Area Section Subsection Infection Control and Additional Precautions N/A Scope Approved By All Staff Original Effective Date Revised Effective Date Reviewed Date Glenda Short, Director Clinical Programs & Services 2016-Aug-17 N/A N/A are the foundation for preventing the transmission of microorganisms during client care in all health care settings. It is a comprehensive set of infection prevention and control (IP&C) measures developed for use in the routine care of ALL CLIENTS at ALL TIMES in ALL HEALTH CARE SETTINGS. aim to minimize or prevent health care-associated infections in all individuals in the health care setting including clients, Health Care Workers (HCWs), other staff, visitors, contractors, and so on. Adherence to can reduce the transmission of microorganisms in all health care settings. All HCWs (physicians, nurses, allied HCWs, support staff, students, volunteers and others) are responsible for complying with and for tactfully calling infractions to the attention of offenders. No one is exempt from complying with. Consistent application of is expected for the care of all clients at all times across the continuum of care. Microorganisms may be transmitted from symptomatic and asymptomatic individuals, emphasizing the importance of adhering to at all times for all clients in all health care settings. Individual components of are determined by a point of care risk assessment (PCRA). A PCRA is performed by HCWs to determine the appropriate control measures required to provide safe client care (i.e., protect the client from transmission of microorganisms) and to protect the HCW from exposure to microorganisms (e.g., from sprays of blood, body fluids, respiratory tract or other secretions or excretions and contaminated needles and other sharps). A PCRA includes an assessment of the task/care to be performed, the client s clinical presentation, physical state of the environment and the health care setting. Clients and visitors have a responsibility to comply with where indicated. Teaching clients and visitors basic principles (e.g., hand hygiene, use of PPE) is the responsibility of all HCWs. Page 1 of 33
include: Point of Care Risk Assessment Hand Hygiene Source Control (triage, early diagnosis and treatment, respiratory hygiene, spatial separation) Client Accommodation, Placement, & Flow Aseptic Technique Personal Protective Equipment (PPE) Specimen Collection Sharps Safety & Prevention of Bloodborne Transmission Management of the Client Care Environment Cleaning of the Environment Cleaning & Disinfection of Non-Critical Client Care Equipment Handling of Linen, Waste, Dishes Handling of Deceased Bodies Visitor Management Education Page 2 of 33
Point of Care Risk Assessment Prior to every client interaction, all Healthcare Workers (HCWs) are responsible to assess the infectious risk posed to themselves and other clients, HCWs and visitors by a client, situation or procedure. Perform a PCRA before each client interaction to determine the appropriate required for safe client care. The PCRA is an evaluation of the risk factors related to the interaction between the HCW, the client and the client s environment to assess and analyze their potential for exposure to infectious agents and identifies risks for transmission. Control measures are based on the evaluation of the risk factors identified. HCWs should routinely perform a PCRA before every interaction with a client and apply control measures for their safety and the safety of clients and others in the environment. A PCRA is performed when a HCW evaluates a client and situation, including, but not limited to: Determine the possibility of exposure to blood, body fluids, secretions and excretions, non-intact skin, and mucous membranes and select appropriate control measures (e.g., personal protective equipment [PPE]) to prevent exposure Determine the need for Additional Precautions when are not sufficient to prevent exposure Within health care facilities, determine the priority for single rooms or for roommate selection if rooms/spaces are to be shared by clients Risk varies in health care settings; therefore, control measures may need to be modified depending on the health care setting, rather than imposing the same level of precautions across all settings. How to Perform a PCRA When performing a PCRA, HCWs consider questions to determine risk of exposure and potential for transmission of microorganisms during client interactions. Examples of such questions are: What contact will the HCW have with the client? What task(s) or procedures(s) is the HCW going to perform? Is there a risk of splashes/sprays? If the client has diarrhea, is he/she continent? If incontinent, can stool be contained in a diaper or incontinent product? Is the client able and willing to perform hand hygiene? Is the client in a shared room? Applying Control Measures Following the PCRA The PCRA of the circumstances of the client, the environment, and task to be performed determine the control measures required. Control measures may include: Hand hygiene (alcohol-based hand rub at point of care) Client placement and accommodation within health care facilities Give priority to clients with uncontained wound drainage, suspected infectious respiratory illness or uncontained diarrhea into a single room. Place a client with suspected or confirmed airborne infection into an Airborne Infection Isolation Room (AIIR) with the door closed Note: When an AIIR room is not available, consult Infection Prevention and Control to determine room placement. All attempts must be made to accommodate the client in a single room with the door closed. Settings that cannot provide AIIRs should Page 3 of 33
transfer a client with infectious forms of tuberculosis to a facility with such accommodation. Coordinate arrangements with receiving facility. Treatment of active infection Roommate selection for shared rooms or for transport in shared ambulances and other types of transportation (e.g., air ambulances, taxis), considering the immune status of clients who will potentially be exposed to certain infections (e.g., measles, mumps, rubella, varicella) Client flow within health care facilities Restrict movement of symptomatic clients within the specific client care area/facility or outside the facility as appropriate for the suspected or confirmed microbial etiology Work assignment, considering the immune status of HCWs who will potentially be exposed to certain infections (e.g., measles, mumps, rubella, varicella) PPE selection, applying PPE appropriate to the suspected or confirmed infection or colonization For example, if a client has uncontained diarrhea, barrier equipment such as gloves and a gown should be considered when changing the bed sheets, to prevent contamination of hands and clothing Cleaning of non-critical client care equipment and the client environment Handling of linen and waste Use avoidance procedures that minimize contact with droplets (e.g., sitting next to, rather than in front of, a coughing client when taking a history or conducting an examination). Restricting visitor access where appropriate Reassessment of need for continuing or discontinuing Additional Precautions Page 4 of 33
