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There are around 200,000 healthcare-associated infections (HAIs) in Australian acute healthcare facilities each year. This makes HAIs the most common complication affecting patients in hospital. As well as causing unnecessary pain and suffering for patients and their families, these adverse events prolong hospital stays and are costly to the health system. Understanding the modes of transmission of infectious organisms and knowing how and when to apply the basic principles of infection prevention and control is critical to the success of an infection control program. This responsibility applies to everybody working and visiting a healthcare facility, including administrators, staff, patients and carers. Successful approaches for preventing and reducing harms arising from HAIs involve applying a risk-management framework to manage 'human' and 'system' factors associated with the transmission of infectious agents. This approach ensures that infectious agents, whether common (for example, gastrointestinal viruses) or evolving (for example, influenza or multi-resistant organisms [MROs]), can be managed effectively. These guidelines provide recommendations that outline the critical aspects of infection prevention and control. The recommendations were developed using the best available evidence and consensus methods by the Infection Control Steering Committee. They have been prioritised as key areas to prevent and control infection in a healthcare facility. It is recognised that the level of risk may differ according to the different types of facility and therefore some recommendations should be justified by risk assessment. When implementing these recommendations all healthcare facilities need to consider the risk of transmission of infection and implement according to their specific setting and circumstances. The Process Report is available at Appendix 2 of the guideline. Clinical Educators Guide for the Prevention and Control of Infection in HealthcareThis Clinical Educators Guide for the prevention and control of infection in healthcare has been developed to provide strategies for clinical educators and supervisors to assist students and graduate healthcare workers integrate a risk management approach into their daily tasks/duties that involve infection prevention and control. The Guide aims to ensure students, and new graduates:
The Guide should be used in conjunction with the Australian Guidelines for the prevention and control of infection in health care (2010) and its key recommendations, as well as the healthcare facility's infection control orientation program. Consumer fact sheets to support this guidelineThese consumer factsheets have been developed to support the messages on healthcare associated infection contained in the NHMRC Australian Guidelines for the prevention and control of infection in healthcare (2010). The factsheets aim to inform patients, visitors, families and carers about healthcare associated infection, what activities healthcare facilities may have in place to make sure infections are prevented as much as possible, and what they can do to limit the spread of infections. There are specific factsheets on the Methicillin resistantStaphylococcus aureus, Vancomycin Resistant Enterococci and Clostridium difficile. Information on infection control issues relating to Creutzfeldt Jacob disease (CJD)Information on infection control issues relating to Creutzfeldt Jacob disease (CJD) and in particular the reprocessing of reusable medical instruments, is beyond the scope of this guideline. Please refer to the Department of Health website. AcknowledgementsInfection Control Guidelines Steering CommitteeThe production of a document such as this requires a considerable effort over a long period. Special thanks and acknowledgment are due to the Infection Control Guidelines Steering Committee members for their generous donation of time, their technical advice and ongoing commitment to the project.
NHMRC – ICG Project Team, Canberra
Technical writers – Ampersand Health Science Writing
Australian Commission on Safety and Quality in Health Care
DisclaimerThis document aims to combine a review of the best available evidence with current clinical and expert practice. It is designed to provide information based on the best evidence available at the time of publication to assist in decision-making. The members of the Infection Control Guidelines Steering Committee, the Australian Commission for Safety and Quality in Health Care and the National Health and Medical Research Council give no warranty that the information contained in this document and any online updates available on the NHMRC website is correct or complete. Infection prevention and control guidelines are necessarily general and are not intended to be a substitute for a healthcare professional's judgment in each case. The members of the Infection Control Guidelines Steering Committee, the Australian Commission for Safety and Quality in Health Care and the National Health and Medical Research Council shall not be liable for any loss whatsoever whether due to negligence or otherwise arising from the use of or reliance on this document. Summary of recommendationsThese guidelines provide recommendations that outline the critical aspects of infection prevention and control. The recommendations were developed using the best available evidence and consensus methods by the Infection Control Steering Committee.[1] They have been prioritised as key areas to prevent and control infection in a healthcare facility. It is recognised that the level of risk may differ according to the different types of facility and therefore some recommendations should be justified by risk assessment. When implementing these recommendations all healthcare facilities need to consider the risk of transmission of infection and implement according to their specific setting and circumstances. The recommendations should be read in the context of the evidence base. This is discussed in Sections B1, B2 and B3, which also include advice on the practical application of the recommendations. Table 1 lists recommendations and the section of the guidelines in which they are discussed.
