Florida Nursing Standard Precautions

 

Objectives:

1. Describe key recommendations for hand hygiene.

2. Describe the proper way to clean medical equipment.

 

Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. These practices are designed to both protect HCP and prevent HCP from spreading infections among patients. Standard Precautions include: 1) hand hygiene, 2) use of personal protective equipment (e.g., gloves, gowns, masks), 3) safe injection practices, 4) safe handling of potentially contaminated equipment or surfaces in the patient environment, and 5) respiratory hygiene/cough etiquette. Each of these elements of Standard Precautions are described in the sections that follow.

Education and training on the principles and rationale for recommended practices are critical elements of Standard Precautions because they facilitate appropriate decision-making and promote adherence. Further, at the facility level, an understanding of the specific procedures performed and typical patient interactions, as described above in Administrative Measures as part of policy and procedure development, will assure that necessary equipment is available.
Hand Hygiene

Good hand hygiene, including use of alcohol-based hand rubs and handwashing with soap and water, is critical to reduce the risk of spreading infections in ambulatory care settings. Use of alcohol-based hand rub as the primary mode of hand hygiene in healthcare settings is recommended by the CDC and the World Health Organization (WHO) because of its activity against a broad spectrum of epidemiologically important pathogens, and because compared with soap and water, use of ABHR in healthcare settings can increase compliance with recommended hand hygiene practices by requiring less time, irritating hands less, and facilitating hand hygiene at the patient bedside. For these reasons, alcohol-based hand rub is the preferred method for hand hygiene except when hands are visibly soiled (e.g., dirt, blood, body fluids), or after caring for patients with known or suspected infectious diarrhea (e.g., Clostridium difficile, norovirus), in which case soap and water should be used.

Key recommendations for hand hygiene in ambulatory care settings:

  • Key situations where hand hygiene should be performed include:
    • Before touching a patient, even if gloves will be worn
    • Before exiting the patient’s care area after touching the patient or the patient’s immediate environment
    • After contact with blood, body fluids or excretions, or wound dressings
    • Prior to performing an aseptic task (e.g., placing an IV, preparing an injection)
    • If hands will be moving from a contaminated-body site to a clean-body site during patient care
    • After glove removal
  • Use soap and water when hands are visibly soiled (e.g., blood, body fluids), or after caring for patients with known or suspected infectious diarrhea (e.g., Clostridium difficile, norovirus). Otherwise, the preferred method of hand decontamination is with an alcohol-based hand rub.

Personal Protective Equipment

Personal Protective Equipment (PPE) refers to wearable equipment that is intended to protect HCP from exposure to or contact with infectious agents. Examples include gloves, gowns, face masks, respirators, goggles and face shields. The selection of PPE is based on the nature of the patient interaction and potential for exposure to blood, body fluids or infectious agents. Examples of appropriate use of PPE for adherence to Standard Precautions include: use of gloves in situations involving possible contact with blood or body fluids, mucous membranes, non-intact skin or potentially infectious material; use of a gown to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated; use of mouth, nose and eye protection during procedures that are likely to generate splashes or sprays of blood or other body fluids. Hand hygiene is always the final step after removing and disposing of PPE.
In addition to protection of HCP, face masks are also effective in limiting the dispersal of oropharyngeal droplets and are recommended when placing a catheter or injecting materials into epidural or subdural spaces, as during myelography or spinal or epidural anesthesia. Failure to wear face masks during these procedures has resulted in development of bacterial meningitis in patients undergoing these procedures. Each ambulatory care facility/setting should evaluate the services they provide to determine specific needs and to assure that sufficient and appropriate PPE is available for adherence to Standard Precautions. All HCP at the facility should be educated regarding proper selection and use of PPE.

Key recommendations for use of PPE in ambulatory care settings:

  • Facilities should assure that sufficient and appropriate PPE is available and readily accessible to HCP
  • Educate all HCP on proper selection and use of PPE
  • Remove and discard PPE before leaving the patient’s room or area
  • Wear gloves for potential contact with blood, body fluids, mucous membranes, non-intact skin or contaminated equipment
    • Do not wear the same pair of gloves for the care of more than one patient
    • Do not wash gloves for the purpose of reuse
    • Perform hand hygiene immediately after removing gloves
  • Wear a gown to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated
    • Do not wear the same gown for the care of more than one patient
  • Wear mouth, nose and eye protection during procedures that are likely to generate splashes or sprays of blood or other body fluids
  • Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space

Injection Safety

Injection safety includes practices intended to prevent transmission of infectious diseases between one patient and another, or between a patient and healthcare provider during preparation and administration of parenteral medications.