Point of Care Risk Assessment Algorithm (PCRA) For All Client Interactions Page 5 of 33
Factors Affecting Risk of Transmission of Microorganisms in a Health Care Setting Within the Chain of Infection Adapted from and Additional Precautions in All Health Care Settings, Provincial Infectious Diseases Advisory Committee (PIDAC), November 2012. Page 6 of 33
HAND HYGIENE Hand hygiene (HH) is a general term referring to any action of hand cleaning. HH relates to the removal of visible soil and removal or killing of transient microorganisms from the hands while maintaining the good skin integrity resulting from a hand care program. HH includes surgical hand antisepsis. Hands of Health Care Workers (HCWs) are the most common vehicle for the transmission of microorganisms from client to client, from client to equipment and the environment, and from equipment and the environment to the client. Transmission of organisms by hands of HCWs between clients can result in health care-associated infections (HAIs). During the delivery of health care, the HCW s hands continuously touch surfaces and substances including inanimate objects, clients intact or non-intact skin, mucous membranes, food, waste, body fluids and the HCW s own body. This movement while carrying out tasks and procedures provides many opportunities for the transmission of organisms on hands. Hand hygiene is a core element of client safety for the prevention of infections and the spread of antimicrobial resistance. There are two methods of performing hand hygiene: Alcohol-Based Hand Rub (ABHR): Use of alcohol-based hand rub (ABHR) has been shown to reduce health care-associated infection rates. ABHR is the preferred method for decontaminating hands. ABHR is faster and more effective than washing hands (even with an antibacterial soap) when hands are not visibly soiled. Hand hygiene with correctly applied alcohol-based hand rub kills organisms in seconds. ABHRs: Provide for a rapid kill of most transient microorganisms. Contain emollients to reduce hand irritation. Are less time consuming than washing with soap and water? Efficacy of ABHRs The efficacy of the ABHR depends on the consistency of the product (e.g., gel, foam, liquid), the concentration of the product (i.e., percentage of alcohol), the amount of product used, and the time spent rubbing, and the hand surface rubbed. ABHR should not be used with water, as water will dilute the alcohol and reduce its effectiveness. ABHR should not be used immediately after hand washing with soap and water as it will result in more irritation of the hands. ABHRs available for health care settings range in concentration from 60 to 90% alcohol. Concentrations higher than 90% are less effective because proteins are not denatured easily in the absence of water. Studies suggest that norovirus is inactivated by alcohol concentrations ranging from 70% to 90%. Since norovirus is a concern in all health care settings, a minimum concentration of 70% alcohol should be used. Page 7 of 33
Hand washing Hand washing with soap and running water must be performed when hands are visibly soiled. Antimicrobial soap may be considered for use in critical care settings such as intensive care units and burn units but is not required and not recommended in other care areas. Bar soaps are not acceptable in health care settings except for the personal use of a single client. In this case the bar must be stored in a soap rack to allow drainage and drying. It should be discarded on client discharge. Only liquid soap or ABHR should be used in a client s home for HCW hand hygiene. Bar soap is allowed for client s personal use. Efficacy of Soaps Plain soaps act on hands by emulsifying dirt and organic substances (e.g., blood, mucous), which are then flushed away with rinsing. Antimicrobial agents in plain soaps are present only as a preservative. Antimicrobial soaps have residual antimicrobial activity and are not affected by the presence of organic material. Disadvantages of antimicrobial soap include: Antimicrobial soaps are harsher on hands than plain soaps and frequent use may result in skin breakdown; and Frequent use of antimicrobial soap may lead to antibiotic resistance. Hand hygiene with soap and water done correctly physically removes organisms. Towelettes/Wipes Hand wipes impregnated with plain soap, antimicrobials or alcohol may be used to remove visible soil and/or organic material, but should not be used as a substitute for alcohol-based hand rub or antimicrobial soap as they are not as effective at reducing bacterial counts on HCWs hands. When hands are visibly soiled, hand wipes may be used as an alternative to washing hands with plain soap and water ONLY in settings where a designated hand washing sink is not available or is not satisfactory (e.g., contaminated sink, sink used for other purposes, no running water, no soap). The use of hand wipes when hands are visibly soiled should be followed by an ABHR and hands should be washed once a suitable sink is available. Non-Alcohol-Based Waterless Antiseptic Agents At the present time there is no evidence for the efficacy of non-alcoholic, waterless antiseptic agents in the health care environment. Non-alcoholic products have a quaternary ammonium compound (QAC) as the active ingredient, which has not been shown to be as effective against most microorganisms as ABHR or soap and water. QACs are prone to contamination by Gram-negative organisms. QACs are also associated with an increase in skin irritancy. Page 8 of 33
