INFECTION PREVENTION AND CONTROL MANUAL Policy and Procedure

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INFECTION PREVENTION AND CONTROL MANUAL

Policy and Procedure

TITLE: Contact Precautions (formerly Contact Measures)

NUMBER: IC 04-008

Effective Date: October 2012 Page 1 of 25

Applies To: All

POLICY

1. Routine Practices will be used in conjunction with Contact Precautions. (Refer to

Appendix A for the conditions, clinical presentations and specific etiologies requiring Contact Precautions in addition to Routine Practices.)

2. Droplet and Airborne Infection Precautions, as applicable, will be used in conjunction with Contact Precautions.

3. Every area is to have a system in place to identify patients with known or suspected infections/conditions that require Contact Precautions.

4. Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) patients (both infected and colonized) require single rooms with a private bathroom.

DEFINITIONS

Contact Transmission: The transference of microorganisms through physical contact between an infected source and a host (direct contact) or

through the passive transfer of the microorganisms to a host via an intermediate object (indirect contact).

GUIDING PRINCIPLES AND VALUES

1. Routine Practices properly and consistently applied will usually prevent transmission by the contact route. For certain situations that may result in extensive contamination of the environment or for microorganisms with a very low infectious dose (i.e. Norovirus), Contact Precautions may be required.

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PROCEDURE

1. Implement Contact Precautions based on presenting signs and symptoms. Do not wait for etiology to be confirmed.

2. Never take health records into the room or bed space of any patient, including those on Contact Precautions.

2.1. Initiate a stool chart (CD0306MR) and place on the health record when Contact Precautions are indicated for diarrhea.

Note: Ongoing assessment and documentation of stools for patients with diarrhea is critical to determine patient status and requirements for continued Contact Precautions.

3. Document the initiation and removal of Contact Precautions in the health record. 4. Notifications

Note: Any health care provider can implement Contact Precautions.

4.1. Notify Infection Prevention and Control and the Administration for the facility (after hours) when initiating Contact Precautions for any unusual activity such as

increased number of potentially infected cases or potential outbreak situation. 5. Accommodation/Placement/Signage

Note: A private room with a private bathroom is preferred for most patients requiring contact precautions, and required for MRSA and VRE positive patients (Refer to Policy Statement # 4).The door to the private room may remain open.

5.1. If a private room is not available, consider co-horting as follows: 5.1.1. When single patient rooms are limited, perform a risk assessment in

conjunction with an Infection Control Practitioner (ICP) to determine patient placement and/or suitability for co-horting.

Note: Cohorting will only be done in conjunction with an ICP or the Administrator on call for the facility (if after-hours).

5.1.2. Prioritize patients with conditions that may facilitate cross-transmission of microorganisms for single patient room placement (e.g.: uncontained drainage, stool incontinence, young age, and cognitive impairment).

5.1.3. Cohort patients who are infected or colonized with the same microorganism and are suitable roommates. Select roommates for their ability and the ability of their visitors to comply with required precautions.

5.1.4. Refer to Appendix B for a cohorting algorithm. 5.2. When cohorting is not feasible:

5.2.1. Avoid placing a patient requiring Contact Precautions in the same room as a patient who is at high risk for complications if infection occurs or with

conditions that may facilitate transmission (e.g.: those who are immunocompromised, or patients with open wounds).

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5.2.2. In a shared room, if a patient has diarrhea, assign a dedicated toilet or commode to that patient.

5.2.3. In shared rooms, ensure all roommates and visitors are aware of the Contact Precautions to follow. Select roommates for their ability and the ability of their visitors to comply with required Contact Precautions.

5.2.4. If possible, close the privacy curtain between beds to minimize opportunities for direct contact.

5.3. Dedicate a commode at the bedside for patient use in multi-bed rooms (use the “Dedicated Commode” sign Prin A786).

5.4. Place a Contact Precautions sign at the entrance to the patient room if a private room or over the head of the bed AND on the privacy curtains in multi-bed room (so that sign is visible when curtains are pulled).

5.5. Place a Contact Precautions sign on the front of the patient’s health record.

5.5.1. Patients on Contact Precautions may use unit shower/tubs. Completely clean and disinfect any equipment, e.g. shower, shower curtain, or tub/shower chairs after patient use.

5.6. Put in place Droplet or Airborne Precautions signage (in addition to Contact Precautions signage) as required.

6. Hand Hygiene

6.1. Follow the Four Moments for hand hygiene to prevent the transmission of infection. 6.2. Ensure a supply of alcohol based hand rub (ABHR) is available at the bedside for

patient and visitor use.