Implementation of the OSHA Bloodborne Pathogens Standard has helped increase the protection of HCP from blood exposure and sharps injuries, but there is room for improvement in ambulatory care settings. For example, efforts to increase uptake of hepatitis B vaccination and implementation of safety devices that are designed to decrease risks of sharps injury are needed.

Further attention to patient protection is also needed as evidenced by continued outbreaks in ambulatory settings resulting from unsafe injection practices. Unsafe practices that have led to patient harm include 1) use of a single syringe, with or without the same needle, to administer medication to multiple patients, 2) reinsertion of a used syringe, with or without the same needle, into a medication vial or solution container (e.g., saline bag) to obtain additional medication for a single patient and then using that vial or solution container for subsequent patients, 3) preparation of medications in close proximity to contaminated supplies or equipment.

Key recommendations for safe injection practices in ambulatory care settings:

  • Use aseptic technique when preparing and administering medications
  • Cleanse the access diaphragms of medication vials with 70% alcohol before inserting a device into the vial
  • Never administer medications from the same syringe to multiple patients, even if the needle is changed or the injection is administered through an intervening length of intravenous tubing
  • Do not reuse a syringe to enter a medication vial or solution
  • Do not administer medications from single-dose or single-use vials, ampoules, or bags or bottles of intravenous solution to more than one patient
  • Do not use fluid infusion or administration sets (e.g., intravenous tubing) for more than one patient
  • Dedicate multidose vials to a single patient whenever possible. If multidose vials will be used for more than one patient, they should be restricted to a centralized medication area and should not enter the immediate patient treatment area (e.g., operating room, patient room/cubicle)
  • Dispose of used syringes and needles at the point of use in a sharps container that is closable, puncture-resistant, and leak-proof.
  • Adhere to federal and state requirements for protection of HCP from exposure to bloodborne pathogens.

Environmental Cleaning

Ambulatory care facilities should establish policies and procedures for routine cleaning and disinfection of environmental surfaces as part of their infection prevention plan. Cleaning refers to the removal of visible soil and organic contamination from a device or environmental surface using the physical action of scrubbing with a surfactant or detergent and water, or an energy-based process (e.g., ultrasonic cleaners) with appropriate chemical agents. This process removes large numbers of microorganisms from surfaces and must always precede disinfection. Disinfection is generally a less lethal process of microbial inactivation (compared to sterilization) that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial spores).

Emphasis for cleaning and disinfection should be placed on surfaces that are most likely to become contaminated with pathogens, including those in close proximity to the patient (e.g., bedrails) and frequently-touched surfaces in the patient-care environment (e.g., doorknobs). Facility policies and procedures should also address prompt and appropriate cleaning and decontamination of spills of blood or other potentially infectious materials.

Responsibility for routine cleaning and disinfection of environmental surfaces should be assigned to appropriately trained HCP. Cleaning procedures can be periodically monitored or assessed to ensure that they are consistently and correctly performed. EPA-registered disinfectants or detergents/disinfectants with label claims for use in healthcare should be selected for disinfection. Disinfectant products should not be used as cleaners unless the label indicates the product is suitable for such use. Healthcare professionals should follow manufacturer’s recommendations for use of products selected for cleaning and disinfection (e.g., amount, dilution, contact time, safe use, and disposal).

Key recommendations for cleaning and disinfection of environmental surfaces in ambulatory care settings:

  • Establish policies and procedures for routine cleaning and disinfection of environmental surfaces in ambulatory care settings
    • Focus on those surfaces in proximity to the patient and those that are frequently touched
  • Select EPA-registered disinfectants or detergents/disinfectants with label claims for use in healthcare
  • Follow manufacturer’s recommendations for use of cleaners and EPA-registered disinfectants (e.g., amount, dilution, contact time, safe use, and disposal)

Medical Equipment

Medical equipment is labeled by the manufacturer as either reusable or single-use. Reusable medical equipment (e.g., endoscopes) should be accompanied by instructions for cleaning and disinfection or sterilization as appropriate. Single-use devices (SUDs) are labeled by the manufacturer for only a single use and do not have reprocessing instructions. They may not be reprocessed except by entities which have complied with FDA regulatory requirements and have received FDA clearance to reprocess specific SUDs.