Hand Hygiene and Clostridium difficile Clostridium difficile is a spore-forming bacterium that causes serious diarrhea and intestinal illness. Wearing gloves and subsequent removal on leaving the care environment has been shown to prevent transmission of C. difficile. Observe meticulous hand hygiene after glove removal. Hand hygiene at the point of care (either with ABHR or soap and water) is necessary before leaving the client environment. When C. difficile is diagnosed or suspected: Soap and water is theoretically more effective in removing spores than ABHR: When a dedicated hand washing sink is immediately available at the point of care, wash hands with soap and water. When a dedicated hand washing sink is not immediately available at the point of care, clean hands using ABHR. Wash hands with soap and water at the nearest hand washing sink. Do not perform hand hygiene at a client s sink as this may re-contaminate HCW hands. Provide education to the client regarding the need and procedure to be used for hand hygiene. Clients who are unable to perform hand hygiene independently should be assisted by the HCW. Indications and Moments for Hand Hygiene during Health Care Activities When should hand hygiene be performed? A hand hygiene indication points to the reason hand hygiene is necessary at a given moment. There may be several indications in a single care sequence or activity. While all indications for hand hygiene are important, there are some essential moments in health care settings where the risk of transmission is greatest and hand hygiene must be performed. Performing hand hygiene at the most essential moments helps to protect the client, the HCW, and the health care environment. These essential hand hygiene indications can be simplified into The 4 Moments for Hand Hygiene: THE 4 MOMENTS FOR HAND HYGIENE: Image source: Just Clean Your Hands - Public Health Ontario. 1. BEFORE INITIAL CLIENT/CLIENT ENVIRONMENT CONTACT When? Clean your hands when entering a client care environment (e.g., client/treatment/exam room or home), before touching the client or any object or furniture in the client s environment. Examples include: Shaking hands, stroking an arm, helping the client move around or get washed. Taking the client s pulse/blood pressure, abdominal palpation. Before touching any object or furniture in the client s environment (e.g., bedside table, personal belongings, stretchers, wheelchairs, adjusting an intravenous rate, silencing a pump). Why? To protect the client and his/her environment from harmful microorganisms carried on your hands. Page 9 of 33
2. BEFORE CLEAN/ASEPTIC PROCEDURES When? Clean your hands immediately before any clean or aseptic procedure and before putting on gloves, if worn. Examples include: Performing invasive procedures. Giving injections. Providing oral/dental care. Handling dressings or touching open wounds. Preparing and administering medications. Giving eye drops. Opening a vascular access system. Opening a drainage system. Inserting catheters. Assessing blood glucose. Preparing, handling, serving or eating food. Feeding a client. Why? To protect the client against harmful microorganisms, including his/her own microorganisms, from entering his/her body. 3. AFTER BODY FLUID EXPOSURE RISK When? Clean your hands immediately after an exposure risk to blood and body fluids, non-intact skin, and/or mucous membranes and after removing gloves, if worn. Examples include: Contact with blood and body fluids. Cleaning up urine/feces/vomit. Contact with items/areas known or considered to be contaminated or are visibly soiled (e.g., bathroom, linen, medical instruments). Between procedures on the same client where soiling of hands is likely, to avoid cross contamination of body sites. Opening a vascular access or drainage system. Oral care, wound care, client toileting. Personal use of toilet or wiping nose/face. Feeding a client. Why? To protect yourself and the health care environment from harmful client microorganisms. 4. AFTER CLIENT/CLIENT ENVIRONMENT CONTACT When? Clean your hands when leaving the client/client environment, after touching the client or any object or furniture in the client s environment. Examples include: Helping a client mobilize, giving a massage. Assessing pulse/blood pressure, performing chest auscultation or abdominal palpation. Changing bed linen, holding a bed rail, clearing the bedside or over bed table. Adjusting an intravenous rate, touching monitors. Why? To protect yourself and the health care environment from harmful microorganisms. It s also important to perform hand hygiene before and after shifts and breaks. Page 10 of 33
HAND HYGIENE AT THE POINT OF CARE Hand hygiene at the point of care using alcohol-based hand rub (ABHR) is the standard of care expected of all HCWs, in all health care settings. Busy HCWs need access to hand hygiene products where client or client environment contact is taking place. Providing ABHR at the point of care (e.g., within arm s reach, as resources permit) is an important system support to improve hand hygiene. Point of care refers to the place where three elements occur together: The client The health care worker Care potentially involving contact is taking place Point of care products should be available at the required moment, without leaving the client environment. This enables HCWs to quickly and easily fulfill the 4 Moments for Hand Hygiene. Point of care HH can be achieved in a variety of methods. (e.g., ABHR attached to the bed, wall or equipment; carried by the HCW). Care Environments: The health care setting is divided into two virtual geographical areas, or care environments: the client environment and the health care environment. Understanding the difference between the client environment and the health care environment is the key to knowing when to perform hand hygiene. The Client Environment: the client s area The client environment refers to the space that contains the client, as well as the immediate surroundings and inanimate surfaces in contact with the client (e.g., bed rails, bedside tables, bed linens, infusion tubing, other medical equipment). It further contains the surfaces frequently touched by HCWs within the vicinity of the client (e.g., monitors, buttons and knobs, and other high frequency touch surfaces within the client environment). The point of care occurs within the client environment. The client environment and thus the point of care extend beyond the client s immediate bed space. Client environment: the client s area In a single room this is everything in the client s room. In a multi-bed room this is the area inside the client s curtain. In an ambulatory or clinic setting, the client environment is the area that may come into contact with the client within their cubicle/clinic room. In an Emergency department cubicle it is the client stretcher and the equipment in close proximity used in the client s care. In a nursery/neonatal and intermediate care setting, the client environment includes the inside of the bassinette/isolette, the equipment outside the bassinette/isolette used for that infant (e.g., ventilator, monitor), as well as an area around the infant (e.g., within approximately 1 meter/3 feet). In the home health care setting, the entire home is the client s environment. If the client bathroom is used for hand hygiene, avoid contamination of hands with potentially contaminated surfaces and objects. Page 11 of 33
