SJMHS Infection Control Policy Standard Precautions (SP) & Transmission-Based Isolation Policies Control of Communicable Disease Section Number 3 Policy Number 1.1 Effective Date: 11/63 Revised Date: 9/96, 12/00, 11/03, 11/07 Reviewed Date: Approved by: ICEOG Introduction Healthcare personnel will adhere to the following precautions when delivering care to all patients. The following policies incorporate Centers for Disease Control and Prevention (CDC) guidelines and other regulatory requirements. Policy Standard Precautions Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during the delivery of health care. Standard Precautions apply to Blood All body fluids (incl. OPIM*), secretions and excretions (except sweat) regardless of whether or not they contain visible blood Non-intact skin Mucous membranes *OPIM (other potentially infectious material) - Semen, vaginal secretions, cerebrospinal, synovial, pleural, pericardial, peritoneal, or amniotic fluids, any body fluid that is visibly contaminated with blood, all body fluids in situations where it is difficult or impossible to differentiate between body fluids. See also Infection Control Policy and Procedures, Section 3 Control of Communicable Diseases, policy 3-6.1 SJMHS Exposure Control Plan for additional details including hazard communication and clean up of spills of blood/opim. Transmission-Based Precautions In addition to Standard Precautions, use Transmission-Based Precautions for patients with documented or suspected infection or colonization with highly transmissible or epidemiologically-important pathogens for which additional precautions are needed to prevent transmission (see Appendix A) The following are Transmission-Based Precautions Contact Precautions Droplet Precautions Airborne Precautions They may be combined together for diseases that have multiple routes of transmission and are to be used in addition to Standard Precautions. Compliance with Standard and Transmission Based Precautions Health care workers (HCW) are expected to use appropriate personal protective equipment for situations where exposure is likely and as specified in this policy. Exceptions to use of Personal Protective Equipment (PPE) are allowed under rare/extraordinary circumstances when the associate determines that use of PPE would have prevented the delivery of essential health care or would pose an increased Page 1 of 24
hazard to safety of the associate or others. These circumstances will be investigated and changes made if possible, to prevent re-occurrences. ELEMENTS OF STANDARD PRECAUTIONS Hand Hygiene During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids, wash hands with soap and water. For instances when hands are not visibly soiled the preferred method of hand hygiene is to use an alcohol-based hand rub. Alternatively, hands may be washed with an antimicrobial soap and water. Perform Hand Hygiene Before having direct contact with patients. After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings. After contact with a patient s intact skin (e.g., when taking a pulse or blood pressure or lifting a patient). If hands will be moving from a contaminated-body site to a clean-body site during patient care. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. After removing gloves. Personal Protective Equipment (PPE) Wear PPE when there is anticipated patient contact with blood or body fluids. Prevent contamination of clothing and skin during the process of removing PPE. Before leaving the patient s room or cubicle, remove and discard PPE in an appropriately designated area, or container for storage, washing, decontamination or disposal. Gloves Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur. Wear gloves with fit and durability appropriate to the task. Wear disposable medical examination gloves for providing direct patient care. Wear disposable medical examination gloves or reusable utility gloves for cleaning the environment or medical equipment. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. Do not wear the same pair of gloves for the care of more than one patient. Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens. Change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site. Gown/Apron Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated. Wear a gown for direct patient contact if the patient has uncontained secretions or excretions. Remove gown and perform hand hygiene before leaving the patient s environment. Do not reuse gowns, even for repeated contacts with the same patient. Mouth, Nose, Eye Protection Use PPE to protect the mucous membranes of the eyes, nose and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed. Page 2 of 24
During aerosol-generating procedures (e.g., bronchoscopy, suctioning of the respiratory tract [if not using in-line suction catheters], endotracheal intubation) wear one of the following: a face shield that fully covers the front and sides of the face, a mask with attached shield, or a mask and goggles (in addition to gloves and gown). Reusable eye protection should be cleaned after use. Resuscitation Equipment Mouth to mask resuscitators or other resuscitation devices are located in patient rooms and in the crash cart (location may vary by facility) and should be used by trained Employees when performing cardiopulmonary resuscitation (CPR). Patient Transport When transporting any patient, ensure that precautions are maintained in order to minimize the risk of transmission of microorganisms to other patients and contamination of environmental surfaces or equipment. Patient-Care Equipment And Instruments/Devices Remove soil from instrument/devices & other reusable equipment, using recommended cleaning agents before disinfection or sterilization. Wear PPE (e.g., gloves, gown), according to the level of anticipated contamination, when handling patient-care