The Challenges of Implementing Isolation Precautions in the LTC Facility Gail Bennett, RN, MSN, CIC 1 What we will cover Overview of recommended practices for various types of isolation precautions Safe injection practices and decontaminating point of use devices Implementation of isolation practices Challenges in using isolation precautions 2 1
History From the days of Moses and leprosy To use of isolation huts and isolation hospitals (in US as early as 1877) To cubicles used for isolation (1910) To today s fairly sophisticated isolation rooms 3 Need for Isolation Precautions Traditional diseases such as Chickenpox, Tuberculosis New and emerging diseases such as SARS, Hantavirus, West Nile Virus, and possibly Smallpox 4 2
Chain of Infection. Infectious Agent Susceptible Host Reservoir Chain of Infection Portal of Entry Portal of Exit Mode of Transmission 5 Centers for Disease Control and Prevention (2003). Available at http://www.cdc.gov/oralhealth/infectioncontrol/guidelines/slides/008.htm CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 6 3
CDC Isolation Precautions Standard Precautions Transmission-based Precautions Contact Direct Indirect Droplet Airborne Infection Isolation Protective Environment 7 Standard Precautions Designed to reduce transmission of bloodborne pathogens HIV HBV HCV Recommended for use with all residents Assume that every resident is potentially colonized or infected 8 4
Standard Precautions Apply to: Blood All body fluids, secretions and excretions except sweat Non-intact skin Mucous membranes 9 Elements of Standard Precautions Hand Hygiene Personal Protective Equipment (PPE): Gloves Masks, Eye Protection or Face Shields when contact with blood and body fluids to face and mucous membranes is likely Gowns/Aprons (fluid resistant) when splashing or spraying of body fluids to clothing is anticipated 10 5
Donning PPE GOWN Fully cover torso from neck to knees, arms to end of wrist, and wrap around the back Fasten in back at neck and waist GLOVES Perform hand hygiene Extend to cover wrist of isolation gown MASK Secure ties or elastic band at middle of head and neck Fit flexible band to nose bridge Fit snug to face and below chin GOGGLES/FACE SHIELD Put over face and eyes and adjust to fit 11 SAFE WORK PRACTICES Keep hands away from face Limit surfaces touched Change with torn or heavily contaminated Perform hand hygiene Removing PPE GOWN Gown front and sleeves are contaminated! Unfasten neck, the waist ties Remove gown using a peeling motion; pull gown from each shoulder toward the same hand Gown will turn inside out Hold removed gown away from body, roll into a bundle and discard into waste or linen receptacle GLOVES Outside of gloves are contaminated! Grasp outside of glove with opposite gloved hand; peel off Hold removed glove in gloved hand Slide fingers of ungloved hand under remaining glove at wrist MASK Front of mask is contaminated DO NOT TOUCH! Grasp bottom then top ties/elastics and remove Discard in waste container 12 HAND HYGIENE Perform immediately after removing all PPE GOGGLES/FACE SHIELD Outside of goggles or face shield are contaminated! To remove, handle by clean head band or ear pieces Place in designated receptacle for reprocessing or in waste container 6
Hand Hygiene CDC Guideline for Hand Hygiene If washing with soap and water, at least 15 seconds Soap and water for spore formers (C. difficile) and Norovirus, before eating, after bathroom, before sterile invasive procedures, if hands are visibly soiled Otherwise, alcohol rubs acceptable No requirement to wash with soap and water after so may uses of alcohol rub 13 Hand Hygiene CDC Guideline for Hand Hygiene Many facilities have mounted them in all resident rooms What about toxicity if swallowed? Less abrasive to hands than soap and water Wash after removing gloves Fingernails short ¼ inch or less past the tip of your finger 14 7
15 Elements of Standard Precautions (cont.) Resident Placement Private room for residents with epidemiologically important or highly transmissible organisms Appropriate roommate Cohorting (grouping same disease or organism together) Low risk roommate Consider epidemiology and mode of transmission of infecting organism to determine placement 16 8