The Health Care Environment The health care environment contains all surfaces outside the client environment (i.e., all other clients and their client environments and the health care program environment). Conceptually, the health care environment is contaminated with microorganisms that might be foreign and potentially harmful to individual clients, either because they are multi-drug resistant or because their transmission might result in infection. Health care environment The environment beyond the client s immediate area. In a single room this is outside the room. In a multi-bed room this is everything outside the client s bed area. In an ambulatory/clinic setting, this is outside the clinic room. In a multi-station treatment room this is everything outside the client s treatment area. In a nursery/neonatal and intermediate care setting, all areas outside of the bassinette/isolette, the environment outside the bassinette/isolette used for that infant (e.g., ventilator, monitor, supplies), and the area around the infant (approximately 1 meter/3 feet) is the health care environment (e.g., nursing station; preparation, storage and utility rooms). In the home health care setting, any items brought in and out of the home by the HCW is considered the health care environment. Two moments for hand hygiene may sometimes fall together. Typically this occurs when going from one client to another without touching any surface outside the corresponding client environments. Naturally, a single hand hygiene action will cover two separate moments for hand hygiene. For example, completing care for one client (moment 4) then moving directly to another client (moment 1) without touching anything in the surrounding health care environment. Techniques Using an Alcohol-Based Hand Rub (ABHR) Ensure hands are visibly clean and dry (if soiled or wet, follow hand washing steps). Apply one to two full pumps of product onto one palm; the volume should be such that 15 seconds of rubbing is required for drying. Spread product over all surfaces of hands, concentrating on finger tips, under fingernails, between fingers, back of hands, and base of thumbs; these are the most commonly missed areas. Continue rubbing hands until product is dry; this will take a minimum of 15 seconds if sufficient product is used. Hands must be fully dry before touching the client, the care environment or equipment for the ABHR to be effective and to eliminate the extremely rare risk of flammability in the presence of an oxygen-enriched environment. Using Soap and Water Wet hands with warm (not hot or cold) water; hot or cold water is hard on the hands, and will lead to dryness. Apply liquid or foam soap. Vigorously lather all surfaces of hands for a minimum of 15 seconds. Removal of transient or acquired bacteria requires a minimum of 15 seconds of mechanical action. Pay particular attention to finger tips, under fingernails, between fingers, backs of hands and base of the thumbs; these are the most commonly missed areas. Page 12 of 33
Using a rubbing motion, thoroughly rinse soap from hands; residual soap can lead to dryness and cracking of skin. Dry hands thoroughly by blotting hands gently with a paper towel; rubbing vigorously with paper towels can damage the skin. Turn off taps with paper towel to avoid recontamination of the hands. DO NOT use ABHR immediately after washing hands, as skin irritation will be increased. Factors that Reduce Effectiveness of Hand Hygiene Condition of the Hands The condition of the hands can influence the effectiveness of hand hygiene. Intact skin is the body s first line of defense against bacteria; therefore careful attention to hand care is an essential part of the hand hygiene program. The presence of dermatitis, cracks, cuts or abrasions can trap bacteria and compromise hand hygiene. Dermatitis also increases shedding of skin squames (cells) and, therefore, shedding of bacteria. Nails Long nails are difficult to clean, can pierce gloves and harbour more microorganisms than short nails. Keep natural nails clean and short. The nail should not show past the end of the finger. Nail Polish Studies have shown that chipped nail polish or nail polish worn longer than four days can harbour microorganisms that are not removed by hand washing, even with surgical hand scrubs. Fingernail polish, if worn, must be fresh and in good condition. Freshly applied nail polish does not result in increased numbers of bacteria around the nails. Gel polish has been shown to damage nails, resulting in nail weakness, brittleness and thinning, putting nails at increased risk for breaking. Nail art (adding decorative paint effects to nails) has been shown to be associated with outbreaks of infection. Artificial Nails or Nail Enhancements Acrylic nails harbor more microorganisms and are more difficult to clean than natural nails. Artificial nails and nail enhancements, such as gel nails and nail wraps (adhesive decorative plastic or vinyl attached to nails) have been implicated in the transfer of microorganisms and in outbreaks, particularly in neonatal nurseries and other critical care areas. Surgical site infections and hemodialysis-related bacteremia have been linked to artificial nails. Artificial nails and nail enhancements are also associated with poor hand hygiene practices and result in more tears to gloves. For these reasons, artificial nails and nail enhancements are not to be worn by those having direct contact with clients or their environment, or those working with sterile linen/supplies, medical device reprocessing, or in the clinical laboratory (See Hand Hygiene policy (PPG-00005)) Rings, Hand Jewelry and Bracelets Hand and arm jewelry hinder hand hygiene. Rings increase the number of microorganisms present on hands and increase the risk of tears in gloves. Arm jewelry, including watches, should not interfere with, or become wet when performing hand hygiene. Page 13 of 33