Finding informationThese recommendations provide the basis for appropriate infection prevention and control practice in the healthcare setting. Practical guidance on their implementation is given in Part B of these guidelines. Table 2 provides a directory for this guidance. Table 2: Directory of key information in these guidelines (table or link list??? See page 4 - 5 of PDF) IntroductionEffective infection prevention and control is central to providing high quality health care for patients and a safe working environment for those that work in healthcare settings. Healthcare-associated infection is preventableThere are around 200,000 healthcare-associated infections (HAIs) in Australian acute healthcare facilities each year [2]. This makes HAIs the most common complication affecting patients in hospital. As well as causing unnecessary pain and suffering for patients and their families, these adverse events prolong hospital stays and are costly to the health system. The problem does not just affect patients and workers in hospitals—HAIs can occur in any healthcare setting, including office-based practices (for example, general practice clinics, dental clinics) and long-term care facilities (see Glossary). Any person working in or entering a healthcare facility is at risk. However, healthcare- associated infection is a potentially preventable adverse event rather than an unpredictable complication. It is possible to significantly reduce the rate of HAIs through effective infection prevention and control. Infection prevention and control is everybody's businessUnderstanding the modes of transmission of infectious organisms and knowing how and when to apply the basic principles of infection prevention and control is critical to the success of an infection control program. This responsibility applies to everybody working and visiting a healthcare facility, including administrators, staff, patients and carers. Successful approaches for preventing and reducing harms arising from HAIs involve applying a risk-management framework to manage 'human' and 'system' factors associated with the transmission of infectious agents. This approach ensures that infectious agents, whether common (for example, gastrointestinal viruses) or evolving (for example, influenza or multi-resistant organisms [MROs]), can be managed effectively. Development of the guidelinesAs part of the Australian Commission on Safety and Quality in Health Care's (ACSQHC) HAIs priority program, the National Health and Medical Research Council (NHMRC) was asked to develop national guidelines that would provide a coordinated approach to the prevention and management of HAI. The NHMRC appointed an expert group to guide the development process (Steering Committee membership and terms of reference are given in Appendix 1). The guidelines are based on the best available evidence. They build on existing guidelines and reviews, as well as systematic reviews of the evidence. AimBy assisting healthcare workers to improve the quality of the care they deliver, these guidelines aim to promote and facilitate the overall goal of infection prevention and control: The creation of safe healthcare environments through the implementation of practices that minimise the risk of transmission of infectious agents. ScopeThe scope of these guidelines was established, following an initial period of consultation that included forums involving a wide range of stakeholders (see Appendix 2). The guidelines were developed to establish a nationally accepted approach to infection prevention and control, focusing on core principles and priority areas for action. They provide a basis for healthcare workers and healthcare facilities to develop detailed protocols and processes for infection prevention and control specific to local settings. This approach is underpinned by a risk-management framework to ensure the basic principles of infection prevention and control can be applied to a wide range of healthcare settings including office-based practice, long-term care facilities, remote area health services, home and community nursing and emergency services. The evidence base for the guidelines addresses the highest level of risk of infection transmission in the healthcare setting, and has predominantly been drawn from the acute-care setting. However, case studies giving examples of risk assessments have been included to help illustrate how these recommendations can be applied to other settings. Supporting documents have been developed for healthcare workers, patients and health facility managers to assist with implementation of the guidelines. These materials will be available on the NHMRC website. The guidelines make reference to but do not include detailed information on:
The guidelines do not duplicate information provided in existing Australian Standards but refer to specific standards wherever relevant. Target audienceThe guidelines are for use by all those working in healthcare—this includes healthcare workers, management and support staff. Evidence baseThese guidelines are based on the best available evidence and knowledge of the practicalities of clinical procedures. They draw from other work in this area, including the two previous national infection control guidelines,[3] international infection control guidelines, systematic literature reviews conducted to inform the development of these guidelines, work on HAI prevention from ACSQHC, national discipline-based infection control guidelines, and Australian Standards relevant to infection prevention and control. Australian data are used wherever available. Limitations of the grading process as it applies to the practice of infection controlThe recommendations in these guidelines were formulated by the Infection Control Steering Committee through a process of consensus. Recommendations are given when an action is deemed critical to preventing or managing infection. Recommendations are graded according to the revised NHMRC gradings for assessing evidence, with the addition of good practice points, which outline actions that are essential to infection prevention and control but where evidence grades cannot be applied. In many areas of infection prevention and control, the evidence may be limited by the inability to conduct certain study designs that are difficult to implement in real practice. This has implications for the level of grading that is assigned to the recommendations, since grading systems will tend to favour study designs that are sometimes not feasible or ethical to conduct in infection control settings, such as randomised controlled trials. For example, it is unethical to compare the incidence of infection related to surgical instruments by allocating one patient group to have sterilised instruments used on them and one patient group to have non-sterile instruments used on them. This may result in a lower grading due to the available evidence but sterilisation of surgical instruments is universally deemed critical to infection control. Given that there is limited evidence available to support many routine practices intended to reduce infection risk, practice is based on decisions made on scientific principles. Some activities, such as performing hand hygiene between administering care to successive patients, have a credible history to support their routine application in preventing cross-infection. Others, such as some uniform and clothing requirements, have more to do with the ethos of quality care and workplace culture than with a proven reduction of cross-infection. It is not acceptable to discontinue practices for which there is a solid scientific basis, even if the level of evidence is not high. Rather, routine practices should continue unless there is sufficient evidence to support alternative procedures. Continuing research is needed to keep evaluating practice, to identify evidence gaps and promote research in these areas, and to ensure that poor practices do not continue. The ICG Steering Committee also assigned additional 'grade' referred to as a good practice point (GPP).