6.3. Instruct patients and visitors on the importance of proper hand hygiene techniques. Use standardized IPAC educational materials such as those found on the IPAC Intranet site or Capital Health patient education website.

6.4. Offer patients frequent opportunities to clean their hands; assist them with hand hygiene as necessary.

7. Personal Protective Equipment (PPE)

7.1. Provide PPE for Contact Precautions outside the patient room for private rooms. 7.1.1. See Appendix C for the set up for an isolation cart.

7.1.2. Do not overstock the isolation cart.

7.1.3. Clean and disinfect isolation carts routinely and when visibly soiled.

7.1.4. Discard unused supplies and clean/disinfect the isolation cart following patient discharge.

7.2. Change PPE and perform hand hygiene between contacts with all patients.

7.2.1. Refer to Appendix D for the correct sequence for applying and removing PPE. 7.3. Housekeeping staff members wear a gown and gloves for all entries into the

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7.4. In addition to the use of PPE as per Routine Practices other staff and physicians wear:

7.4.1. Gloves

Always wear gloves to enter the patient room, cubicle or patient’s designated bed space.

7.4.2. Gowns

When indicated by a point of care risk assessment (see Appendix E), wear a long sleeved gown.

Apply before entering the room or bed space of the patient. 7.4.3. Mask/Protective Eye Wear

When indicated by a point of care risk assessment (see Appendix E), wear a mask and/or eye protection.

Key Point: If a patient with MRSA has signs and symptoms of a respiratory tract infection, wear a mask.

8. Patient Flow/Transport

Note: The ambulatory freedom of patients on Contact Precautions is restricted in order to minimize the potential transmission of contact spread illness/microorganisms. (See Table 1 for criteria for Out of Room Activity

8.1. Advise patients on Contact Precautions to leave their room only for medically essential purposes.

8.2. Restrict patients on Contact Precautions from participating in pet therapy programs. 8.3. Ensure that patients are accompanied by a healthcare provider whenever outside of

the room, unless alternative arrangements have been agreed upon and documented in advance with an ICP.

8.3.1. Refer to IC 04-013 Out of Room Ambulation for more details. Table 1

The 5Cs - Criteria for Patient Out of Room Activity with Contact Precautions Competent - The patient must be able to verbalize understanding of instructions. Cooperative - The patient must be able to follow directions and engage in

treatment.

Contain - Any wounds should be covered. A mask should be worn if the patient has respiratory symptoms.

Clean - Patient should wear clean robe/gown/clothes. The patient must wash hands before leaving the room and be encouraged to use alcohol based hand rub frequently.

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Transport Procedures

8.4. Wear appropriate PPE while in the room/bed space and while preparing the patient for transport (Refer to Procedure #7 - PPE).

8.5. Ensure that the patient cleans his/her hands before leaving the room.

8.6. Whenever possible, do not transport patients in their beds. Use a clean stretcher or wheelchair draped with a clean linen sheet to minimize direct contact between the patient and the transport device.

8.7. Transport the patient with clean bedding and ensure that wounds are covered with clean dressings.

8.8. Remove and dispose of PPE and perform hand hygiene prior to transporting patients.

8.8.1. Put on clean gloves for transport.

8.9. Put on cleanPPEto assist the patient if necessary,during transport and at the transport destination.

8.10. Patients do not wear PPE for transport or ambulating unless required by other policies (i.e.:Droplet/Airborne).

8.11. Place the health record in a clear plastic bag.

Note: Patients should not routinely hold their own health records.

8.12. Advise the receiving area that the patient requires Contact Precautions as per Transfer of Accountability protocols.

8.13. Clean and disinfect the transport device immediately after use. 8.14. Refer to Appendix F for a summary of transport steps.

9. Patients/Families/Visitors Education

9.1. Educate patients, families and visitors on Contact Precautions. Use appropriate patient education materials

9.2. Advise visitors to:

9.2.1. clean hands before and after visiting.

9.2.2. if assisting with direct patient care, use the same personal protective equipment as healthcare providers (i.e. gloves and a gown).

