimize their contact with other unaffected residents on the same unit. 2.11 Contact: An individual who may be exposed to a Clostridium difficile Associated Disease (CDAD) case in which transmission can occur. 2.12 Contact Precautions: Precautions and practices that include single room or at least one meter between beds in multi- bed rooms, with health care workers wearing gown and gloves for interactions that involve contact with the resident or the resident s equipment and environment. 2.13 Date of Diagnosis: Date and time of the first specimen positive for C- difficile toxin. 2.14 Facility Approved Disinfectant: A disinfectant cleaner that has been approved by the facility or organization. 2.15 Hand Hygiene: A general term that applies to handwashing, antiseptic handwash, antiseptic hand rub, or surgical hand antisepsis. 2.16 Handwashing: The process of washing hands with soap (plain or antimicrobial) and water. 2.17 Health Care Worker (HCW): An individual who provides care to patients/clients/residents in the healthcare workplace, e.g. nurses, physicians, allied health workers, and emergency responders. 2.18 Resident: An individual who resides in a long-term care facility/interim care. 2.19 Loose stool: Stool that takes the shape of the container in which it is held. 2.20 Routine Practices: A set of infection control precautions and practices used for all direct care regardless of the presumed infection status or diagnosis. 2.21 Terminal Cleaning: Thorough cleaning of all surfaces and equipment within the room with a facility approved disinfectant. This will include spot cleaning of visible soil on walls and removal of privacy curtains. Operational Directive: Management of Clostridium Difficile Associated Diseases (Approved Dec 2007)

PCH/LTCF Operational Directive: Management of Clostridium Difficile Associated Diseases. Page 4 of 9 3.0 OPERATIONAL DIRECTIVES: 3.1 Residents with symptoms of CDAD shall be placed on Contact Precautions in addition to Routine Practices. 3.2 The diagnosis of CDAD does not preclude transferring patients from acute care to personal care homes/long term care facilities (PCH/LTCF) or movement to and from PCHs/LTCFs. 3.2.1 Patients, in hospital, who are acutely ill with CDAD should have transfer postponed until the condition has stabilized. 3.3 Residents with CDAD shall have their status noted on their health record. 3.4 Individuals who have CDAD and are being transferred must have the CDAD status clearly documented on the Regional Health Authorities of Manitoba Transfer Referral Form (Appendix A). Negative toxin results are not required before transfer. 3.5 The Manitoba Health Communicable Disease Control Unit (CDC) Investigation Form for Clostridium difficile-associated Diseases (CDAD) (Appendix B) shall be completed for each confirmed case of CDAD infection diagnosed at the facility. Outcomes must be reviewed at 30 days post diagnosis and the investigational form must be returned to the CDC Unit of Manitoba Health. 4.0 PROCEDURE: 4.1 In the event a Resident has diarrhea and CDAD is suspected the registered nurse will: 4.1.1 Notify the attending physician of the Resident with diarrhea suspected of CDAD. 4.1.2 Notify the Infection Control Practitioner or designate. 4.1.3 Send an unpreserved liquid stool specimen for C. difficile toxin testing, to the laboratory, as soon as possible after suspected clinical diagnosis. If transport is more than two hours, sample must be refrigerated. Operational Directive: Management of Clostridium Difficile Associated Diseases (Approved Dec 2007)

PCH/LTCF Operational Directive: Management of Clostridium Difficile Associated Diseases. Page 5 of 9 4.1.3.1 Stool sample must be liquid or loose stool, which takes the shape of the container. The container must be 1/3 full (25 ml) without preservatives. Note: A maximum of two stool samples per diarrhea episode (collected on separate days) will be tested. 4.1.3.2 Formed stool is not an appropriate specimen and should not be sent. 4.2 The registered nurse will initiate Contact Precautions in addition to Routine Practices. 4.2.1 Resident Placement, Cohorting & Activities 4.2.1.1 A single room is preferred if the Resident is incontinent (i.e.: feces that cannot be contained) or the resident has poor hygiene that might lead to contamination of the surrounding environment. The room door may remain open. If the room does not have a toilet and hand washing facilities dedicate an individual commode for that Resident. 4.2.1.2 If a single room is not possible and the room is a shared room maintain spatial separation of at least one meter between infected Resident(s) and other residents and their visitors. Roommates should not have serious medical conditions (i.e.: end stage renal disease, cancer or immunodeficiency) that would put them at high risk of CDAD if transmission of C. difficile occurred. Roommates and their visitors should have the ability to comply with the precautions. Roommates and all visitors must be made aware of, and should comply with any precautions that are being taken. An individual commode must be designated to the symptomatic Resident. 4.2.1.3 If cohorting, consult the Infection Control Practitioner regarding this decision. Residents known to be infected with the same organisms may be grouped together unless transmission of different strains is a concern. Operational Directive: Management of Clostridium Difficile Associated Diseases (Approved Dec 2007)