Structure of the guidelinesThese guidelines are based around the following core principles:
The parts of the document are based on these core principles and are organised according to the likely readership. Part A presents background information that should be read by everyone working in health care (for example as orientation or as part of annual review) – this includes important basics of infection prevention and control, such as the main modes of transmission of infectious agents and the application of risk-management principles. This part of the guidelines does not include recommendations. Part B is specific to the practice of healthcare workers and support staff, and outlines effective work practices that minimise the risk of transmission of infectious agents. Recommendations are given in Sections B1 to B3. Each section includes advice on putting the recommendations into practice, a risk-management case study and resources.
Part C describes the responsibilities of management of healthcare facilities, including governance structures that support the implementation, monitoring and reporting of effective work practices. The chapters outline the main components of a systems approach to facility-wide infection prevention and control, giving guidance on management and staff responsibilities, protection of healthcare workers, requirements for education and training of all staff, considerations for facility design and renovation, and other important activities such as surveillance and antibiotic stewardship. Legislation, regulations and standards relevant to infection prevention and control are listed at the end of each section before the references. The appendices provide additional information on the guideline development process. Key information is highlighted in the guidelines as follows.
Case studies illustrate the application of risk-management principles (Sections B1, B2 and B3) and measures to support good practice (Part C) Table 6 summarises the key topics discussed in the document.
PART A: BASICS OF INFECTION PREVENTION AND CONTROLSummary
The information presented in this part is relevant to everybody employed by a healthcare facility, including management, healthcare workers and support service staff. A1: Infection prevention and control in the healthcare settingSummary
A1.1: Risks of contracting a healthcare-associatedMost infectious agents are microorganisms. These exist naturally everywhere in the environment, and not all cause infection (for example, 'good' bacteria present in the body's normal flora). Several classes of microorganism—including bacteria, viruses, fungi, parasites and prions—can be involved in either colonisation or infection, depending on the susceptibility of the host:
Transmission of infectious agents within a healthcare setting requires the following elements:
Chain of infectionFigure A1.1: Chain of infectionInfectious agents transmitted during health care come primarily from human sources, including patients, healthcare workers and visitors. Source individuals may be actively ill, may have no symptoms but be in the incubation period of a disease, or may be temporary or chronic carriers of an infectious agent with or without symptoms. Other sources of transmission include:
Infection is the result of a complex interrelationship between a host and an infectious agent and people vary in their response to exposure to an infectious agent:
Important predictors of an individual's outcome after exposure include his or her:
Factors influencing healthcare-associated infectionFigure A1.2: Factors influencing healthcare-associated infectionIn healthcare settings, the most common susceptible hosts are patients and healthcare workers.
In healthcare settings, the main modes of transmission of infectious agents are contact (including bloodborne), droplet and airborne. The modes of transmission vary by type of organism. In some cases the same organism may be transmitted by more than one route (for example, norovirus, influenza and respiratory syncytial virus [RSV] can be transmitted by contact and droplet routes). A1.1.1 Routes of transmissionContract transmissionContact is the most common mode of transmission, and usually involves transmission by touch or via contact with blood or body substances. Contact may be direct or indirect.