For those who have direct contact with clients or their environment, or work in reprocessing or the laboratory, rings should be limited to a single smooth band without projections or mounted stones. If watches and other wrist jewelry are present, remove or push up above the wrist before performing hand hygiene. Other Impediments to Effective Hand Hygiene Long sleeves should not interfere with, or become wet when performing hand hygiene. Hand Drying (paper towel, air dryers) Effective hand drying is important for maintaining hand health. Considerations include: Disposable paper hand towels provide the lowest risk of cross-contamination and should be used for drying hands in clinical practice areas. Cloth drying towels must not be used. Towel dispensers must be mounted such that access to them is unobstructed and splashing or dripping onto adjacent wall and floor surfaces is minimized. Towel dispenser design should be such that only the towel is touched during removal of towel for use. Towels hanging from the dispenser should not hang directly into a garbage can. To avoid recontamination of the hands, paper towels should be available to use on the exit door hardware and a waste container for used towels should be located near the exit door. Hot-air dryers, including jet air dryers, must not be used in clinical areas. If hot-air dryers are used in non-clinical (public) areas: Hands-free taps are required. There must be a contingency for power interruptions. Lotions and Creams HCWs must use program-approved lotions compatible with products and gloves in use. Hand lotion bottles must not be reused. Barrier Creams Unlike hand lotions, which penetrate the skin via pores, barrier creams are adsorbed to the skin and are designed to form a protective layer that is not removed by standard hand washing. Barrier creams may actually be harmful as they trap agents beneath them, ultimately increasing risk for either irritant or allergic contact dermatitis. Furthermore, inappropriate barrier cream application on HCW hands may exacerbate irritation rather than provide benefit. Dispensers To prevent contamination, liquid products must be dispensed in a disposable pump/squirt container that is discarded when empty. They should never be topped-up or refilled. Do not add soap or hand rub to a partially empty dispenser. Page 14 of 33
Source Control (Respiratory Hygiene, Triage, Early Diagnosis and Treatment, Spatial Separation) These measures are used to contain microorganisms from dissemination from an infectious source. Individuals with symptoms require direction at the point of initial encounter in any healthcare setting (e.g., triage in emergency departments; acute assessment settings; and reception and waiting areas in emergency departments, outpatient clinics and physician offices) and in strategic places (e.g., elevators, cafeterias) within ambulatory and inpatient or residential settings. Source control measures may include but are not limited to: Signage at healthcare setting entrances for early recognition of symptoms. Separate entrances/waiting areas. Spatial separations. Physical barriers for acute assessment. Early identification, diagnosis and treatment of infection. Respiratory etiquette/hygiene. Hand hygiene. Client placement (e.g., client care areas, single rooms/airborne Infection Isolation Rooms [AIIRs]). Respiratory Etiquette/Respiratory Hygiene Respiratory hygiene refers to a combination of measures designed to minimize the transmission of respiratory pathogens. These source control measures are targeted to all individuals with symptoms of respiratory infection starting at the initial encounter in a healthcare setting and maintained throughout every encounter in the setting as listed above. Respiratory hygiene involves educating and encouraging all individuals (clients, Health Care Workers (HCWs) and visitors) who have the physical and cognitive abilities to do so, to practice respiratory hygiene. Specific measures may include instructional signs, education programs and provision of materials for respiratory hygiene (e.g., tissues, plastic lined waste receptacles, alcohol-based hand rub [ABHR]). Encourage respiratory hygiene for clients and accompanying individuals who have signs and symptoms of an acute respiratory infection (manifested by new or worsening cough, shortness of breath and fever), beginning at the point of initial encounter in any healthcare setting. Respiratory hygiene includes: Covering the mouth and nose against a sleeve/shoulder during coughing or sneezing. Using tissues to contain respiratory secretions to cover the mouth and nose during coughing or sneezing, with prompt disposal of these into a hands-free waste receptacle. Wearing a mask when coughing or sneezing. Turning the head away from others when coughing or sneezing. Maintaining a spatial separation of two metres/six feet between clients symptomatic with an acute respiratory infection and those who do not have symptoms of a respiratory infection. If this cannot be achieved, the clients must be at least one metre/three feet apart and the symptomatic person must wear a mask. One metre/three feet may be sufficient for young children and others whose cough is not forceful enough to propel the droplets as far as two metres/six feet. Family and HCWs with signs/symptoms of respiratory illness should not come to direct care areas. Page 15 of 33
Triage 1. In Emergency rooms and acute assessment settings; Post signs to direct clients with symptoms of acute infection (e.g., cough, fever, vomiting, diarrhea, coryza, rash, conjunctivitis) to perform hand hygiene and/or respiratory hygiene appropriate for symptoms. Ensure a physical barrier (e.g., plastic partition at triage desk) is located between infectious sources (e.g., clients with symptoms of a respiratory infection) and others. Place clients who are likely to contaminate the environment directly into a single examining room whenever possible: Clients with gastrointestinal (acute diarrhea/vomiting) illness. Clients with respiratory infections. These clients should be placed either directly into an examining room or an airborne infection isolation room, as indicated by the respiratory infection suspected. Place a procedure mask on these clients until isolated or spatial separation is achieved. Clients with excessive bleeding or body fluid drainage. 