Standard & Transmission-based Precautions

Standard & Transmissionbased Precautions Janet D. Robinson, RN, MEd, CIC March 30, 2017 CMS Reform of Requirements (a)(2) Written standards, policies, and procedures.. (iii) Standard and transmission-based precautions to be followed to prevent spread of infections: (iv) When and how isolation should be used for a resident;

including but not limited to: (A) The type and duration of isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. Objectives Identify the CDC Guideline containing the principles of standard and transmission-based precautions.

Recognize the main components of standard precautions. Identify contact precautions as the most commonly used transmission-based precaution. CDC Guidelines www.cdc.gov Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007

Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006 Guideline for Hand Hygiene in Health-Care Settings, 2002 2007 Guideline Objectives 1. Provide infection control recommendations for all components of the healthcare delivery system, including hospitals, long-term care facilities, ambulatory care, home care and hospice 2. Reaffirm Standard Precautions as the foundation for

preventing transmission during patient care in all healthcare settings 3. Reaffirm the importance of implementing Transmission-Based Precautions based on the clinical presentation or syndrome and likely pathogens until the infectious etiology has been determined 4. Provide epidemiologically sound and, whenever possible, evidence-based recommendations Standard Precautions Hand Hygiene

Pers. Prot. Equipment Safe Injection Practices Resp Hygiene/Cough Etiquette Environmental Cleaning Did You Know Alcohol-based hand rub is the preferred method of hand hygiene for health-care workers.

Did You Know Pathogens can be transferred from surfaces to HCW hands without direct patient contact. Did You Know There are more microorganisms under your fingernails than

anywhere else on your hands. Artificial nails (and rings) increases the number of bacteria on hands, both before and after washing. Did You Know Germs on your hands grow much faster inside gloves where it is warm and moist.

Hand Hygiene Alcohol Based Hand Rub preferred method Before and after resident and environment contact Soap & water for visibly dirty hands, before eating, after bathroom use and for Clostridium difficile and norovirus Hand Hygiene Monitoring Tool

Personal Protective Equipment Gloves contact with body fluids, mucous membranes, non intact skin, potentially contaminated equipment/environment Gown contact with body fluids always worn with gloves Mask (goggles, face shields )

contact with respiratory secretions, or fluid sprays Gloves DO NOT: Wear too long One resident only One activity only Touch too much

Wheelchairs Equipment in room Self Trust too much Gowns & Masks Gowns Fluid-repellent Apron does not offer same protection Always worn with gloves

Masks Surgical are FDA cleared Procedure/isolation not FDA cleared Safe Injection Practices Hand hygiene before and after touching equipment Insulin pens/fingerstick devices one resident use only Sterile needle/syringe use dedicated to one patient/

one use Single dose vials = best practice Multi dose vials sterile needle & syringe each entry, one resident only/dated Respiratory Etiquette Visual Alerts (signs) Availability of supplies Masking and Distancing Droplet Precautions when needed

Cleaning & Disinfection Cleaning: physical removal of organic matter and dirt Disinfection: EPA approved method for pathogen destruction (Contact time is critical) Cleaning & Disinfection: part of standard precautions Why Clean & Disinfect? Environment becomes contaminated with pathogens

which can be picked up by patients and HCWs. Multiple publications/studies suggest environmental disinfection can reduce acquisition of healthcareassociated pathogens. Effective environmental cleaning combined with hand hygiene and appropriate use of gloves and gowns decreases HCW/patient contamination and reduces spread of MDROs. Why Clean & Disinfect? Patient infected or colonized with a

pathogen. Patient is discharged and room is not cleaned and disinfected correctly. Surfaces remain contaminated with the pathogen. The next room occupant is at increased risk of acquiring the pathogen. Environmental Staff

Key Education Points Standardized procedures checklists Daily room cleaning & Terminal room cleaning Emphasis on frequently-touched surfaces Frequency of: changing wipes, mopheads, solutions Hand hygiene and PPE use (esp. gloves) Read and follow cleaner/disinfectant labels All rooms and equipment need a schedule

Clean to dirty Resident Rooms & Bathrooms Standard precaution rooms Contact precaution rooms Last cleaned Personal protective equipment Disposable vs. re-usable supplies Terminal Cleaning

Resident discharge Discontinuation of contact precautions (especially for Clostridium difficile) Bleach product Dining Room Hand hygiene should be a requirement to utilize the dining room Tables & chairs wiped down after each meal

at least once per day Residents with draining wounds and uncontained incontinence do not belong in the dining room Activity Room Hand hygiene at room entry Respiratory etiquette Equipment cleaned/disinfected after each use Tables & chairs wiped down at least once per day

Residents with contained secretions/excretions may participate Physical & Occupational Therapy Room Hand hygiene at room entry Respiratory etiquette Equipment cleaned/disinfected after each use Individual gait belts Plan in place for MDROs last client, in-room

therapy Carpeting Organisms present in larger numbers as well as dust and debris More difficult to keep clean Need routine vacuuming and deep cleaning Minimize aerosolization of dust (fungal spores) Disinfection challenging, especially after blood and body fluid spills

Equipment Resident-care devices (e.g. electronic thermometers or glucose monitoring devices) may transmit pathogens if devices contaminated with blood or body fluids are shared without cleaning and disinfecting between uses for different residents; surveyor guidance for F TAG 441 CDC. Transmission of Hepatitis B Virus Among Persons

Undergoing Blood Glucose Monitoring in Long-TermCare-Facilities Mississippi, North Carolina, and Los Angeles County, California, 2003-2004. MMWR, 2005;54(No.9):220-223 Technology Ultraviolet (UV-C) Light All pathogens not vulnerable to same wavelength Hydrogen peroxide vapor Microfiber

Static charge attracts dirt Enhanced surface area Challenges for Keeping it Clean Environmental contamination is ongoing. Limited time, staff and money Culture Change Least restrictive isolation Home-like atmospherecarpeting!