Examples of infectious agents transmitted by contact include multi-resistant organisms (MROs), Clostridium difficile, norovirus and highly contagious skin infections/infestations (for example, impetigo, scabies). Droplet transmissionDroplet transmission can occur when an infected person coughs, sneezes or talks, and during certain procedures. Droplets are infectious particles larger than 5 microns in size.[6] Respiratory droplets transmit infection when they travel directly from the respiratory tract of the infected person to susceptible mucosal surfaces (nasal, conjunctivae or oral) of another person, generally over short distances. Droplet distribution is limited by the force of expulsion and gravity and is usually at least 1 metre. However, droplets can also be transmitted indirectly to mucosal surfaces (for example, via hands). Examples of infectious agents that are transmitted via droplets include influenza virus and meningococcus. Airborne transmissionAirborne dissemination may occur via particles containing infectious agents that remain infective over time and distance. Small-particle aerosols are created during breathing, talking, coughing or sneezing and secondarily by evaporation of larger droplets in conditions of low humidity. Certain procedures, particularly those that induce coughing, can promote airborne transmission. These include diagnostic sputum induction, bronchoscopy, airway suctioning, endotracheal intubation, positive pressure ventilation via face mask and high-frequency oscillatory ventilation. Aerosols containing infectious agents can be dispersed over long distances by air currents (for example, ventilation or air conditioning systems) and inhaled by susceptible individuals who have not had any contact with the infectious person. These small particles can transmit infection into small airways of the respiratory tract. Examples of infectious agents that are transmitted via the airborne route include measles (rubeola) virus, chickenpox (varicella) virus and M. tuberculosis. Other modes of transmissionTransmission of infection can also occur via common sources such as contaminated food, water, medications, devices or equipment. A1.2 Standard and transmission-based precautionsSuccessful infection prevention and control involves implementing work practices that prevent the transmission of infectious agents through a two-tiered approach including:
If successfully implemented, standard and transmission-based precautions prevent any type of infectious agent from being transmitted. A1.2.1 Standard precautionsAll people potentially harbour infectious agents. Standard precautions refer to those work practices that are applied to everyone, regardless of their perceived or confirmed infectious status and ensure a basic level of infection prevention and control. Implementing standard precautions as a first-line approach to infection prevention and control in the healthcare environment minimises the risk of transmission of infectious agents from person to person, even in high-risk situations. Standard precautions are used by healthcare workers to prevent or reduce the likelihood of transmission of infectious agents from one person or place to another, and to render and maintain objects and areas as free as possible from infectious agents. Guidance on implementing standard precautions is given in Sections B1 and B5.
A1.2.2 Transmission-based precautionsAny infection prevention and control strategy should be based on the use of standard precautions as a minimum level of control. Transmission-based precautions are recommended as extra work practices in situations where standard precautions alone may be insufficient to prevent transmission. Transmission-based precautions are also used in the event of an outbreak (for example, gastroenteritis), to assist in containing the outbreak and preventing further infection. Transmission-based precautions should be tailored to the particular infectious agent involved and its mode of transmission. This may involve a combination of practices. Guidance on when and how to implement transmission-based precautions is given in Sections B2, B3 and B5.
A2 Overview of risk management in infection prevention and controlSummary
A2.1 Risk management basicsIn the context of these guidelines, 'risk' is defined as the possibility of acquisition or infection of patients or healthcare workers arising from activities within a healthcare facility. Risk management is the basis for preventing and reducing harms arising from healthcare-associated infection. A successful approach to risk management occurs on many levels within a healthcare facility:
As healthcare settings differ greatly in their day-to-day function, it is not possible to provide a one size fits all approach to risk management. Even within a single setting (for example, primary care), increasingly complex care is delivered by a range of health professionals with diverse qualifications and training. All healthcare facilities need to be able to determine the risks in their own context and select the appropriate course of action. Therefore it is necessary for facilities to regularly conduct infection prevention risk assessments within their facility and ensure that all staff understand their responsibility in managing these risks. The Australian/New Zealand Standard on Risk Management AS/NZS ISO 31000:2009 outlines a stepwise approach to risk management that allows continuous quality improvement and involves:
Monitoring and review is an essential component of the risk-management process. This ensures that:
Communication and consultation are also key elements of clinical risk management. An interactive exchange of information between management, healthcare workers, patients and other stakeholders provides the basis for increased awareness of the importance of infection prevention and control, identification of risks before they arise and prompt management of risks as they occur. A2.2 Risk management processThe following flowchart outlines key considerations during the process of risk management in the context of infection prevention and control in the healthcare setting. Risk-management flowchartFigure A2.1: Risk-management flowchartThe following case study gives an example of applying the risk-management process in a primary care setting. Case studies giving examples of how to use this process in primary, acute and longterm care settings, including relevant considerations in specific situations, are included in Part B. While the basic process of risk management applies regardless of setting, all healthcare facilities should develop risk-management policies and procedures that are appropriate to the setting. Case study: measles (rubeola) virus outbreakState health authorities notify a general practice of an outbreak of measles, and will assist the practice with advice about management of potential exposures. Communicate and consult
Establish contextIn developing protocols and procedures, consideration is given to the following questions:
Identify risksConsideration is given to how measles might be transmitted within the practice:
Analyse risks
Note that in other settings, outcomes of the analysis may reveal a lower level of risk (for example, if there is sufficient herd immunity in the community to not pose a risk) or a higher level of risk (for example, if there are insufficient resources to manage airborne precautions and triage of patients). Evaluate risks
Note that priority must be given to activities that address risks that are high and which have a potentially catastrophic outcome.