equipment and instruments/devices that is visibly soiled or may have been in contact with blood or body fluids. When using common equipment or items, they must be adequately cleaned and disinfected before use by another patient. Refer to Infection Control Policies and Procedures, Section 5 Special Cleaning and Disinfection Procedures, policy 5-6.1 Cleaning of Reusable Medical Instruments/Equipment for Non-Surgical Services Areas & Units and policy 5-3.1 High Level Disinfection of Endoscopes & Other Semi-Critical Items. Environmental Cleaning Clean and disinfect surfaces that are likely to be contaminated with pathogens, including those that are in close proximity to the patient (e.g., bed rails, over bed tables) and frequently-touched surfaces in the patient care environment (e.g., door knobs, surfaces in and surrounding toilets in patients rooms) on a more frequent schedule compared to that for other surfaces (e.g., horizontal surfaces in waiting rooms). Clean and disinfect electronic equipment used by patients, used during delivery of patient care, and mobile devices that are moved in and out of patient rooms frequently (e.g., daily). Cover surfaces such as computer keyboards with protective covers that can facilitate disinfection. Use EPA-registered disinfectants that have microbiocidal (i.e., killing) activity against the pathogens most likely to contaminate the patient-care environment. Use in accordance with manufacturer s Instructions. For select pathogens (e.g. C.difficile, norovirus) use dilute bleach (available from Environmental Services) for disinfection of high touch surfaces and equipment. Note: Refer to device manufactures instructions prior, to assure bleach will not damage equipment. Child play toys (e.g., obstetric/gynecology offices, clinics & inpatient pediatrics), select play toys that can be easily cleaned and disinfected & do not permit use of stuffed furry toys. Clean and disinfect large stationary toys (e.g., climbing equipment) at least weekly and whenever visibly soiled. If toys are likely to be mouthed, rinse with water after disinfection; alternatively wash in a dishwasher. When a toy requires cleaning and disinfection, do so immediately or store in a designated labeled container separate from toys that are clean and ready for use. Textiles And Laundry Handle used textiles and fabrics with minimum agitation to avoid contamination of air, surfaces and persons. If laundry chutes are used, ensure that they are properly designed, maintained, and used in a manner to minimize dispersion of aerosols from contaminated laundry. Safe Injection Practices The following recommendations apply to the use of needles, cannulas that replace needles, and, where applicable intravenous delivery systems. Use aseptic technique to avoid contamination of sterile injection equipment. Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient. Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient s intravenous infusion bag or administration set. Use single-dose vials for parenteral medications whenever possible. Page 3 of 24
Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use. If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer s recommendations; discard if sterility is compromised or questionable. Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients. Use infection control practices for special lumbar puncture procedures. Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space (i.e., during myelograms, lumbar puncture and spinal or epidural anesthesia. Worker Safety Adhere to federal and state requirements for protection of healthcare personnel from exposure to bloodborne pathogens. See Appendix C: Standard Precautions Summary Table & Infection Control Policy and Procedures, Section 3 Control of Communicable Diseases, policy 3-6.1 SJMHS Exposure Control Plan. ELEMENTS OF TRANSMISSION BASED PRECAUTIONS (TBP) In addition to Standard precautions The specific category of TBP should be ordered thru the electronic patient information system by licensed health care personnel. Obtain appropriate precaution sign and place outside of patient door. Patients placed in Transmission Based Precautions should have type of precautions communicated to all ancillary departments involved in patient s care (i.e. flag chart, verbal report). Refer to Appendix A for Type and Duration of Precautions needed for selected infections and conditions. Note: Because laboratory testing and other information may not be available at time of presentation of a patient, use empiric precautions based on clinical symptoms or conditions as outlined in Appendix B. Contact Precautions Use Contact Precautions as recommended in Appendix A for patients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. For additional, specific recommendations for use of Contact Precautions for colonization or infection with multi drug-resistant organisms (MDROs) refer to the CDC MDRO guideline: www.cdc.gov/ncidod/dhqp/pdf/ar/mdroguideline2006.pdf Contact Precautions are to be used for the specific patient that is known to be infected or colonized with a microorganism that Is not easily treated with antibiotics and can be transmitted easily by direct contact between the patient and healthcare worker, Can be transmitted patient to patient (hand or skin to skin), Can be transmitted by indirect contact with environmental surfaces or patient-care items. Discontinue Contact Precautions after signs and symptoms of the infection have resolved or according to pathogen-specific recommendations in Appendix A. Patient Placement Place patients who require Contact Precautions in a single-patient room when available. When single-patient rooms are in short supply, apply the following principles for making decisions on patient placement: o Prioritize patients with conditions that may facilitate transmission (e.g., uncontained drainage, stool incontinence) for single-patient room placement. o Place together in the same room (cohort) patients who are infected or colonized with the same pathogen and are suitable roommates. If it becomes necessary to place a patient who requires Contact Precautions in a room with a patient who is not infected or colonized with the same infectious agent: Page 4 of 24