Elements of Standard Precautions (cont.) Resident Care Equipment cleaning and disinfection Environmental Controls cleaning and disinfection of resident care areas and high-touch surfaces Linens handle with minimum agitation, use PPE as appropriate; no special handling precautions for residents in precautions 17 Blood Spill Kits Use the kits approved by your facility/company Disinfectant must meet one of the following: (OSHA requirement) Tuberculocidal Has EPA kill claim against Hepatitis B and HIV May mix bleach and water 1:10 daily more labor intensive and all spill kit components must be gathered 18 9
Additional Elements of Standard Precautions (2007) Respiratory Hygiene/Cough Etiquette Safe Injection Practices Use of masks for insertion of catheters or injection material into spinal or epidural spaces via lumbar procedures 19 Respiratory Hygiene: Cough Etiquette Use for preventing transmission of all respiratory illnesses Signs and posters should be displayed in public areas where residents are admitted, communicating the following: Cover the nose/mouth when coughing or sneezing Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use Perform hand hygiene after having contact with respiratory secretions and contaminated objects/materials Sit at least 3 feet away from others if coughing 20 10
Respiratory Hygiene: Cough Etiquette Provide tissues, no-touch receptacles, and alcohol handrubs in waiting areas Offer masks to residents, visitors, others who are coughing 21 A printable version of this poster is available for free download at: 22 http://www.cdc.gov/flu/protect/pdf/covercough_school8-5x11.pdf 11
Safe Injection Practices Do NOT: Reinsert used needles into multi-dose vials or solution containers Use a single needle/syringe to administer IV medication to multiple residents See next slide for resource comprehensive information 23 One and Only Campaign www.cdc.gov 24 24 12
IC Practices for Special Lumbar Puncture Procedures Wear a surgical face mask: when placing a catheter injecting material into the spinal or epidural space 25 Standard Precautions (cont.) Use Standard Precautions for the care of all residents, all the time. 26 13
Transmission-Based Precautions Designed for residents infected or suspected to have highly transmissible or epidemiologically important pathogens that need more than Standard Precautions. Three types of Transmission-Based Precautions Droplet Precautions Contact Precautions Airborne Infection Isolation (AII) 27 Droplet Precautions Designed to reduce the risk of droplet transmission large-particle droplets (>5 um in size ) of infectious agents Contact with conjunctivae, mucous membranes of the nose or mouth of a susceptible person Particles may be suspended in the air and can generally travel up to 3-6 feet 28 14
Droplet Precautions (cont.) Droplets generated during coughing sneezing talking 29 Elements of Droplet Precautions Resident Placement Private room if unavailable, Cohort OR Consider risk to the specific roommate Spatial separation of at least 3 feet. Draw privacy curtain. Mask Don surgical mask on entry to the room or cubicle Resident transport Mask resident or maintain 3 feet distance from others; instruct on cough etiquette 30 15
Droplet Precautions (cont.) Invasive Haemophilus influenzae type b meningitis pneumonia epiglottitis Invasive Neisseria meningitidis Pertussis Influenza Mumps, Rubella 31 Contact Precautions Designed to reduce the risk of transmission of microorganisms by direct or indirect contact Direct contact skin-to-skin contact physical transfer (turning residents, bathing residents, other resident care activities) Indirect contact contaminated objects 32 16
Elements of Contact Precautions Gloves Don gloves on entering the room Handwashing/hand hygiene Gowns Don gown on entering the room 33 Elements of Contact Precautions (cont.) Resident placement 34 Private room if unavailable, Cohort OR Consider risk to the specific roommate Spatial separation of at least 3 feet. Draw privacy curtain as reminder of precautions and limit direct or indirect contact 17
Contact Precautions (cont.) Resident Transport infected/colonized areas covered Resident-Care Equipment Dedicate to single resident if possible If not feasible, decontaminate equipment prior to use on another resident Environmental Measures Frequent cleaning and disinfection of the room with a focus on frequently touched surfaces and equipment in the immediate vicinity of the resident 35 Contact Precautions (cont.) Herpes simplex virus Impetigo Pediculosis Scabies Conjunctivitis Ebola Lassa or Marburg Multi-drug Resistant Organisms 36 18