9.3. Refer to Contact Precautions “Rooming In” Guidelines for Family/Visitors IC 04-025 for those individuals who request to room in with a patient on Contact Precautions. 10. Management of Visitors

10.1. Advise visitors to speak with a nurse before entering the patient’s room.

10.2. Minimize the number of visitors to essential visitors only, with no more than two (2) at a time.

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10.3.1. visit only one (1) patient. If the visitor must visit more than one patient, instruct the visitor to use the same PPE as the healthcare providers and perform hand hygiene before going to the next patient room/bed space. 10.3.2. to clean their hands before accessing unit fridges, ice machines etc. 10.3.3. refrain from visiting other areas of the hospital if possible.

11. Cleaning of the Patient Environment

11.1. Allow sufficient time for cleaning and disinfecting of rooms of patients/residents on Contact Precautions.

11.2. Do not remove Contact Precautions signage from outside the room/over the bed until the terminal clean has been completed.

11.3. Communicate to Housekeeping staff the type of Contact Clean required. 11.4. Housekeeping Staff Responsibilities

11.4.1. Follow established Housekeeping cleaning protocols.

11.4.2. Ensure awareness of the type of cleaning required for individual patients on Contact Precautions, and seek clarification when necessary. (Refer to Table 2 for the 3 categories of cleaning for Contact Precautions.)

Table 2

Three categories of cleaning for Contact Precautions Contact Clean: a “regular” Contact Precautions clean and includes

patients colonized or infected with MRSA (or if being tested for MRSA and results are not known prior to transfer or discharge).

Enhanced Clean: to be completed when a patient is infected or colonized with VRE (or if being tested for VRE and results are not known prior to transfer or discharge)

Enteric Clean: to be completed when a patient has diarrhea.

11.4.3. Remove the signage and return to the nursing station upon completion of the terminal clean.

12. Linen

12.1. Place a laundry hamper in the single room or at the bedside of patients on Contact Precautions if space allows.

12.2. Carefully roll soiled linen and place in the linen hamper. Minimize shaking of soiled linen.

12.3. Double bag laundry into a clean bag for disposal only if the outside of the bag is visibly soiled with blood or body substances.

13. Dishes

Note: Disposable dishes and cutlery are not required. 13.1. Dietary Staff Members Responsibilities

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13.1.1. Clean hands and wear clean gloves to drop off and pick up trays from patients on Contact Precautions.

13.1.2. As Dietary Staff members do not set up patients for meals or clear space for trays, bring the tray to the nursing desk for delivery by nursing staff if a location to place the tray cannot be immediately found.

13.2. Place used trays from patients on Contact Precautions on tray carts if all deliveries are completed and the carts are being returned to the dish room for sanitizing.

13.3. If trays from patients on Contact Precautions are left after pick up by Food and Nutrition staff, bag the tray and leave for pick up in a designated area.

14. Waste

14.1. Place a garbage receptacle in the single room or at the bedside of patients on Contact Precautions if space allows.

14.2. Double bag waste into a clean bag for disposal only if the outside of the bag is visibly soiled with blood or body substances.

15. Patient Care Equipment/Supplies/Medications

15.1. Dedicate equipment for use with patients on Contact Precautions or clean and disinfect between patients.

15.2. Dedicate a commode at the bedside for patient use in multi-bed rooms (use the designated commode sign Prin A786).

15.3. Refer to IC 08-001Cleaning and Disinfection of Non-Critical Patient Care Equipment for more information.

15.4. Limit the amount of supplies taken into the patient’s room or bed space to prevent wastage. Discard unused items such as dressing supplies, suction catheters, syringes, linens, and paper goods upon transfer or discharge.

15.5. Have medications delivered and stored as per routine pharmacy procedures. (No special measures are required for medications.)

16. Duration of Precautions

16.1. Always contact the Infection Prevention and Control department and consult an Infection Control Practitioner before discontinuing Contact Precautions.

Note: Duration of Contact Precautions will be determined on a case-by-case basis. Re-evaluate the patient with persistent symptoms for underlying chronic disease. Repeated microbiological testing may sometimes be warranted. 16.2. For patients with C. difficile infection (CDI), confirm that the patient has been

symptom free (patient’s normal baseline stools) for 48 hours before discontinuing Contact Precautions. (Refer to Procedure #16.1.)

16.3. Discontinue Contact Precautions for CDI only after the room/bed space and bathroom have been terminally (Enteric Clean) cleaned.

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17. Handling of Deceased Bodies

17.1. Use Contact Precautions for handling deceased individuals, when Contact Precautions were in place prior to death.

MODIFICATION OF CONTACT PRECAUTIONS FOR LONG-TERM CARE 18. Resident Placement, Accommodation and Activities

18.1. Perform a risk assessment (in conjunction with an ICP on a case by case basis) to determine resident placement, removal from a shared room, or participation in group activities. Consider the presence of risk factors that increase the likelihood of transmission and the potential adverse psychological impact on the affected resident when balancing infection risks to other residents.