Group activities Animal visits Resources Cleaning & Disinfection CDC Guideline for Disinfection & Sterilization in Healthcare Facilities, 2008 CDC Guidelines for Environmental Infection Control in Health-care Facilities, 2003 Association for the Healthcare Environment ahe.org

2nd Edition Practice Guidance for Healthcare Environmental Cleaning Additional Precautions Standard Precautions = MUST. Transmission-based precautions = add-on when indicated. Maintain as long as necessary to prevent transmission. Modify the CDC GUIDELINES for your facilitys

capabilities and resources. Modifying Isolation Precautions CDC Guideline for Isolation Precautions .recommendations that can be applied in all health care settings using common principles of infection control practice, yet can be modified to reflect setting-specific needs. Residents who are colonized or infected with certain micro-organisms are, in some cases, restricted to their room. However, because of the psychosocial risks associated with such restriction, it has been recommended that

psychosocial needs be balanced with infection control needs in the LTCF setting. CDC Management of Multidrug-Resistant Organisms consider the individual patients clinical situation and prevalence or incidence of MDRO in the facility when deciding whether to implement or modify contact precautions in addition to standard precautions.. Culture Change knowing and respecting each nursing home

resident and providing individualized care that best enhances each residents quality of life. transform the traditional institutional approach to care delivery into one that is person directed, and responds to what each person wants and needs. CMS 2008 Action Plan for Nursing Home Quality Person-Centered Care values of respect for persons, individual right to self determination, mutual respect, and understanding.

The physical environment of care has for a long time been recognised as having a significant impact on the care experiences and patient outcomes. Developing Person-Centred Care: Addressing Contextual Challenges Through Practice Development (The Online Journal of Issues in Nursing, A Scholarly Journal of the American Nurses Association. May 31, 2011) In a Perfect World many patient-centered hospitals opt to make the

change from semi-private, shared rooms to private rooms, which growing evidence suggests is not only a patient-satisfier, but also decreases the incidences of hospital-acquired infections. Patient-Centered Care Improvement Guide 2008 by Planetree (www.planetree.org) and Picker Institute (www.pickerinstitute.org) In the Real World Industry pressure to provide homelike environment

Financial pressure to fill beds Resident acuity may limit the homelike environment Transmission-based Precautions Airborne TB negative pressure, N-95s usually transferred ASAP Droplet Influenza

mask within 6-10 feet (room entry) Contact MDROs and C. difficile gloves & gown for room entry dedicated equipment enhanced cleaning/disinfection Airborne Transmission Tiny droplet nuclei - 5 microns or smaller

Aerosolized during coughing, sneezing, speaking or singing Travel on air currents and are inhaled Airborne Precautions negative pressure room Private room with private bathroom Negative pressure relative to hallway Air sent outdoors or through HEPA filter

Six or more air changes per hour (in some settings 12 or more air changes per hour are recommended) N95 respirator use for staff & visitors Droplet Transmission Large heavy droplets Discharged from nose or mouth during coughing or sneezing Direct contact with anothers eyes and mucous membranes of nose or mouth

3 feet? 6 feet? Droplet Precautions Private room preferred prioritize for patients with excessive cough/sputum make room decisions on case-by-case basis consider infection risks to other patient in room/available alternative spatial separation of at least 3 feet if shared room/draw curtain Mask on room entry for staff

Mask for patient (if tolerated) when transported out of room Direct Contact Transmission Infectious organisms on the skin, in a body substance, or on the hands of one person are acquired directly by another person Indirect Contact Transmission Infectious organisms are acquired indirectly

from contact with a contaminated object or surface Contact Precautions Gloves/Gowns - all contact with resident/environ Dedicated Equipment Enhanced Environmental Cleaning Private Room Movement restrictions

Room Placement Private always first choice for any transmission based isolation MRSA pneumonia and Clostridium difficile uncontained secretions resp, wound, excretions Cohort same bug no mix & match Room-mate with limited risk factors

no tubes no open areas no immunosupression Out of Room Criteria Clean Contained ... Cooperative Hand Hygiene Clean clothes Covered wound Continent/briefed

Cooperative with direction Reusable Dishware II.M. Dishware and eating utensils The combination of hot water and detergents used in dishwashers is sufficient to decontaminate dishware and eating utensils. Therefore, no special precautions are needed for dishware (e.g., dishes, glasses, cups) or eating utensils; reusable dishware and utensils may be used

for patients requiring Transmission-Based Precautions. Excerpted from CDC 2007 Guideline for Isolation Precautions:Preventing Transmission of Infectious Agents in Healthcare Settings Odds & Ends Food trays Trash Double bagging Double gloving

Categorizing Recommendations IA Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiological studies. IB Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale. IC Required for implementation, as mandated by federal and/or state

regulation or standard. II Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale. No recommendation; unresolved issue. Practices for which in sufficient evidence or no consensus regarding efficacy exists. Summary Standard Precautions for All Transmission-based Precautions for Some

Modifications when indicated Short duration Hand hygiene and environmental cleanliness are essential