Airborne Infection Isolation (AII) Use airborne precautions for residents known or suspected to be infected with infectious agents transmitted person to person by the airborne route Measles Varicella (including disseminated zoster) Tuberculosis Smallpox Viral hemorrhagic fevers SARS 37 Airborne Infection Isolation (AII) Not often available in long term care facilities Specific environmental controls required 38 19
Elements of Airborne Infection Isolation Resident Placement Place in an Airborne Infection Isolation Room (AIIR) [If room not available, transfer resident to a facility with an available AIIR] 6 air changes per hour (existing facility); 12 for new construction Direct exhaust to outside. If not possible, air may be returned to the air handling system or adjacent spaces if all air is directed through HEPA filters Door closed When an AIIR is in use, monitor air pressure daily with visual indicators, regardless of the presence of differential pressure sensing devices 39 Elements of Airborne Infection Isolation (cont.) Personnel Restrictions Restrict susceptible personnel form entering rooms of residents known or suspected to have measles, chickenpox, disseminated zoster, or smallpox if other immune personnel are available. 40 20
Elements of Airborne Infection Isolation (cont.) Respiratory Protection Fit-tested NIOSH-approved respiratory protection (N95 respirator or higher) Wear when entering the room of a resident with infectious TB or smallpox CDC makes no recommendation on use of an N95 vs. surgical mask for measles and varicella Resident Transport Essential purposes only Mask on resident 41 Airborne Isolation: Respiratory Protection N95 respirator may be worn until damaged soiled breathing resistance is too great compromised integrity of the mask 42 21
If you do not provide AAI Would not have to have a respiratory protection plan or use of N-95s EXCEPT 43 Remember Even in LTCFs, CDC recommends that we wear N-95 respirators when performing cough inducing procedures on residents with influenza Most often in LTCFs: suctioning So, a written respiratory protection program is required Fit testing of respirators Training, etc. 44 22
Protective Environment For allogeneic hematopoietic stem cell transplant (HSCT) residents To reduce exposure to environmental fungi 45 Protective Environment NOT IMPLEMENTED IN LTCFs Filter incoming air using central or point-of-use HEPA filters capable of removing 99.97% of particles greater than or equal to 0.3 um in diameter Directed room airflow Positive air pressure; monitor daily with visual indicators Well sealed room At least 12 air changes per hour 46 23
A Critical Issue Decontamination of Point of Use Devices 47 Glucometers 48 48 24
What went wrong? Multiple outbreaks with transmission of bloodborne pathogens relating to blood glucose monitoring Some breaches in technique were apparent use of pen like reusable lancets, poor hand hygiene or glove use, etc. In one outbreak, a cause was not identified and investigators said there might have been transmission relating to contamination of the glucometer The rest is history! 49 49 50 50 25
CDC statement Outbreaks of hepatitis B virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration 51 51 At a hospital in Texas in 2009, more than 2,000 persons were notified and recommended to undergo testing for bloodborne viruses after individual insulin pens were used for multiple persons At a health fair in New Mexico in 2010, dozens of attendees were potentially exposed to bloodborne viruses when fingerstick devices were inappropriately reused for multiple persons to conduct diabetes screening 52 52 26