18.2. Use appropriate signage when Contact Precautions are required (bedside and health record).

Note: At the Veterans Memorial Building, this may consist of a green star/flower on the door.

18.3. Restrict participation in group activities only if wound drainage or diarrhea cannot be contained.

18.4. Ensure all residents perform hand hygiene (or are assisted as necessary) before and after participation with group activities.

Rationale: Reduces the stigmatization of residents on Contact Precautions. 18.5. Refer to Appendix G, Modifications of Contact Precautions for Transitional Care

Units (TCUs), for Recreation Therapy. 19. Use of PPE

19.1. Wear gloves if direct personal care contact with the resident is required or if direct contact with frequently touched environmental surfaces is anticipated.

19.2. Wear other PPE as per the point of care risk assessment. (Refer to Appendix E) MODIFICATIONS OF CONTACT PRECAUTIONS FOR AMBULATORY CARE

20. Source Control

20.1. Triage patients promptly.

20.2. Minimize contact between symptomatic patients and others by minimizing time spent in waiting rooms.

20.3. When possible, schedule symptomatic patients at a time when less likely to encounter other patients.

20.4. Place in a separate room as soon as possible.

21. Cleaning and Disinfection of Patient Care Equipment and Patient Environment 21.1. Clean equipment and surfaces in direct contact with the patient or infective

material (e.g., respiratory secretions, stool or skin exudates) before the room is used for another patient. Place contaminated reusable non-critical patient care equipment in a plastic bag for transport to a soiled utility area for reprocessing.

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21.2. Clean all horizontal surfaces and frequently touched surfaces in the room prior to use by another patient if the source patient is likely to cause extensive

environmental contamination (E.g.: diarrhea or fecal incontinence not contained by diapers, copious wound drainage, copious uncontrolled respiratory secretions or sputum).

22. Special Considerations for the Care of Patients with Antibiotic Resistant Microorganisms in Ambulatory Care Settings

22.1. Adhere to modifications of Contact Precautions for ambulatory care as found in

Appendix H.

MODIFICATIONS OF CONTACT PRECAUTIONS FOR HOME CARE 23. Accommodation

23.1. Advise symptomatic patients to:

23.1.1. Rest away from others, in a separate room if available. 23.1.2. Use a dedicated bathroom, whenever possible.

23.1.3. Clean and disinfect the bathroom frequently, especially frequently touched surfaces.

23.1.4. Not share towels or other personal items. 24. Patient Activity

24.1. Do not exclude asymptomatic patients from group/social activities.

24.2. Advise symptomatic patients how to contain secretions/excretions to minimize the risk of transmission to others (e.g., contain draining wounds with an intact

dressing) and to perform hand hygiene prior to group activities.

24.3. Advise symptomatic patients to exclude themselves from group/social activities when experiencing acute symptoms and when secretions/excretions cannot be contained.

24.4. Reschedule care and services (e.g., appointments at foot care clinics, volunteer visiting and volunteer transportation) that are not medically necessary, until clients are asymptomatic.

25. PPE

25.1. Wear gloves and gowns when direct contact is anticipated with a symptomatic patient or equipment and environmental surfaces in the patient’s immediate environment.

26. Duration of Precautions

26.1. Discontinue precautions when patient is asymptomatic in the home care setting. 27. Special Considerations For The Care of Patients With Antibiotic Resistant

Microorganisms In Home Care

27.1. Notify the home care agency (completed by the health care provider making the referral) when a patient is known to have an antibiotic resistant microorganism to

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ensure appropriate precautions are implemented. If asymptomatic, Routine Practices properly and consistently applied are sufficient.

27.2. Do not use Contact Precautions for patients who are asymptomatic including asymptomatic carriers of antibiotic resistant organisms; Routine Practices, properly and consistently applied are sufficient.

MODIFICATIONS FOR MENTAL HEALTH SETTINGS 28. Patient Placement

28.1. Place in a single room with a private bathroom or dedicated commode chair. If a single room is not available, a double room with use of dedicated commode or designated bathroom may be utilized with privacy curtains.