All reusable medical equipment must be cleaned and maintained according to the manufacturer’s instructions to prevent patient-to-patient transmission of infectious agents. The Spaulding Classification is a traditional approach that has been used to determine the level of disinfection or sterilization required for reusable medical devices, based upon the degree of risk for transmitting infections if the device is contaminated at the time of use.

  • Critical items (e.g., surgical instruments) are objects that enter sterile tissue or the vascular system and must be sterile prior to use.
  • Semi-critical items (e.g., endoscopes used for upper endoscopy and colonoscopy) contact mucous membranes or non-intact skin and require, at a minimum, high-level disinfection prior to reuse.
  • Noncritical items (e.g., blood pressure cuffs) are those that may come in contact with intact skin but not mucous membranes and should undergo low- or intermediate-level disinfection depending on the nature and degree of contamination.
  • Environmental surfaces (e.g., floors, walls) are those that generally do not contact the patient during delivery of care. Cleaning may be all that is needed for the management of these surfaces but if disinfection is indicated, low-level disinfection is appropriate.

Cleaning to remove organic material must always precede disinfection or sterilization because residual debris reduces the effectiveness of the disinfection and sterilization processes.
Facilities should establish policies and procedures for containing, transporting, and handling equipment that may be contaminated with blood or body fluids. Manufacturer’s instructions for reprocessing any reusable medical equipment in the facility (including point-of-care devices such as blood glucose meters) should be readily available and used to establish clear and appropriate policies and procedures. Instructions should be posted at the site where equipment reprocessing is performed. Responsibility for cleaning, disinfection and/or sterilization of medical equipment should be assigned to HCP with training in the required reprocessing steps and in the appropriate use of PPE necessary for handling of contaminated equipment. Competencies of HCP responsible for reprocessing of equipment should be documented initially upon assignment of those duties, whenever new equipment is introduced, and periodically (e.g., semi-annually).

Key recommendations for cleaning, disinfection, and/or sterilization of medical equipment in ambulatory care settings:

  • Facilities should ensure that reusable medical equipment (e.g., blood glucose meters and other point-of-care devices, surgical instruments, endoscopes) is cleaned and reprocessed appropriately prior to use on another patient
  • Reusable medical equipment must be cleaned and reprocessed (disinfection or sterilization) and maintained according to the manufacturer’s instructions. If the manufacturer does not provide such instructions, the device may not be suitable for multi-patient use
  • Assign responsibilities for reprocessing of medical equipment to HCP with appropriate training
    • Maintain copies of the manufacturer’s instructions for reprocessing of equipment in use at the facility; post instructions at locations where reprocessing is performed
    • Observe procedures to document competencies of HCP responsible for equipment reprocessing upon assignment of those duties, whenever new equipment is introduced, and on an ongoing periodic basis (e.g., quarterly)
  • Assure HCP have access to and wear appropriate PPE when handling and reprocessing contaminated patient equipment

Respiratory Hygiene/Cough Etiquette

Respiratory Hygiene/Cough Etiquette is an element of Standard Precautions that highlights the need for prompt implementation of infection prevention measures at the first point of encounter with the facility/ambulatory settings (e.g., reception and triage areas). This strategy is targeted primarily at patients and accompanying family members or friends with undiagnosed transmissible respiratory infections, and applies to any person with signs of illness including cough, congestion, rhinorrhea, or increased production of respiratory secretions when entering the facility.

Key recommendations for Respiratory Hygiene/Cough Etiquette in ambulatory care settings:

  • Implement measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at point of entry to the facility and continuing throughout the duration of the visit.
    • Post signs at entrances with instructions to patients with symptoms of respiratory infection to:
      • Cover their mouths/noses when coughing or sneezing
      • Use and dispose of tissues
      • Perform hand hygiene after hands have been in contact with respiratory secretions
    • Provide tissues and no-touch receptacles for disposal of tissues
    • Provide resources for performing hand hygiene in or near waiting areas
    • Offer masks to coughing patients and other symptomatic persons upon entry to the facility
    • Provide space and encourage persons with symptoms of respiratory infections to sit as far away from others as possible. If available, facilities may wish to place these patients in a separate area while waiting for care
  • Educate HCP on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens when examining and caring for patients with signs and symptoms of a respiratory infection.

