The key aspects of applying contact precautions relate to: • standard precautions
• use of appropriate PPE • special handling of equipment • patient placement
• minimising patient transfer or transport. Hand hygiene and PPe
Effective hand hygiene is particularly important in preventing contact transmission and the 5 moments for hand hygiene outlined in Section B1.1.2 should be followed at all times. When the presence of C. difficile or non-enveloped viruses is known or suspected, use of alcohol-based hand rubs alone may not be sufficient to reduce transmission of these organisms (see Section B1.1.3). Putting on both gloves and gown upon entering the patient-care area helps to contain infectious agents, especially those that have been implicated in transmission through environmental contamination (e.g. VRE, MRSA, C. difficile, norovirus and other intestinal tract pathogens, respiratory syncytial virus) (Hall & Douglas 1981; CDC 1995; Evans et al 2002; Bhalla et al 2004; Donskey 2004; Duckro et al 2005; Wu et al 2005). Considerations in selecting a gown appropriate to the situation are outlined in Section B1.2.
A surgical mask and protective eyewear must be worn if there is the potential for generation of splashes or sprays of blood and body substances into the face and eyes.
recommendation
16 Hand hygiene and personal protective equipment to prevent contact
transmission Grade
When working with patients who require contact precautions: • perform hand hygiene;
• put on gloves and gown upon entry to the patient-care area;
• ensure that clothing and skin do not contact potentially contaminated environmental surfaces; and
• remove gown and gloves and perform hand hygiene before leaving the patient-care area.
C
Single-use or patient-dedicated equipment
Standard precautions concerning patient-care equipment (see Section B1.5) are very important in the care of patients on contact precautions. If patient-care devices (e.g. blood pressure cuffs, nebulisers, mobility aids) are shared between patients without being reprocessed between uses, they may transmit infectious agents (Brooks et al 1992; Desenclos et al 2001; Rutala & Weber 2008).
recommendation
17 Patient-care equipment for patients on contact precautions Grade
Use patient-dedicated equipment or single-use non-critical patient-care equipment. If common use of equipment for multiple patients is unavoidable, clean the equipment and allow it to dry before use on another patient.
Patient placement
A single-patient room is recommended for patients who require contact precautions. Rooms with ensuites and anterooms are preferred (see also C6). Other points relevant to patient placement include the following:
• keep patient notes outside the room
• keep patient bedside charts outside the room
• disinfect hands upon leaving room and after writing in the chart • keep doors closed
• make sure rooms are clearly signed.
When a single-patient room is not available, consultation with infection control professionals is recommended to assess the various risks associated with other patient placement options (e.g. cohorting).
If it is necessary to place a patient who requires contact precautions in a room with a patient who is not infected or colonised:
• avoid placing these patients with patients who are at increased risk of an adverse outcome from infection (e.g. patients who are immunocompromised, have open wounds or have anticipated prolonged lengths of stay)
• 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.
transfer of patients
Limiting transfer of a patient on contact precautions reduces the risk of environmental
contamination. If transfer within or between facilities is necessary, it is important to ensure that infected or colonised areas of the patient’s body are contained and covered. Contaminated PPE should be removed and disposed of and hand hygiene performed before the patient is moved. Clean PPE should be put on before the patient is handled at the destination.
risk-management case study
Klebsiella pneumoniae sepsis in a neonatal unit
During a 7-month period, seven infants in a neonatal unit developed septicaemia from multi-
resistant extended spectrum β lactamase producing Klebsiella pneumoniae, and two babies died.
Molecular typing revealed that four of the strains were identical; not all isolates were available for typing. Screening of all babies was not carried out, as it was expected that many would already be colonised, and that babies whose gut was colonised by the bacteria would be the source of infection through the hands of healthcare workers. The outbreak was brought under control by in-service education and improvement of hand hygiene compliance, and wearing of single-use gloves when babies’ nappies were being changed. Nurses were declared to be the advocates for the babies, and the nurse caring for each baby was responsible for ensuring that all attending personnel perform hand hygiene before and after handling the baby, with non-compliance being reported to the infection control team.
eliminating risks In this situation it is not possible to eliminate the risk entirely, so it must be managed.
Identifying risks In this case, the risk has been identified as cross-transmission of Klebsiella pneumoniae.
analysing risks The major source of the risk is transmission between neonates by healthcare workers’ hands,
with failure to wear gloves when changing nappies, and lack of appropriate hand hygiene practices by some staff members.
evaluating risks The balance of likelihood and consequences identify this as a ‘very high risk’ situation requiring
immediate response.
treating risks Immediate measures include implementation of contact precautions, with strict enforcement
of hand hygiene, wearing of PPE (e.g. gloves), and provision of in-service education on hand hygiene.
Longer-term measures might include increased frequency of environmental cleaning,
performance of surveillance cultures, and cohorting of colonised babies, if the outbreak could not be brought under control by immediate measures.
monitoring Changes in rates of infection could be monitored through ongoing surveillance.