29. Inpatient Services: Nova Scotia Hospital, East Coast Forensic Hospital, Abbie J. Lane

29.1. If a single room is not available, space isolation may be initiated:

29.1.1. Designate a commode chair to the patient or dedicate a toilet stall and sink in shared facilities.

29.1.2. Place disinfectant wipes at the sink, clean and disinfect after use. 29.1.3. Disinfect shower and clean/replace shower drapes after patient use. 29.1.4. Advise the patient to shower last if possible.

29.1.5. If the patient is unable to remain in his/her room, monitor hand hygiene. 29.1.6. Prevent the patient from entering areas of food preparation (i.e;

kitchenette.)

30. Personal Protective Clothing (PPE) 30.1. Staff

30.1.1. Wear gloves for direct patient contact such as providing personal care to the patient.

30.1.2. Determine the need for the use of a gown or other PPE based on a risk assessment.

Note: In cases where there is only dialogue with no direct contact, careful hand hygiene only, before and after the dialogue session, is indicated. 30.1.3. Hand hygiene is essential in preventing transmission. After any contact

with the patient, bedside equipment or other contaminated articles, clean hands immediately.

30.2. Visitors

Note: No PPE is required unless direct personal care is being provided. 30.2.1. Direct visitors to clean hands before and after visiting.

31. Clinical Equipment

31.1. Keep necessary items in the patient’s room for the sole use of the patient whenever possible.

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31.2. If necessary, store carts at the nursing station or designate an “isolation area” for the protection and safety of other patients.

32. Meals

32.1. A patient who has an antibiotic resistant microorganism may eat in the unit dining room under the following conditions;

32.1.1. The patient uses alcohol based hand rub (ABHR) before and after sitting at the table for meals; staff provide assistance and directly observed.

32.1.2. Cover draining/open lesions, if any. 32.1.3. Separate the patient from others. 32.1.4. Clean and disinfect the chair after use. 32.1.5. Clean and disinfect the table after meals.

32.2. Staff members do not eat at the nursing station or in the patient dining area. 33. Respiratory Therapy Equipment

33.1. Dedicate aerosol equipment to the patient; (I.e: nebulizer, tubing and masks.) Keep in a locked area, or area designated as area for use by this patient only. Clean and disinfect after use with disinfectant wipes.

34. Electroconvulsive Therapy (ECT) Guidelines

34.1. Schedule MRSA/VRE patients as the last case of the day. 34.2. Notify the ECT unit prior to patient transport to the ECT unit. 34.3. The ECT unit/staff members:

34.3.1. Remove all unnecessary equipment.

34.3.2. Receive the patient directly into the treatment room. 34.3.3. Gown and glove to administer treatment.

34.3.4. Use disposable equipment when indicated; send non disposable items to Dartmouth General Hospital for reprocessing

REFERENCES

The Public Health Agency of Canada. (2010). Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care.

Infection Prevention and Control Nova Scotia. Department of Health and Wellness (2012). Best Practice Guidelines for Reducing Transmission of Antibiotic Resistant Organisms (AROs) in Acute & longer Term Care settings, Home Care & Prehospital Care.

Appendix A

Conditions, Clinical Presentations and Specific Etiologies Requiring Contact Precautions (In Addition To Routine Practices)

Conditions/Clinical Presentation Based on Signs and Symptoms

Other Considerations

Routine Practices are the base upon which additional precautions are applied. Note: Droplet or Airborne Infection

Precautions may also be required. All patients with diarrhea (gastroenteritis):

Until infectious cause ruled out

Diarrhea is defined as new onset diarrhea (3 or more loose stools in 24 hours) and no likely non-infectious cause (e.g. pre-existing condition or laxative use).

Diarrhea is liquid stool-if poured into a container, it conforms to the shape of the container.

Major wound infection, abscess or infected pressure (decubitus) ulcer, cellulitus or other skin infection if drainage cannot be

completely contained by dressings

Use Contact Precautions for children who are unable to comply with hand hygiene requirements, appropriate handling and disposal of purulent discharges and skin exudates, and maintain dressings in place. Extensive desquamating skin infection, until

S.

aureus infection ruled out

Use Contact Precautions for children who are unable to comply with hand hygiene requirements, appropriate handling and disposal of purulent discharges and skin exudates, and maintain dressings in place. Skin infection, (draining) not contained by a

dressing

Use Contact Precautions for children who are unable to comply with hand hygiene requirements, appropriate handling and disposal of purulent discharges and skin exudates, and maintain dressings in place. Skin rash, compatible with scabies Until 24 hours after initiation of appropriate

treatment. Skin rash, vesicular in appropriate

epidemiologic context until smallpox and monkeypox ruled out

Use Airborne Infection Precautions as well. Local public health authorities must be notified (for smallpox and monkeypox). Hemorrhagic fever, acquired in appropriate

endemic area

Use Airborne Infection Precautions as well, if pneumonia.