PCH/LTCF Operational Directive: Management of Clostridium Difficile Associated Diseases. Page 6 of 9 4.2.1.4 Consult the Infection Control Practitioner regarding the Resident s activities. Participation in activities involving food preparation such as baking groups should be restricted; however, activities do not need to be restricted if feces can be contained and hands washed with soap and water. 4.2.2 Hand Hygiene 4.2.2.1 Use soap and water for hand hygiene. Alcohol based hand rubs are not effective against C.difficile spores. 4.2.2.2 Follow Routine Practices. 4.2.3 Gloves 4.2.3.1 Wear gloves when: Entering the resident s single room or designated bed space in a shared room. Contact with infected material or any object in the resident s room. Resident care 4.2.3.2 Remove gloves before leaving the resident s room or bed space when tasks are completed. Wash hands immediately after removing gloves. 4.2.4 Gowns (long sleeved) 4.2.4.1 Wear gowns if: Clothing or forearms will have direct contact with the resident. Clothing or forearms will be in direct contact with frequently touched environmental surfaces, objects or infectious materials. There is increased risk of environmental contamination i.e.: resident is incontinent of feces, diarrhea or drainage from a colostomy or ileostomy that cannot be contained. 4.2.4.2 Remove gown before leaving the resident s room or bed space. 4.2.5 Equipment 4.2.5.1 Dedicate equipment for individual Resident use. 4.2.5.2 Identify and store all equipment/supplies designated for individual Resident use in a manner that prevents use by or for other residents. Operational Directive: Management of Clostridium Difficile Associated Diseases (Approved Dec 2007)

PCH/LTCF Operational Directive: Management of Clostridium Difficile Associated Diseases. Page 7 of 9 If equipment cannot be dedicated, it must be cleaned 4.2.5.3 and disinfected with a Facility Approved Disinfectant before use on another Resident. 4.2.6 Linen 4.2.6.1 Follow Routine Practices 4.2.7 Dishes 4.2.7.1 Follow Routine Practices 4.2.8 Needles and Syringes 4.2.8.1 Follow Routine Practices 4.2.9 Waste Disposal 4.2.9.1 Follow Routine Practices 4.2.10 Resident Health Record and Personal Documents e.g. Wills, Voting 4.2.10.1 Follow Routine Practices 4.2.11 Environmental Cleaning/ Housekeeping 4.2.11.1 Clean twice daily and when visibly soiled, all horizontal surfaces in the room and frequently touched surfaces i.e.: side rails, call bells, light cords, door handles, commodes and bathroom areas. 4.2.11.2 Cleaning must be thorough: Work from clean items and surfaces to dirty ones. Apply Facility Approved Disinfectant directly to all cleaning cloths ensuring full saturation prior to cleaning surfaces. Do not spray or squirt disinfectant onto the surfaces to be cleaned. Change cleaning clothes and mop heads frequently. Avoid putting used cloths into the disinfectant solution to reduce contamination of disinfection solution and recontamination of cloths. Use disposable toilet brushes for toilet cleaning. Operational Directive: Management of Clostridium Difficile Associated Diseases (Approved Dec 2007)