o Avoid placing patients on Contact Precautions in the same room with patients who have conditions that may increase the risk of adverse outcome from infection or that may facilitate transmission (e.g., those who are immunocompromised, have open wounds, or have anticipated prolonged lengths of stay). o Ensure that patients are physically separated (i.e., >3 feet apart) from each other. Draw the privacy curtain between beds to minimize opportunities for direct contact.) o Change protective attire and perform hand hygiene between contact with patients in the same room, regardless of whether one or both patients are on Contact Precautions. In ambulatory settings, place patients who require Contact Precautions in an examination room or cubicle as soon as possible Use of PPE Gloves Wear gloves whenever touching the patient s intact skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails) Don gloves upon entry into the room or cubicle. Gowns Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Don gown upon entry into the room or cubicle. Remove gown and observe hand hygiene before leaving the patient-care environment. After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transfer of microorganism to other patients or environmental surfaces. Patient Transport Limit transport and movement of patients outside of the room to medically-necessary purposes. When transport or movement in any healthcare setting is necessary, ensure that infected or colonized areas of the patient s body are contained and covered. Patient may attend therapies e.g. group, physical, occupational, inpatient or rehab, if patient feels well enough to participate and all drainage i.e. wound, diarrhea etc, is covered and contained. Remove and dispose of contaminated PPE and perform hand hygiene prior to transporting patients on Contact precautions. Don clean PPE to handle the patient at the transport destination. Patient-Care Equipment And Instruments/Devices Handle patient-care equipment and instruments/devices according to Standard Precautions Use disposable noncritical patient-care equipment (e.g., blood pressure cuffs) or implement patient-dedicated use of such equipment. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient. If unable to dedicate equipment, refer to Infection Control Policies and Procedures, Section 5 Special Cleaning and Disinfection Procedures, policy 5-6.1 Cleaning of Reusable Medical Instruments/Equipment for Non-Surgical Services Areas & Units Environmental Cleaning. Ensure that rooms of patients on Contact Precautions are prioritized for frequent cleaning and disinfection (e.g., at least daily) with a focus on frequently touched surfaces (e.g., bed rails, overbed table, bedside commode, lavatory surfaces in patient bathrooms, doorknobs) and equipment in the immediate vicinity of the patient. Droplet Precautions Use Droplet Precautions as recommended in Appendix A for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing or talking. (Or during the performance of procedures that induce coughing.) Page 5 of 24
Discontinue Droplet Precautions after signs and symptoms have resolved or according to pathogen-specific recommendations in Appendix A. Patient Placement Place patients who require Droplet Precautions in a single-patient room when available. Note: Any single patient room is adequate. Airborne infection isolation room is not necessary. When single-patient rooms are in short supply, apply the following principles for making decisions on patient placement: o Prioritize patients who have excessive cough and sputum production for single-patient room placement. o Place together in the same room (cohort) patients who are infected the same pathogen and are suitable roommates. If it becomes necessary to place patients who require Droplet Precautions in a room with a patient who does not have the same infection: Avoid placing patients on Droplet Precautions in the same room with patients who have conditions that may increase the risk of adverse outcome from infection or that may facilitate transmission (e.g., those who are immunocompromised, have or have anticipated prolonged lengths of stay). Ensure that patients are physically separated (i.e., >3 feet apart) from each other. Draw the privacy curtain between beds to minimize opportunities for close contact. Change protective attire and perform hand hygiene between contact with patients in the same room, regardless of whether one patient or both patients are on Droplet Precautions. In ambulatory settings, place patients who require Droplet Precautions in an examination room or cubicle as soon as possible. Instruct patients to follow recommendations for Respiratory Hygiene/Cough Etiquette. Use of PPE Don a mask upon entry into the patient room or cubicle. If splash or cough directly into face is anticipated consider use of eye protection (e.g., goggle or face shield), in addition to a mask, for close contact with patients who require Droplet Precautions. For patients with suspected or proven SARS, avian influenza or pandemic influenza, notify Infection Control Services. Refer to the following websites for additional recommendations ( www.cdc.gov/ncidod/sars/ ; www.cdc.gov/flu/avian/ ;www.pandemicflu.gov/) Patient Transport Limit transport and movement of patients outside of the room to medically-necessary purposes. If transport or movement in any healthcare setting is necessary; o Instruct patient to wear a mask and follow Respiratory