Local public health authorities must be notified.

Meningitis Use Droplet Precautions as well (for children

and adults) until 24 hours after initiation of appropriate treatment.

Use Contact Precautions in children less than 5 years of age due to possible

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incontinent or unable to comply with hand hygiene requirements).

Not indicated for older children who are continent and able to comply with hand hygiene

All suspected or confirmed respiratory tract infections until viral infection ruled out: • Asthma, febrile • Bronchiolitis • Colds • Croup • Influenza-like illness • Pneumonia • Pharyngitis

Use Droplet Precautions as well

Specific Etiology (Microorganism Specific)

Other Considerations

Routine Practices are the base upon which additional precautions are applied. Note: Droplet or Airborne Precautions may also be required.

Antibiotic-resistant microorganisms MRSA

VRE

Multi Resistant Gram Negative Bacteria

Infection or asymptomatic (i.e., colonization) When asymptomatic, precautions are not required in prehospital and home care. Includes MRSA, VRE, Gram-negative bacteria and other organisms as per Infection Prevention and Control policy. B. cepacia respiratory tract colonization or

infection in patient with cystic fibrosis Gastroenteritis:

All cases: C. difficile, norovirus and rotavirus *Child or incontinent adult:

Campylobacter

E.coli (0157:H7 and other strains) Giardia

Salmonella Shigella Yersinia

Adenovirus, other enteric viruses

Consider Contact Precautions for incontinent adults if stool cannot be contained or for adults with poor hygiene who contaminate their environment.

Diptheria, cutaneous

Enteroviral infections (child) Use Contact Precautions for children who are incontinent or unable to comply with hand hygiene requirements.

Not indicated for older children who are continent and able to comply with hand hygiene.

Hepatitis A, E Use Contact Precautions for children who

are incontinent or unable to comply with hand hygiene requirements.

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incontinent adults if stool cannot be contained or for adults with poor hygiene who contaminate their environment. Herpes simplex virus (neonatal or

disseminated mucocutaneous) Pediculosis (Lice) Head, body, pubic

Until 24 hours after an appropriate

pediculocide has been applied according to the manufacturer’s instructions.

Polio, acute infantile paralysis Local public health authorities must be notified.

Rubella, congenital (German Measles) Use Droplet Precautions as well. Immune healthcare workers only. Local public health authorities must be notified.

Scabies Until 24 hours after initiation of treatment.

Smallpox, monkeypox, generalized vaccinia and

eczema vaccinatum

Use Airborne Infection Precautions as well. Local public health authorities must be notified.

Staphylococcus aureus skin infections: • major wound or skin infection where drainage

is not contained by a dressing

Streptococcus group A skin infections • major wound or skin infection where drainage

cannot be contained by dressing

• all cases of severe *invasive streptococcal disease or toxic shock syndrome

Use Droplet Precautions as well until 24 hours after initiation of appropriate treatment.

*Local public health authorities must be notified.

Vaccinia (eczema vaccinatum or disseminated

vaccinia)

Varicella zoster virus • Varicella (chickenpox)* • Shingles (zoster) -disseminated*

-localized (immunocompromised host)*

-localized normal host

Varicella immune healthcare workers *Use Airborne Infection Precautions as well.

Viral hemorrhagic fevers: Lassa, Ebola, Marburg, Crimean-Congo and others Please refer to body of text for further details.

Use Airborne Infection Precautions as well, if pneumonia.

Viral respiratory tract infections

• Adenovirus

• Bocavirus

• Coronavirus

• Human metapneumovirus

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• Influenza

• Parainfluenza virus

• Rhinovirus

• Respiratory syncytial virus

• Severe acute respiratory syndrome

• Coronavirus (SARS Co-V )

Reference: The Public Health Agency of Canada. (2010). Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care

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Contact Precautions Cohorting (placing in the same room)

Patient infected/colonized with the same lab confirmed microorganism?

NO YES

Consider Cohort

Patient suitable to have roommate? No open wounds? Able to comply

with precautions? YES Cohort Do not Cohort NO Do not Cohort

APPENDIX B

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APPENDIX D

Sequence for Applying and Removing Personal Protective Equipment (PPE) The PPE chosen depends on the anticipated risk for exposure to contaminated surfaces or blood and body substances/fluids.