Additional Considerations

The majority of ambulatory care settings are not designed to implement all of the isolation practices and other Transmission-Based Precautions (e.g., Airborne Precautions for patients with suspected tuberculosis, measles or chicken pox) that are recommended for hospital settings. Nonetheless, specific syndromes involving diagnostic uncertainty (e.g., diarrhea, febrile respiratory illness, febrile rash) are routinely encountered in ambulatory settings and deserve appropriate triage. Facilities should develop and implement systems for early detection and management of potentially infectious patients at initial points of entry to the facility. To the extent possible, this includes prompt placement of such patients into a single-patient room and a systematic approach to transfer when appropriate. When arranging for patient transfer, facilities should inform the transporting agency and the accepting facility of the suspected infection type.

Conclusions

The recommendations described in the preceding document represent the absolute minimum infection prevention expectations for safe care in outpatient (ambulatory care) settings. This guidance is not all-encompassing. Facilities and HCP are encouraged to refer to the original source documents, which provide more detailed guidance and references for the information included in this document.

Fundamental elements needed to prevent transmission of infectious agents in ambulatory care settings.

Dedicate Resources to Infection Prevention (Administrative Measures)

Infection prevention must be made a priority in any setting where healthcare is delivered. Those with primary administrative oversight of the ambulatory care facility/setting must ensure that sufficient fiscal and human resources are available to develop and maintain infection prevention and occupational health programs. This includes the availability of sufficient and appropriate equipment and supplies necessary for the consistent observation of Standard Precautions, including hand hygiene products, injection equipment, and personal protective equipment (e.g., gloves, gowns, face and eye protection).

Infection prevention programs must extend beyond Occupational Safety and Health Administration (OSHA) bloodborne pathogen training to address patient protection. Facilities should assure that at least one individual with training in infection prevention is employed by or regularly available to the facility. This individual should be involved in the development of written infection prevention policies and have regular communication with HCP to address specific issues or concerns related to infection prevention. The development and ongoing refinement of infection prevention policies and procedures should be based on evidence-based guidelines, regulations, or standards. These policies and procedures should be tailored to the facility and re-assessed on a regular basis (e.g., annually), taking into consideration the types of services provided by the facility and the patient population that is served. This process (referred to as risk assessment by the Infection Prevention profession) will allow facilities to better prioritize resources and focus extra attention on those areas that are determined to pose greater risk to their patients. For example, an ambulatory surgical center, which performs on-site sterilization of surgical equipment, would be expected to have more detailed policies regarding equipment reprocessing than a substance abuse clinic, where on-site sterilization is unlikely to be performed. However, both facilities should have policies and procedures addressing handling of reusable medical equipment. Similarly, a clinic primarily serving patients infected with tuberculosis will have infection prevention needs beyond those of a general pediatric office.

Facility administrators should also assure that facility policies and procedures address occupational health needs including vaccination of HCP, management of exposures or infections in personnel requiring post-exposure prophylaxis and/or work restrictions, and compliance with OSHA bloodborne pathogen standards.
Key administrative recommendations for ambulatory care settings:

  • Develop and maintain infection prevention and occupational health programs
  • Assure sufficient and appropriate supplies necessary for adherence to Standard Precautions (e.g., hand hygiene products, personal protective equipment, injection equipment)
  • Assure at least one individual with training in infection prevention is employed by or regularly available to the facility
  • Develop written infection prevention policies and procedures appropriate for the services provided by the facility and based upon evidence-based guidelines, regulations, or standards

  • Educate and Train Healthcare Personnel
  • Ongoing education and training of HCP are critical for ensuring that infection prevention policies and procedures are understood and followed. Education on the basic principles and practices for preventing the spread of infections should be provided to all HCP. Training should include both HCP safety (e.g., OSHA bloodborne pathogen training) and patient safety, emphasizing job- or task-specific needs. Education and training should be provided upon orientation to the facility and should be repeated regularly (e.g., annually) to maintain competency, including anytime policies or procedures are updated/revised. Competencies should be documented initially and as appropriate for the specific HCP positions.
    Key recommendations for education and training of healthcare personnel in ambulatory care settings:
  • Provide job- or task-specific infection prevention education and training to all HCP
    • This includes those employed by outside agencies and available by contract or on a volunteer basis to the facility
  • Training should focus on principles of both HCP safety and patient safety
  • Training should be provided upon orientation and repeated regularly (e.g., annually)
  • Competencies should be documented initially and repeatedly, as appropriate for the specific HCP positions

Monitor and Report Healthcare-associated Infections

Surveillance is defined as the ongoing, systematic collection, analysis, interpretation, and dissemination of data regarding a health-related event for use in public health action to reduce morbidity and mortality and to improve health. Surveillance typically refers to tracking of outcome measures (e.g., HAIs) but can also refer to tracking of adherence to specific process measures (e.g., hand hygiene, environmental cleaning) as a means to reduce infection transmission. Surveillance for outcome measures in ambulatory care settings is challenging because patient encounters may be brief or sporadic and evaluation and treatment of consequent infections may involve different healthcare settings (e.g., hospitals).