Hygiene/Cough Etiquette. www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm o No mask is required for persons transporting patients on Droplet Precautions. Airborne Precautions Use Airborne Precautions as recommended in Appendix A for patients known or suspected to be infected with infectious agents transmitted person-to-person by the airborne route (e.g., M tuberculosis, measles, chickenpox, disseminated herpes zoster). Discontinue Airborne Precautions according to pathogen-specific recommendations in Appendix A. Patient Placement Place patients who require Airborne Precautions in an airborne infection isolation room, AIIR. o Contact facility engineering prior to placement of the patient into an AIIR to verify room is working properly or o For SJMH-AA & SJM-Saline obtain key, activate air pressure monitor and close door to AIIR. At SJM- Livingston check ball-in-tube monitor to verify room is in negative pressure. Whenever an AIIR is in use for a patient on Airborne Precautions, have Facility Engineering monitor air pressure daily with visual indicators (e.g., smoke tubes, flutter strips), regardless of the presence of electronic or manual pressure sensors. Keep the AIIR door closed when not required for entry and exit. When an AIIR is not available (SJMH-AA & SJM-Saline) contact Engineering or building technicians to set up portable ant-room device. Page 6 of 24
In the event of an outbreak or exposure involving large numbers of patients who require Airborne Precautions: Consult Infection Control Services before patient placement to determine the safety of alternative room that do not meet engineering requirements for an AIIR. Place together (cohort) patients who are presumed to have the same infection (based on clinical presentation and diagnosis when known) in areas of the facility that are away from other patients, especially patients who are at increased risk for infection (e.g., immunocompromised patients). Use temporary portable solutions (portable anteroom) to create a negative pressure environment in the converted area of the facility. Air from converted areas must be exhausted through HEPA filters before return to occupied spaces. In ambulatory settings develop systems (e.g., triage, signage) to identify patients with known or suspected infections that require Airborne Precautions upon entry into ambulatory settings. o Place the patient in an AIIR as soon as possible. If an AIIR is not available, place a surgical mask on the patient and place him/her in an examination room. Once the patient leaves, the room should remain vacant for the appropriate time, generally one hour, to allow for a full exchange of air. o Instruct patients with a known or suspected airborne infection to wear a surgical mask and observe Respiratory Hygiene/Cough Etiquette. Once in an AIIR, the mask may be removed; the mask should remain on if the patient is not in an AIIR. Personnel with Susceptibility to Select Infections Restrict susceptible healthcare personnel from entering the rooms of patients known or suspected to have measles (rubeola), varicella (chickenpox), disseminated zoster, or smallpox if other immune healthcare personnel are available. Use of PPE Wear a fit-tested NIOSH-approved N95 or higher level respirator for respiratory protection when entering the room or home of a patient when the following diseases are suspected or confirmed: o Infectious pulmonary or laryngeal tuberculosis or when infectious tuberculosis skin lesions are present and procedures that would aerosolize viable organisms (e.g., irrigation, incision and drainage, whirlpool treatments) are performed. o Smallpox (vaccinated and unvaccinated). Respiratory protection is recommended for all healthcare personnel, including those with a documented take after smallpox vaccination due to the risk of a genetically engineered virus against which the vaccine may not provide protection, or of exposure to a very large viral load (e.g., from high-risk aerosol-generating procedures, immunocompromised patients, hemorrhagic or flat smallpox). Healthcare personnel who are presumed to be immune to measles (rubeola) or varicella-zoster based on history of disease, vaccine, or serologic testing do not need to wear respiratory protection when caring for an individual with known or suspected measles, chickenpox or disseminated zoster. Important: Communicate to others who may enter AIIR that they need to be immune to enter the AIIR. For susceptible healthcare personnel, when immune personnel are not available and contact with patients with known or suspected measles, chickenpox or disseminated herpes zoster cannot be avoided, wear an N95 or higher level respirator plus put on gown & gloves prior to entering AIIR. Patient Transport Limit transport and movement of patients outside of the room to medically necessary purposes. If transport or movement outside an AIIR is necessary, instruct patients to wear a surgical mask, if possible, and observe Respiratory Hygiene/Cough Etiquette. For patients with skin lesions associated with varicella or smallpox or draining skin lesions caused by M. tuberculosis, cover the affected areas to prevent aerosolization or contact with the infectious agent in skin lesions. Healthcare personnel transporting patients who are on Airborne Precautions do not need to wear a mask or respirator during transport if the patient is wearing a mask and infectious skin lesions are covered. Exposure Management Contact ICS & EHS for guidance on management of exposure to patients with airborne diseases. Page 7 of 24
Reference Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007 http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf Questions regarding the above policies and procedures should be addressed to Infection Control Services SJMH-AA 712-3158 SJM Saline 429-8621 SJM Livingston 545-6438 Page 8 of 24