Application (order is

not critical)

Clean hands Clean hands with soap and water or an alcohol-based hand rub. 1. Gown A long sleeved gown is applied with opening at the back and is tied

at neck and waist to cover exposed skin and clothing.

If gown is too small, wear two gowns. Gown one ties in front and gown two in back.

2. Mask (when required)

Mask is placed over nose, mouth and chin. Adjust the flexible nose piece to fit.

Secure with ties or elastics. 3. Protective eyewear Adjust to fit comfortably.

4. Gloves Select correct type and size. Extend gloves over gown cuff.

Removal (order

important)

1. Gloves Pinch outside edge of glove near wrist.

Peel away from hand, turning glove inside-out. Hold in opposite gloved hand.

Slide ungloved finger under cuff of the remaining glove. Peel off from inside, creating a bag for both gloves. Discard.

2. Gown Unfasten ties.

Peel gown away from neck and shoulders. Pull arms out (gown will turn inside out). Fold or roll into a bundle.

Discard. Clean hands.

3. Protective eyewear Grasp ear of head pieces. Lift away from face.

Place in designated receptacle for reprocessing or disposal or disinfect at point of care.

4. Mask Untie the bottom, then top tie, and remove from face by the ties. Do not grasp the front of the mask. Remove a procedure mask by grasping the elastic bands around the ears.

Discard.

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APPENDIX E

Point of Care Risk Assessment:

Before every patient interaction ask yourself: What task am I doing?

What are the patient’s symptoms?

What is my risk of exposure to blood, body fluids, excretions, secretions, non-intact skin & mucous membranes?

What is my skill level for this task? How cooperative is the patient?

What is the environment where I will be performing this task? What actions do I need to take?

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APPENDIX F

Transport Protocol - Patients on Contact Precautions

1. When possible, prior to transport, have the patient wash his/her hands or use an alcohol based hand rub.

2. Staff will wear gloves and a gown for close transfers from the bed to the transport vehicle. 3. Wrap (swaddle) the patient in a clean blanket or sheet to contain them during transport. 4. Remove gloves, gown and wash hands or use alcohol based hand rub.

5. Put on clean gloves, pick up the chart, and transport the patient to destination.

6. Ensure the health record has a Contact Precautions sign securely fastened to the chart cover.

7. To avoid contamination of the health record, enclose it in a clear plastic bag if placing it on the stretcher or giving it to the patient to hold for transport.

8. Notify the receiving department to advise that the patient is in transport to them. 9. Decontaminate the stretcher or wheelchair immediately after use to avoid

cross-contamination to others. Use a hospital approved disinfectant. 10. Discard plastic bag chart cover appropriately.

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APPENDIX G

February/2011

Additional Recreational Therapy

Guidelines for Nursing Unit 4B

These guidelines are intended to accompany the Infection Control/ Recreation Therapy Group/Individual Participation Guidelines for Patients under MRSA Precautions

The following guidelines have been approved for Nursing Unit 4B only These guidelines are not to be considered applicable to any other unit Any patient with MRSA/VRE, or a patient positive for Vancomycin Resistant Entercoccus (VRE) will need to be assessed by the Infection Prevention and Control

Practitioner on a case by case basis

1. The Infection Prevention and Control Team do NOT need to be consulted for every patient entered in every recreation therapy activity as long as the participation

guidelines are followed. Any patient under additional precautions (such as isolation for VRE, enteric measures, droplet precautions, etc. will require a consult with the

Infection Prevention and Control Practitioner

2. Patients who cannot independently understand and follow infection control guidelines may participate in programs provided they can successfully follow guidelines when cued by staff

3. Patients may participate in food based programs as long as the infection prevention and control guidelines are adhered to

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APPENDIX H

ANTIBIOTIC RESISTANT MICROORGANISM (ARO) POSITIVE PATIENTS in Capital Health Ambulatory Care Settings

General Infection Prevention and Control (IPAC) Recommendations

These recommendations are for outpatients in ambulatory care settings. They are not for use on the inpatient units. These do not apply to Endoscopy, Minor

Procedures and Emergency Department areas.

*Note: inpatient precaution guidelines are to be followed when seeing inpatients on precautions in ambulatory care settings.