2. In Ambulatory/Clinic setting; If possible, identify clients with symptoms of an acute infection when scheduling appointments for routine clinic visits and request they defer routine clinic visits until symptoms of the acute infection have subsided. Inform clients who cannot defer their routine clinic visit (e.g., those that require assessment of symptoms/condition) to follow hand hygiene and/or respiratory hygiene recommendations appropriate for their symptoms. Direct these clients into an examining room as soon as they arrive and/or schedule their appointment for a time when other clients are not present. Post signs at clinic entrances reminding symptomatic clients to perform hand hygiene and/or respiratory hygiene appropriate for symptoms. 3. The Client Home: If the client is showing symptoms of an acute infection, if possible, encourage the use of a separate bathroom, frequent cleaning and limited prolonged interaction with other individuals Early Diagnosis and Treatment Ensure symptomatic clients are assessed in a timely manner and that any potential communicable infection is considered (e.g., tuberculosis, norovirus, RSV, pertussis). Spatial Separation Appropriate spatial separation and spacing requirements are necessary to decrease exposure to microorganisms for clients and visitors in clinical and waiting areas. A two metre/six feet spatial distance between a coughing/sneezing infected source (e.g., symptomatic individual with acute respiratory illness) and an unprotected susceptible host (e.g., clients, HCWs, visitors, contractors) is recommended to prevent the transmission of droplet borne infectious particles. In inpatient and residential facilities, a single room with in-room designated toilet and sink is preferable, as it may be difficult to maintain the recommended spatial separation of two metres/six feet between clients. If two metres/six feet cannot be achieved, clients must be at least one metre/three feet apart and the symptomatic person must wear a mask. One metre/three feet may be sufficient for young children and others whose cough is not forceful enough to propel the droplets as far as two metres/six feet. Page 16 of 33
CLIENT ACCOMMODATION, PLACEMENT, & FLOW Recommendations for Accommodation & Placement within Health Care Facilities: Accommodation of clients in facility in single rooms facilitates Infection Prevention and Control (IP&C) activities. Single rooms with a private toilet, designated client hand washing sink and designated staff hand washing sink may reduce opportunities for cross transmission between clients, particularly when the client has poor hygiene, contaminates the environment or cannot comply with IP&C measures because of age or decreased cognitive abilities. When availability of single rooms is limited, priorities for placement of clients in single rooms are determined by the Point of Care Risk Assessment (PCRA). Priority for single rooms goes to clients: Requiring Additional Precautions. Identified as high risk for transmission of microorganisms (e.g., stool incontinence, uncontained secretions). Identified as being at higher risk of acquisition and adverse outcomes resulting from transmission of microorganisms (e.g. immunosuppression, open wounds, indwelling catheters). When single rooms are not available and rooms must be shared, factors to be considered with shared rooms include: Selecting appropriate roommates. (Roommates that are not immunocompromised, have drainage tubes, IV s, open wounds etc). Delineating the boundary of the potentially contaminated client area within the shared room (e.g., draw privacy curtain around client). Preventing transmission risks through sharing of sinks and toilets. Assessing activities of the roommates and their visitors. Page 17 of 33
Client Flow/Transport within Facility Settings Client flow refers to client transfer/transport within and outside of the facility, and client activity. There is a potential for exposure to and transmission of microorganisms as a result of client activity and transport due to inadvertent contact with other clients, client care items and environmental surfaces. Frequent client transfers should be avoided as this increases opportunities for transmission to occur. In facility settings, the Health Care Worker, including bed/accommodation coordinators or those responsible for coordinating accommodation, are responsible for selecting the most appropriate accommodation type based on the PCRA and for prioritizing use of single rooms and Airborne Infection Isolation Rooms (AIIRs) if these are scarce. When in doubt regarding accommodation, consult IP&C professional. Client Flow/Transport Outside and Between Facility Settings: Single client transport is preferred If multi-client transport is required, consider the following to prioritize single client transport: o o o Requires Additional Precaution. Identified as high risk for transmission of microorganisms (e.g., stool incontinence, uncontained secretions). Identified as being at higher risk of acquisition and adverse outcomes resulting from transmission of microorganisms (e.g. immunosuppression, open wounds, indwelling catheters). Page 18 of 33
Aseptic Technique Aseptic technique, sometimes referred to as sterile technique, refers to practices designed to render the client s skin, medical supplies and surfaces as maximally free from microorganisms. These practices are required when performing procedures that expose the client s normally sterile sites (e.g., intravascular system, spinal canal, subdural space, urinary tract) to minimize contamination with microorganisms. Components of aseptic technique involve the following: Preparing skin with an antiseptic Hand hygiene, preferably with alcohol-based hand rub (ABHR), or if not accessible, an antimicrobial soap Sterile gloves Gowns Masks, where required, to prevent microorganisms carried in the HCW s nose and mouth from contaminating the sterile field Sterile drapes, used to prevent transferring microorganisms from the environment to the client while the procedure is being performed Maintaining a sterile field Infections may result from failure to use proper skin antisepsis prior to injection of medications, vaccines or venipuncture. Chlorhexidine in alcohol inactivates microorganisms on the skin more effectively than most other antiseptics and is the preferred antiseptic for skin preparation prior to insertion of central venous catheters and pulmonary artery catheters. Transmission of Hepatitis B and Hepatitis C virus has followed the reuse of needles and/or syringes for withdrawing from multi-use vials. Recommendations for Injection Safety include: Never administer medications from the same syringe to more than one client, even if the needle is changed. Consider a syringe or needle contaminated after it has been used to enter or connect to a client s intravenous infusion bag or administration set. Do not enter a vial with a syringe or needle which has been previously used. Never use medications packaged as single use vials for more than one client. Assign medications packaged as multi-use vials to a single client whenever possible. Do not use bags or bottles of intravenous solution as a common source of supply for more than one client. Aseptic Technique for Invasive Procedures and Handling Injectable Products: Perform hand hygiene, preferably with alcohol-based hand rub (ABHR) prior to opening supplies. When ABHR is not accessible, perform hand hygiene with antimicrobial soap and water. Page 19 of 33