Centers for Disease Control and Prevention. Nosocomial hepatitis B virus associated with spring-loaded fingerstick blood sampling devices Ohio and New York City, 1996. MMWR 1997;46:217-221. Centers for Disease Control and Prevention. Notes from the Field: Deaths from Acute Hepatitis B Virus Infection Associated with Assisted Blood Glucose Monitoring in an Assisted-Living Facility North Carolina, August- October 2010. MMWR 2011;60:182. Centers for Disease Control and Prevention. Transmission of hepatitis B virus among persons undergoing blood glucose monitoring in long-term-care facilities Mississippi, North Carolina, and Los Angeles County, California, 2003-2004. MMWR 2005;54:220-223. Counard CC, Perz JF, Linchancgo PC, et al. Acute hepatitis B outbreaks related to fingerstick blood glucose monitoring in two assisted living facilities. J Am Geriatric Soc 2010;58:306-311. Khan AJ, Cotter SM, Schulz B, et al. Nosocomial transmission of hepatitis B virus infection among residents with diabetes in a skilled nursing facility. Infect Control Hosp Epidemiol 2002;23:313-318. 53 53 CDC report - MMWR, 2005 relating to Nursing Home C Glucose monitors, insulin vials, or other surfaces contaminated with blood from an HBV-infected person might have resulted in transfer of infectious virus to a health-care worker's gloves and to the fingerstick wound or subcutaneous injection site of a susceptible resident. Transmission of Hepatitis B Virus Among Persons Undergoing Blood Glucose Monitoring in Long-Term--Care Facilities --- Mississippi, North Carolina, and Los Angeles County, California, 2003 2004. MMWR, March 5411, 2005 / 54(09);220-223 54 27
Keep Sight on the Problem Preventing transmission of bloodborne pathogens 55 Dedicate to use by one resident OR Decontaminate after every use! 2 steps: clean and disinfect See manufacturer s recommendation re: product to use but verify that what they say meets OSHA requirements for blood contamination Disinfectant needs to kill bloodborne pathogens (EPA registered kill data against HIV and HBV OR tuberculocidal) 56 56 28
Germicidal Wipes The most convenient method for disinfection of shared medical equipment May use one wipe to clean the item (no specific contact time required) To disinfect, use an additional wipe for the correct contact time as noted on the label Use the right wipes for the right type of job 57 Germicidal Wipes The user should: Know the contact time for the germicide used Know the ability of the wipe to maintain contact time for the task for it will be used Be involved in selection of the right type of wipes Staff must be trained to use the wipes appropriately 58 29
Safe Practices 59 The entire lancet is disposable, one time use One meter per resident if possible; although sharing is sometimes necessary Cleaning the meter: Clean hands prior to cleaning the meter Wear gloves Use a wipe to clean the surfaces of the meter Dispose of the wipe 59 Safe practices (cont.) Disinfect the meter using an appropriate product Hypochlorite (bleach) based OR Disinfectant with EPA label claim against HIV and HBV OR tuberculocidal Follow wet contact time for the disinfectant Place on a clean surface Remove gloves and clean hands 60 60 30
Safe practices (cont.) Meters dedicated for single-resident use should ideally be stored in the resident s room Protect against inadvertent use on another resident Whether single or shared use Protect against cross contamination from one meter to another during storage 61 61 www.apic.org 62 31
Effective Implementation of Isolation Precautions Be familiar with national standards of practice Develop policies and practices based on these standards Make policies easily accessible to staff; frequent need for reminders or refreshers Provide effective training of staff Orientation Annual training As needed 63 Effective Implementation of Isolation Precautions Monitor performance using objective means Observe! Consider using checklists 64 32
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What are some of the Challenges with Isolation Precautions in LTCFs? 67 Challenges with Isolation Precautions in LTCFs Who orders isolation precautions? Is it in a timely manner? 68 34
Challenges with Isolation Precautions in LTCFs Where do you place clean PPE for use with precautions? 69 Challenges with Isolation Precautions in LTCFs How do you handle trash and linens in isolation rooms? 70 35
Challenges with Isolation Precautions in LTCFs Who monitors compliance with precautions and how is it done? 71 Challenges with Isolation Precautions in LTCFs How do you get the information you need from your referral source relating to infection and precautions? 72 36
Other challenges 73 References Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, CDC, 2007. www.cdc.gov/hicpac/2007ip/2007isolationpre cautions.html OSHA TB Standards Overview http://www.osha.gov/sltc/tuberculosis/ind ex.html 74 37
Thank you!! Gail Bennett, RN, MSN, CIC ICP Associates, Inc. www.icpassociates.com gaibennett@icpasssociates.com 75 38