At a minimum, ambulatory care facilities need to adhere to local, state, and federal requirements regarding reportable disease and outbreak reporting. Certain types of facilities (e.g., ambulatory surgical centers) may also be subject to additional HAI surveillance or process measure reporting requirements, for example as part of accreditation, Medicare certification, or state/local statutes. Facilities should check the requirements for their state/region to assure that they are compliant with all regulations and should have contact information for their local and/or state health department available to ensure required reporting is done in a timely manner.

Regular focused practice surveys or audits (e.g., audits of infection prevention practices including hand hygiene, medication handling and preparation, reprocessing of patient equipment, environmental cleaning) offer a means to assess competencies of HCP as recommended under Education and Training. One example of an audit tool being used by federal surveyors to assess adherence to elements of Standard Precautions in ambulatory surgical centers:

  • Adhere to local, state, and federal requirements regarding HAI surveillance, reportable diseases, and outbreak reporting
  • Perform regular audits and competency evaluations of HCP adherence to infection prevention practices

Adhere to Standard Precautions

Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. These practices are designed to both protect HCP and prevent HCP from spreading infections among patients. Standard Precautions include: 1) hand hygiene, 2) use of personal protective equipment (e.g., gloves, gowns, masks), 3) safe injection practices, 4) safe handling of potentially contaminated equipment or surfaces in the patient environment, and 5) respiratory hygiene/cough etiquette. Each of these elements of Standard Precautions are described in the sections that follow.

Education and training on the principles and rationale for recommended practices are critical elements of Standard Precautions because they facilitate appropriate decision-making and promote adherence. Further, at the facility level, an understanding of the specific procedures performed and typical patient interactions, as described above in Administrative Measures as part of policy and procedure development, will assure that necessary equipment is available.

Standard Precautions Standard

Precautions combine the major features of Universal Precautions (UP) 780, 896 and Body Substance Isolation (BSI) 640 and are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. These include: hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Also, equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents (e.g. wear gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient).

The application of Standard Precautions during patient care is determined by the nature of the HCW-patient interaction and the extent of anticipated blood, body fluid, or pathogen exposure. For some interactions (e.g., performing venipuncture), only gloves may be needed; during other interactions (e.g., intubation), use of gloves, gown, and face shield or mask and goggles is necessary. Education and training on the principles and rationale for recommended practices are critical elements of Standard Precautions because they facilitate appropriate decision-making and promote adherence when HCWs are faced with new circumstances. An example of the importance of the use of Standard Precautions is intubation, especially under emergency circumstances when infectious agents may not be suspected, but later are identified (e.g., SARS-CoV, N. meningitides). Guidance on donning and removing gloves, gowns and other PPE is presented in the Figure. Standard Precautions are also intended to protect patients by ensuring that healthcare personnel do not carry infectious agents to patients on their hands or via equipment used during patient care.

New Elements of Standard Precautions Infection control problems that are identified in the course of outbreak investigations often indicate the need for new recommendations or reinforcement of existing infection control recommendations to protect patients. Because such recommendations are considered a standard of care and may not be included in other guidelines, they are added here to Standard Precautions. Three such areas of practice that have been added are: Respiratory Hygiene/Cough Etiquette, safe injection practices, and use of masks for insertion of catheters or injection of material into spinal or epidural spaces via lumbar puncture procedures (e.g., myelogram, spinal or epidural anesthesia). While most elements of Standard Precautions evolved from Universal Precautions that were developed for protection of healthcare personnel, these new elements of Standard Precautions focus on protection of patients.