Open tray and supplies only when ready to use to ensure a sterile field. Perform hand hygiene prior to applying PPE, as indicated by the specific procedure. Prepare the client s skin with an appropriate antiseptic before performing an invasive procedure. Use the appropriate size drape when a drape is required, to maintain a sterile field. Do not administer medications or solutions from single dose vials, ampules or syringes to multiple patient/residents or combine leftover contents for later use. Use a sterile, single use disposable needle and syringe for each medication/fluid withdrawal from vials or ampules. Clean the stoppers or injection ports of medication vials, infusion bags, etc., with alcohol before entering the port, vial or bag. Use single dose medication vials, prefilled syringes, and ampules in clinical settings. If the product is only available as multi-dose vials, see *multi-dose vials below. *When a product is only available for purchase in multi-dose vials: Restrict the multi-dose vial to single client use whenever possible. Prepare syringes from multi-dose vials from a centralized medication preparation area (e.g., do not take multi-dose vials to the client). Store the multi-dose vial to restrict access (e.g., in a secure location away from client bedside and where access is restricted, such as a medication room or locked cart). Use a sterile, single use needle and syringe each time the multi-dose vial is entered. Do not re-enter the multi-dose vial with a previously used needle or syringe. Label the multi-dose vial with date of first opening. Inspect the multi-dose vial for clouding or particulate contamination prior to each use and discard multi-dose vial if clouding or particulate contamination present. Discard the multi-dose vial if sterility or product integrity is compromised. Single Client Multi-Use Devices: Assign single client multi-use devices (e.g., glucose sampling devices, finger stick capillary blood sampling devices) to only one client. If not feasible to assign glucose meters to individual clients, clean and disinfect before use between clients. Insertion of Urinary Catheters: Use aseptic technique including sterile equipment (e.g., gloves, drapes, sponges and catheters), sterile antiseptic solution for cleaning the meatus, and a single use packet of sterile lubricant jelly for insertion. Injecting Material and Placing a Catheter into the Spinal Canal or Subdural Space: Use aseptic technique including a mask and sterile gloves (e.g., during lumbar puncture, myelogram, and spinal or epidural anesthesia). Insertion of Central Venous Catheters: Use maximal aseptic barriers as outlined in Aseptic Technique for Invasive Procedures and Handling Injectable Products (above), in addition to a cap, mask, long sleeved sterile surgical gown, sterile gloves, and a large full body sterile drape. Prepare the skin with chlorhexidine in alcohol or an equal alternative for inserting any central venous catheter or pulmonary catheter. Page 20 of 33
Insertion of Peripheral Venous Catheters or Peripheral Arterial Lines: Perform hand hygiene, prepare the skin with an antiseptic and wear clean disposable gloves. Storage, Assembly or Handling Components of Intravenous Delivery Systems: Use intravenous bags, tubing and connectors for one client only and dispose appropriately after use. Consider a syringe, needle or cannula as contaminated once it has been used to enter or connect to one client s intravenous infusion bag or administration set and do not reuse. Do not assemble sterile components until time of need with the exception of the emergency department, operating room, intensive care unit, or pre-hospital settings where it may be essential to maintain one system primed and ready for emergency use. If so, store the primed system in a clean and dry area secure from tampering and label with the date of priming. Replace if not used within 24 hours. Store sterile intravenous equipment components in a clean, dry and secure environment. Page 21 of 33
PERSONAL PROTECTIVE EQUIPMENT (PPE) PPE provides a physical barrier between the uninfected individual and an infectious agent/infected source, and protects the user from exposure to bloodborne and other microorganisms (e.g., sprays of blood, body fluids, respiratory tract or other secretions or excretions). PPE should not be relied on as a stand-alone primary prevention program. Focusing only on availability and use of various PPE will result in suboptimal protection of all persons, including clients, HCWs and other staff. A Point of Care Risk Assessment (PCRA) identifies hazards and enables the HCW to select PPE compatible with the hazard likely to be encountered during the client care interaction. HCWs should determine what PPE is needed by assessing the risk of exposure to blood, body fluids, secretions and excretions, mucous membranes, or non-intact skin during client care interactions. Appropriate PPE must be available for use by HCWs, visitors, clients, contractors, and others, to prevent exposure to an infectious agent/infected source. Health care workers should be fully knowledgeable of the application and limitations of the specific PPE available for their use. The selected PPE should maximize protection, dexterity and comfort. Appropriate and proper use of PPE includes: Point of Care Risk Assessment (PCRA) to determine need for PPE. Correct technique for putting on and taking off PPE. Correct technique when wearing PPE (e.g., not contaminating self). Discarding into designated/appropriate receptacles immediately after use, followed by hand hygiene, preferably with alcohol-based hand rub (ABHR). Following the PCRA, PPE for the appropriate application of may include: Gloves. Gowns. Facial protection: Masks (procedure or surgical). Eye protection (safety glasses or face shields) Does NOT include prescription or fashion glasses. Masks with visor attachment. Performing a PCRA to determine whether PPE is necessary is also important to avoid overreliance on PPE, misuse or waste. Over-reliance on PPE may result in a false sense of security. Misapplication or incorrect removal of PPE can result in inadvertent exposure of the user or client to infectious agents or contamination of the client s environment. Refer to: Personal Protective Equipment Options. Putting on Personal Protective Equipment. Removing Personal Protective Equipment. Page 22 of 33