Definition: ARO (antibiotic resistant microorganism) Carrier - a patient with MRSA and/or VRE who is “flagged” with an Infection Control alert in the STAR/PHS patient

registration system or offers a history of MRSA and/or VRE colonization/infection identified outside of CDHA. Note for clerks: Infection Control alerts are only visible in STAR/PHS, not GUI. Ensure STAR/PHS registration is completed prior to the patient being seen.

Preamble:

Precautions taken in ambulatory care settings are situation dependent and based on a risk/benefit assessment. This assessment takes into consideration the type and duration of patient/ health care worker interaction, the medical condition of the patient, responsible use of resources, and need to maintain efficient patient flow.

Underlying Principles:

Maintaining the dignity, privacy, and confidentiality of every patient must be paramount when implementing IPAC recommendations.

All patients presenting to reception/registration should clean their hands on arrival with alcohol based hand rub (ABHR).

o Signage should be clearly displayed to convey this message to all patients/visitors.

o Staff should remind patients to clean their hands upon entry/exit to the area. AROs such as methicillin-resistant Staphylococcus aureus (MRSA) and

vancomycin-resistant enterococci (VRE) are spread by contact. If a patient or a health care worker’s hands have not touched something, they are not contaminated.

o Supplies in patient care rooms should be kept to a minimum at all times.

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 Supplies are not to be touched with soiled hands or gloves (in order to prevent cross-contamination).

o Privacy curtains in patient care rooms are not to be handled with

contaminated hands or soiled gloves. Curtains are changed on a rotating schedule and when visibly soiled.

ARO contacts are cared for in the ambulatory care setting using Routine Practices. These are patients flagged in the *STAR system as “contacts”.

o * If possible, collect requested specimens (contact IPAC if clarification required).

Recommendations:

After registration, MRSA/VRE positive patients (carriers) go directly to a patient care room, if possible.

o Note, once the patient’s hands are clean the risk of ARO transmission from a clean and fully clothed patient (who does not have uncovered draining

wounds etc…) in a waiting room setting is considered negligible.

o If a patient does sit in a public waiting area (fully clothed with wounds

covered) it is not necessary to clean or disinfect the chair afterwards. Routine scheduled environmental cleaning is sufficient.

o Waiting areas should have a ready supply of ABHR, tissues and a garbage receptacle(s). Signage should be in place in waiting areas regarding the importance of hand hygiene.

o If magazines are kept in waiting areas, they should be discarded when visibly soiled and at regular intervals. Binders or protective coverings on magazines are not recommended unless they can be cleaned. Toys are not

recommended. Refer to the Capital Health IPAC Position Statement on Toys and Magazines in Waiting Areas.

If a patient must undress, a disposable patient belongings bag should be provided for their clothing and personal effects if required. Communal lockers may then be used (if applicable).

ARO carriers may use the public washrooms in the area. The washroom does not need to be put out of service and no enhanced cleaning by Housekeeping is required unless there is visible soiling.

A Contact Precautions sign may be placed on the patient care room door to communicate this patient’s ARO status to members of the health care team. Charts may be brought into the patient care room provided they are placed in a

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A point of care risk assessment is conducted by the health care provider(s). This is done to determine the nature of the health care interaction and the likelihood of personal contamination and/or contamination of the care environment.

o Gloves are worn by health care providers when touching the patient and as per Routine Practices.

o Masks are worn as per Routine Practices i.e. as an element of Personal Protective Equipment (PPE).

o Determine if a gown is required as part of the point of care risk assessment.  Gowns are used to protect health care providers’ exposed skin and

clothing from contamination.

 In general, gowns are worn for dressing changes, physical examinations, direct physical assistance, and other procedures requiring close contact at the point of care.

Dedicate equipment for use with this patient (e.g. a blood pressure cuff, stethoscope, etc…).

Post Visit/Cleaning Procedures:

Responsibility for cleaning is area and resource specific. It may be done by clinic staff and/or Housekeeping Services.

1. Touch surfaces (that have been contaminated during patient care) and equipment used during the visit require thorough cleaning and disinfection following the visit. Use a regular hospital approved cleaner/ low level disinfectant and appropriate PPE.

a. Examples of touch surfaces and equipment – arms of chair, doorknob, examining table, stethoscope, and B/P cuff.

2. In general, basic cleaning can be delegated to a member of the care team (i.e. the Clinic Aide if applicable) and if clinic resources permit.

3. If gross soiling of the room or washroom has occurred, Housekeeping Services are required.

INFECTION PREVENTION AND CONTROL MANUAL Policy and Procedure