Respiratory Hygiene/Cough Etiquette The transmission of SARS-CoV in emergency departments by patients and their family members during the widespread SARS outbreaks in 2003 highlighted the need for vigilance and prompt implementation of infection control measures at the first point of encounter within a healthcare setting (e.g., reception and triage areas in emergency departments, outpatient clinics, and physician offices). The strategy proposed has been termed Respiratory Hygiene/Cough Etiquette 9, 828 and is intended to be incorporated into infection control practices as a new component of Standard Precautions. The strategy is targeted at patients and accompanying family members and friends with undiagnosed transmissible respiratory infections, and applies to any person with signs of illness including cough, congestion, rhinorrhea, or increased production of respiratory secretions when entering a healthcare facility. The term cough etiquette is derived from recommended source control measures for M. tuberculosis 12, 126. The elements of Respiratory Hygiene/Cough Etiquette include 1) education of healthcare facility staff, patients, and visitors; 2) posted signs, in language(s) appropriate to the population served, with instructions to patients and accompanying family members or friends; 3) source control measures (e.g., covering the mouth/nose with a tissue when coughing and prompt disposal of used tissues, using surgical masks on the coughing person when tolerated an appropriate); 4) hand hygiene after contact with respiratory secretions; and 5) spatial separation, ideally >3 feet, of persons with respiratory infections in common waiting areas when possible. Covering sneezes and coughs and placing masks on coughing patients are proven means of source containment that prevent infected persons from dispersing respiratory secretions into the air. Masking may be difficult in some settings, (e.g., pediatrics, in which case, the emphasis by necessity may be on cough etiquette. Physical proximity of <3 feet has been associated with an increased risk for transmission of infections via the droplet route (e.g., N. meningitidis and group A streptococcus and therefore supports the practice of distancing infected persons from others who are not infected. The effectiveness of good hygiene practices, especially hand hygiene, in preventing transmission of viruses and reducing the incidence of respiratory infections both within and outside healthcare settings is summarized in several reviews.

These measures should be effective in decreasing the risk of transmission of pathogens contained in large respiratory droplets (e.g., influenza virus, adenovirus. pertussis and Mycoplasma pneumoniae. Although fever will be present in many respiratory infections, patients with pertussis and mild upper respiratory tract infections are often afebrile. Therefore, the absence of fever does not always exclude a respiratory infection. Patients who have asthma, allergic rhinitis, or chronic obstructive lung disease also may be coughing and sneezing. While these patients often are not infectious, cough etiquette measures are prudent.

Healthcare personnel are advised to observe Droplet Precautions (i.e., wear a mask) and hand hygiene when examining and caring for patients with signs and symptoms of a respiratory infection. Healthcare personnel who have a respiratory infection are advised to avoid direct patient contact, especially with high risk patients. If this is not possible, then a mask should be worn while providing patient care.

Safe Injection Practices The investigation of four large outbreaks of HBV and HCV among patients in ambulatory care facilities in the United States identified a need to define and reinforce safe injection practices. The four outbreaks occurred in a private medical practice, a pain clinic, an endoscopy clinic, and a hematology/oncology clinic. The primary breaches in infection control practice that contributed to these outbreaks were 1) reinsertion of used needles into a multiple-dose vial or solution container (e.g., saline bag) and 2) use of a single needle/syringe to administer intravenous medication to multiple patients. In one of these outbreaks, preparation of medications in the same workspace where used needle/syringes were dismantled also may have been a contributing factor. These and other outbreaks of viral hepatitis could have been prevented by adherence to basic principles of aseptic technique for the preparation and administration of parenteral medications. These include the use of a sterile, single-use, disposable needle and syringe for each injection given and prevention of contamination of injection equipment and medication.
Whenever possible, use of single-dose vials is preferred over multiple-dose vials, especially when medications will be administered to multiple patients. Outbreaks related to unsafe injection practices indicate that some healthcare personnel are unaware of, do not understand, or do not adhere to basic principles of infection control and aseptic technique. A survey of US healthcare workers who provide medication through injection found that 1% to 3% reused the same needle and/or syringe on multiple patients. Among the deficiencies identified in recent outbreaks were a lack of oversight of personnel and failure to follow-up on reported breaches in infection control practices in ambulatory settings. Therefore, to ensure that all healthcare workers understand and adhere to recommended practices, principles of infection control and aseptic technique need to be reinforced in training programs and incorporated into institutional polices that are monitored for adherence.