1) Gloves The use of gloves is not a substitute for hand hygiene, but an additional measure of protection. For, glove use is dependent on a risk assessment of the client, the environment and the interaction. Gloves are not required for routine client care activities when contact is limited to a client s intact skin. Available gloves for client care include procedure and surgical (e.g., sterile) gloves. Gloves are used to reduce the transmission of microorganisms from one client to another or from one body site to another, and to reduce the risk of exposure of the user to blood, body fluids, secretions and excretions, mucous membranes, draining wounds or non-intact skin and for handling items or touching surfaces visibly or potentially soiled. Wear gloves as determined by the PCRA: For anticipated contact with blood, body fluids, secretions and excretions, mucous membranes, draining wounds or non-intact skin (including skin lesions or rash). For handling items or touching surfaces visibly or potentially soiled with blood, body fluids, secretions or excretions. While providing direct care if the user has an open cut or abrasions on the hands. Page 23 of 33
Single-use gloves must never be washed. Washing affects glove integrity and has not been shown to be effective in removing inoculated microorganisms. 2) Long-Sleeved Gowns and Other Apparel Long-sleeved gowns are worn for as indicated by the PCRA, to protect uncovered skin and clothing during procedures and client care activities likely to produce soiling or generate splashes or sprays of blood, body fluids, secretions or excretions. Gowns include isolation gowns reusable/disposable, fluid repellent, or sterile. The type of gown selected is based on the: Anticipated degree of contact with infectious material. Potential for blood and body fluid penetration of the gown; fluid repellence when heavy liquid contamination is anticipated (e.g., operating theatre, dialysis; equipment cleaning). Requirement for sterility (e.g., operating theatre, central line insertion). There is no evidence the routine use of gowns for all client care is beneficial in the prevention of health care-associated infections (HAIs), even in high-risk units such as intensive care or haematopoietic stem cell transplant units. Universal gown use has had no effect on HAI rates in neonatal or paediatric ICUs or on rates of neonatal colonization on post-partum wards. In the laboratory setting, wearing of laboratory coats is considered PPE. Outside of the laboratory, apparel such as uniforms, laboratory coats or scrub suits may be worn by HCWs for purposes of comfort, convenience or identity but do not have a role in the prevention of infection (e.g., they are not considered PPE). Page 24 of 33
For aesthetic purposes and professional etiquette, HCW apparel and uniforms should be clean. It is safe to launder HCWs uniforms at home. Adhere to regional policy regarding the laundering of scrub suits and uniforms supplied by the region. 3) Facial Protection Facial protection includes masks (procedure or surgical), eye protection (safety glasses or face shields), or masks with visor attachment. Masks Masks include procedure or surgical masks and have several uses: To protect from sprays or splashes. As a barrier for infectious sources. As a barrier when performing aseptic/sterile procedures. To protect susceptible hosts when within two metres/six feet of clients with respiratory signs/symptoms. Eye Protection The eye is an important portal of entry for some pathogens. Pathogens may be introduced into the eye directly via respiratory droplets generated during coughing or suctioning, or by self-inoculation if the eyes are touched with contaminated fingers. Eyes may be protected through use of: Masks with visor attachment. Safety glasses, or Face shields. The need for facial protection during routine client care is determined by the risk assessment of the client interaction and the task to be performed. Interactions involving activities likely to generate coughing, splashes or sprays of blood, body fluids, secretions or excretions, and procedures that potentially expose the mucous membranes of the eyes, nose or mouth, require facial protection. Transmission of Hepatitis C and HIV has been reported by splashes of blood to the mucous membranes of the face. Users should avoid touching their faces with their hands during client care. Wear facial protection (e.g., masks plus eye protection, face shields, or masks with visor attachment) as determined by the PCRA: To protect the mucous membranes of the eyes, nose and mouth during procedures and client care activities likely to generate splashes or sprays of blood, body fluids, secretions or excretions including respiratory secretions. When caring for a coughing/sneezing client. Remove eye protection or face shields immediately after use, place promptly into a hands-free waste receptacle and perform hand hygiene. If eye protection or face shields are reusable, clean and disinfect as per regional policy before reuse. When eye protection is required, wear eye protection over prescription or fashion glasses; prescription or fashion glasses alone are not adequate for eye protection. Page 25 of 33
Personal Protective Equipment (PPE) Options for This list identifies PPE available to provide appropriate protection: Gloves: Options include nitrile, vinyl or surgical gloves Non-powdered gloves are recommended to avoid reactions with alcohol-based hand rub Should cover the sleeve cuffs when a gown is worn Are single-use, task-specific, and appropriately sized Do not re-use or wash single-use gloves Prolonged use can result in germ transmission. When another indication for hand hygiene occurs while wearing gloves, remove gloves and perform hand hygiene Long-Sleeved Gowns and Other Apparel: Protect uncovered skin and clothing during activities and procedures likely to produce soiling or generate splashes or sprays of blood, body fluids, secretions or excretions Different options available (e.g., reusable/disposable, fluid repellent, sterile) Select appropriate gown based on the: Page 26 of 33