PCH/LTCF Operational Directive: Management of Clostridium Difficile Associated Diseases. Page 8 of 9 4.2.11.3 Do a thorough Terminal Cleaning when Contact Precautions are discontinued or the Resident is moved or transferred. Change the privacy curtain. Wipe down window coverings including pull cords, if visibly soiled take them down and launder. Clean wipeable light cords and bells. Change cloth or string light cords and bell. Discard disposable items including paper towels and toilet tissue. Discard toilet brushes. Immediately clean soiled equipment or furnishings with a Facility Approved Disinfectant. Launder mop heads before reusing them. 4.3 Duration of Additional Precautions 4.3.1 Consult the Infection Control Practitioners regarding discontinuing Contact Precautions. 4.3.2 Contact Precautions may be discontinued when the resident has had at least 48 hours of normal stools and Terminal Cleaning completed. 4.4 Reporting Requirements 4.4.1 The infection control practitioner/ designate shall complete the Manitoba Health CDC Unit Investigational Form for CDAD (Appendix B) for each confirmed case diagnosed including recurrent cases. Review the outcomes at 30 days post diagnosis. Send the investigational form to the Manitoba Health CDC unit fax: (204) 948-2040. 4.5 Transfer Between Facilities 4.5.1 The diagnosis of CDAD does not preclude transferring patients from acute care to personal care homes/ long-term care facilities (PCH/LTCF) or movement to and from PCHs/LTCFs. 4.5.2 Patients/residents who are acutely ill with C. difficile should have transfer postponed until the condition has stabilized. 4.5.3 Negative culture/toxin results are not required for transfer. 4.5.4 Document the resident s status on his/her health record and clearly document the CDAD diagnosis on the Regional Health Authorities of Manitoba Transfer Referral Form (Appendix A). 4.5.5 Notify the receiving facility of the CDAD status prior to the transfer. Operational Directive: Management of Clostridium Difficile Associated Diseases (Approved Dec 2007)

PCH/LTCF Operational Directive: Management of Clostridium Difficile Associated Diseases. Page 9 of 9 4.5.6 If the Resident is considered infectious, inform the transferring service (ambulance, medi van) that Contact precautions should be used during transfer. 4.6 All current antibiotic therapy should be discontinued if possible and antidiarrheal agents such as Imodium, Codeine and Morphine should not be used until CDAD has been excluded. However, the decision to discontinue all current antibiotic therapy and not to use antidiarrheal agents is a medical decision. 5.0 REFERENCES: 5.1 Manitoba Health, Communicable Disease Control Unit (September 2006). Communicable Disease Management Protocol Clostridium difficile Associate Disease (CDAD). 5.2 Health Canada, Laboratory Centre for Disease Control. (July 1999). Routine Practices and additional Precautions for Preventing the Transmission of Infection in Health Care. Operational Directive Contact: Betty Taylor, Manager, PCH Infection Prevention & Control Operational Directive: Management of Clostridium Difficile Associated Diseases (Approved Dec 2007)

Operational Directive: Management of Clostridium difficile Page 1 of 2 Appendix A

Operational Directive: Management of Clostridium difficile Page 2 of 2 Appendix A

Operational Directive: Management of Clostridium difficile Page 1 of 2 Appendix B

Operational Directive: Management of Clostridium difficile Page 2 of 2 Manitoba Health CDC Unit Investigation Form for CDAD Case Definition: Appendix B A diagnosis of C. difficile-associated Diseases (CDAD) applies to a person with: Acute onset of diarrhea (loose stool). Loose stool is defined as stool which takes the shape of the container that holds it. and Laboratory confirmation (positive Clostridium difficile toxin, or C. difficile culture with evidence of toxin production or histological/pathological diagnosis of CDAD). or Diagnosis of typical pseudo-membranes on endoscopy. or Diagnosis of toxic megacolon supported by diagnostic imaging. Nosocomial Case (current facility): Patient s initial signs of diarrhea occur greater than 48 hours post-admission to a health care facility. or A patient who has been discharged from the current health care facility within the preceding four weeks who develops an onset of CDAD which requires readmission to the same health care facility. Nosocomial Case (imported from different facility): Patient s initial signs of diarrhea occur within 48 hours post-admission to a health care facility, or attendance in out-patient. and The patient who has been discharged from or has been in ambulatory care in a different health care facility within the preceding four weeks. Community Acquired Case: Patient does not meet either Nosocomial Case definition. Recurrent Case: An individual who has a second confirmed episode of CDAD between the end of treatment and eight weeks from the date of the end of treatment of the first episode, is classified as recurrent case. If the second episode is greater than eight weeks from the end of treatment date, it is no longer considered a recurrence. It is classified as a new case. If two C. difficile toxin positive specimens are separated by under two weeks, the second specimen is described as an additional test result of the original episode, and not counted as a recurrence. * Patient refers to patient, resident, client. ** The Date of Diagnosis is the date and time of the first specimen positive for C. difficile toxin. September 2006