Infection Control Practices for Special Lumbar Puncture Procedues In 2004, CDC investigated eight cases of post-myelography meningitis that either were reported to CDC or identified through a survey of the Emerging Infections Network of the Infectious Disease Society of America. Blood and/or cerebrospinal fluid of all eight cases yielded streptococcal species consistent with oropharyngeal flora and there were changes in the CSF indices and clinical status indicative of bacterial meningitis. Equipment and products used during these procedures (e.g., contrast media) were excluded as probable sources of contamination. Procedural details available for seven cases determined that antiseptic skin preparations and sterile gloves had been used. However, none of the clinicians wore a face mask, giving rise to the speculation that droplet transmission of oralpharyngeal flora was the most likely explanation for these infections. Bacterial meningitis following myelogram and other spinal procedures (e.g., lumbar puncture, spinal and epidural anesthesia, intrathecal chemotherapy) has been reported previously. As a result, the question of whether face masks should be worn to prevent droplet spread of oral flora during spinal procedures (e.g., myelogram, lumbar puncture, spinal anesthesia) has been debated. Face masks are effective in limiting the dispersal of oropharyngeal droplets and are recommended for the placement of central venous catheters. In October 2005, the Healthcare Infection Control Practices Advisory Committee (HICPAC) reviewed the evidence and concluded that there is sufficient experience to warrant the additional protection of a face mask for the individual placing a catheter or injecting material into the spinal or epidural space.

Transmission-Based Precautions

There are three categories of Transmission-Based Precautions: Contact Precautions, Droplet Precautions, and Airborne Precautions. Transmission-Based Precautions are used when the route(s) of transmission is (are) not completely interrupted using Standard Precautions alone. For some diseases that have multiple routes of transmission (e.g., SARS), more than one Transmission-Based Precautions category may be used. When used either singly or in combination, they are always used in addition to Standard Precautions. When Transmission-Based Precautions are indicated, efforts must be made to counteract possible adverse effects on patients (i.e., anxiety, depression and other mood disturbances, perceptions of stigma, reduced contact with clinical staff, and increases in preventable adverse events  in order to improve acceptance by the patients and adherence by HCWs.

Contact Precautions Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment.  Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. A single-patient room is preferred for patients who require Contact Precautions. When a single-patient room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate). In multi-patient rooms, >3 feet spatial separation between beds is advised to reduce the opportunities for inadvertent sharing of items between the infected/colonized patient and other patients. Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental.

Droplet Precautions Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Because these pathogens do not remain infectious over long distances in a healthcare facility, special air handling and ventilation are not required to prevent droplet transmission. Infectious agents for which Droplet Precautions are indicated are found in B. pertussis, influenza virus, adenovirus, rhinovirus, N. meningitides, and group A streptococcus (for the first 24 hours of antimicrobial therapy). A single patient room is preferred for patients who require Droplet Precautions. When a single-patient room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate). Spatial separation of > 3 feet and drawing the curtain between patient beds is especially important for patients in multi-bed rooms with infections transmitted by the droplet route. Healthcare personnel wear a mask (a respirator is not necessary) for close contact with infectious patient; the mask is generally donned upon room entry. Patients on Droplet Precautions who must be transported outside of the room should wear a mask if tolerated and follow Respiratory Hygiene/Cough Etiquette.

Airborne Precautions Airborne Precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (e.g., rubeola virus [measles], varicella virus [chickenpox], M. tuberculosis, and possibly SARS-CoV).  The preferred placement for patients who require Airborne Precautions is in an airborne infection isolation room (AIIR). An AIIR is a single-patient room that is equipped with special air handling and ventilation capacity that meet the American Institute of Architects/Facility Guidelines Institute (AIA/FGI) standards for AIIRs (i.e., monitored negative pressure relative to the surrounding area, air exchanges per hour for new construction and renovation and 6 air exchanges per hour for existing facilities, air exhausted directly to the outside or recirculated through HEPA filtration before return). Some states require the availability of such rooms in hospitals, emergency departments, and nursing homes that care for patients with M. tuberculosis. A respiratory protection program that includes education about use of respirators, fit-testing, and user seal checks is required in any facility with AIIRs. In settings where Airborne Precautions cannot be implemented due to limited engineering resources (e.g., physician offices), masking the patient, placing the patient in a private room (e.g., office examination room) with the door closed, and providing N95 or higher level respirators or masks if respirators are not available for healthcare personnel will reduce the likelihood of airborne transmission until the patient is either transferred to a facility

Syndromic and empiric applications of Transmission-Based Precautions

Diagnosis of many infections requires laboratory confirmation. Since laboratory tests, especially those that depend on culture techniques, often require two or more days for completion, Transmission-Based Precautions must be implemented while test results are pending based on the clinical presentation and likely pathogens. Use of appropriate Transmission-Based Precautions at the time a patient develops symptoms or signs of transmissible infection, or arrives at a healthcare facility for care, reduces transmission opportunities. While it is not possible to identify prospectively all patients needing Transmission-Based Precautions, certain clinical syndromes and conditions carry a sufficiently high risk to warrant their use empirically while confirmatory tests are pending. Infection control professionals are encouraged to modify or adapt this table according to local conditions.

Discontinuation of Transmission-Based Precautions

Transmission-Based Precautions remain in effect for limited periods of time (i.e., while the risk for transmission of the infectious agent persists or for the duration of the illness. For most infectious diseases, this duration reflects known patterns of persistence and shedding of infectious agents associated with the natural history of the infectious process and its treatment. For some diseases (e.g., pharyngeal or cutaneous diphtheria, RSV), Transmission-Based Precautions remain in effect until culture or antigen-detection test results document eradication of the pathogen and, for RSV, symptomatic disease is resolved. For other diseases, (e.g., M. tuberculosis) state laws and regulations, and healthcare facility policies, may dictate the duration of precaution). In immuno-compromised patients, viral shedding can persist for prolonged periods of time (many weeks to months) and transmission to others may occur during that time; therefore, the duration of contact and/or droplet precautions may be prolonged for many weeks. The duration of Contact Precautions for patients who are colonized or infected with MDROs remains undefined. MRSA is the only MDRO for which effective decolonization regimens are available. However, carriers of MRSA who have negative nasal cultures after a course of systemic or topical therapy may resume shedding MRSA in the weeks that follow therapy.

Although early guidelines for VRE suggested discontinuation of Contact Precautions after three stool cultures obtained at weekly intervals proved negative, subsequent experiences have indicated that such screening may fail to detect colonization that can persist for >1 year 27. Likewise, available data indicate that colonization with VRE, MRSA, and possibly MDR-GNB, can persist for many months, especially in the presence of severe underlying disease, invasive devices, and recurrent courses of antimicrobial agents. It may be prudent to assume that MDRO carriers are colonized permanently and manage them accordingly. Alternatively, an interval free of hospitalizations, antimicrobial therapy, and invasive devices (e.g., 6 or 12 months) before reculturing patients to document clearance of carriage may be used. Determination of the best strategy awaits the results of additional studies.

Application of Transmission-Based Precautions in ambulatory and home care settings
Although Transmission-Based Precautions generally apply in all healthcare settings, exceptions exist. For example, in home care, AIIRs are not available. Furthermore, family members already exposed to diseases such as varicella and tuberculosis would not use masks or respiratory protection, but visiting HCWs would need to use such protection. Similarly, management of patients colonized or infected with MDROs may necessitate Contact Precautions in acute care hospitals and in some LTCFs when there is continued transmission, but the risk of transmission in ambulatory care and home care, has not been defined. Consistent use of Standard Precautions may suffice in these settings, but more information is needed.

Protective Environment

A Protective Environment is designed for allogeneic HSCT patients to minimize fungal spore counts in the air and reduce the risk of invasive environmental fungal infections. The need for such controls has been demonstrated in studies of aspergillus outbreaks associated with construction. As defined by the American Insitute of Architecture and presented in detail 2003  air quality for HSCT patients is improved through a combination of environmental controls that include 1) HEPA filtration of incoming air; 2) directed room air flow; 3) positive room air pressure relative to the corridor; 4) well-sealed rooms (including sealed walls, floors, ceilings, windows, electrical outlets) to prevent flow of air from the outside; 5) ventilation to provide >12 air changes per hour; 6) strategies to minimize dust (e.g., scrubbable surfaces rather than upholstery and carpet, and routinely cleaning crevices and sprinkler heads); and 7) prohibiting dried and fresh flowers and potted plants in the rooms of HSCT patients. The latter is based on molecular typing studies that have found indistinguishable strains of Aspergillus terreus in patients with hematologic malignancies and in potted plants in the vicinity of the patients. The desired quality of air may be achieved without incurring the inconvenience or expense of laminar airflow. To prevent inhalation of fungal spores during periods when construction, renovation, or other dust-generating activities that may be ongoing in and around the health-care facility, it has been advised that severely immunocompromised patients wear a high-efficiency respiratory-protection device (e.g., an N95 respirator) when they leave the Protective Environment ). The use of masks or respirators by HSCT patients when they are outside of the Protective Environment for prevention of environmental fungal infections in the absence of construction has not been evaluated. A Protective Environment does not include the use of barrier precautions beyond those indicated for Standard and Transmission-Based Precautions. No published reports support the benefit of placing solid organ transplants or other immunocompromised patients in a Protective Environment.

 

CEUs Home | CEUs Courses |Provider Approved | CEUs Contact Us | Ceus Logon | Ceus Questions |