Treat risks
Monitor and reviewMechanisms are implemented to ensure early awareness of notifications from public health authorities to assist in the early implementation of additional infection control measures. Source: Adapted from RACGP (2006) Infection Control Standards for Office-Based Practices (4th edition). A3. A patient-centred approachSummary
A3.1 Patient-centred health carePeople receiving healthcare increasingly expect to be given information about their condition and treatment options and this extends to their rights and responsibilities as users of healthcare services. Although patient satisfaction with health services in Australia is generally high, patients' experiences are not always valued and their expectations are not always met. While this does not necessarily lead to poor outcomes for the individuals concerned, the best possible outcomes are more likely where patient-centred health care is a priority of the healthcare facility and a strong and consistent effort is made to respect patients' rights and expectations. The ACSQHC has developed an Australian Charter of Healthcare Rights,[8] which recognises that people receiving care and people providing care all have important parts to play in achieving healthcare rights. The Charter allows patients, families, carers and services providing health care to share an understanding of the rights of people receiving health care. The Charter stipulates that all Australians have the right to:
Patient-centred care cannot just be 'added on' to usual care. The rights, experiences and views of patients should be at the centre of the care process and drive the way in which care is delivered. In most healthcare facilities, a significant culture change is necessary to embed patient-centred care principles into the philosophy and practices of the organisation. Healthcare workers and organisations need to acknowledge and understand the Charter of Healthcare Rights and work to ensure that patients' rights are integral to the care process. A3.2 How does patient-centred care relate to infection prevention and control?Infection prevention and control is ultimately about people. Effective infection prevention and control is central to providing high quality, patient-centred health care. Putting patients at the centre of infection prevention and control and enabling them to participate in the care process is not just about explaining the risks of treatments, but involves considering patients' needs at every level. This ranges from designing the facility to maximise patient comfort and safety to having a range of processes to engage patients in their care and listen and act on their feedback as well as providing the patient with education and support so that they can be involved in looking after themselves. To support a two-way approach to infection prevention and control and encourage the patient participation required to minimise cross-infection or transmission, it is important to:
Specific guidance on providing patient-centred care is highlighted throughout the guidelines, in text boxes, in the 'Putting it into practice' section at the end of each chapter in Part B, and in each chapter of Part C. PART B: STANDARD AND TRANSMISSION-BASED PRECAUTIONSSummary
The information presented in this part is particularly relevant to healthcare workers and support staff. It outlines effective work practices that minimise the risk of transmission of infectious agents. Patient-care tipIn applying standard and transmission-based infection prevention and control strategies as part of day-to-day practice, healthcare workers should ensure that their patients understand why certain practices are being undertaken, and that these practices are in place to protect everyone from infection. Patients and visitors should also be aware of their role in minimising risks by following basic hand hygiene and respiratory hygiene and cough etiquette and informing staff about aspects of their care or services if necessary. B1 Standard precautionsSummaryIt is essential that standard precautions are applied at all times. This is because:
Standard precautions consist of:
Standard precautions should be used in the handling of: blood (including dried blood); all other body substances, secretions and excretions (excluding sweat), regardless of whether they contain visible blood; non-intact skin; and mucous membranes. Evidence supporting practice [9]
Importance of hand hygieneFigure B.1.1: Importance of hand hygieneThese images illustrate the critical importance of hand hygiene in caring for patients, including those not known to carry antibiotic-resistant organisms. An imprint of a healthcare worker's ungloved hand was obtained after routine abdominal examination of a patient with no history of MRSA infection but found on routine surveillance to have MRSA colonisation. The resultant culture shows MRSA colonies (image on left). Another hand imprint obtained after the worker's hand had been cleaned with alcohol-based hand rub was negative for MRSA (image on right). Source: Donskey CJ & Eckstein BC (2009). Improved hand hygiene practices have been associated with:
Hand hygiene practices alone are not sufficient to prevent and control infection and need to be used as part of a multifactorial approach to infection control. This section discusses routine hand hygiene. Surgical hand preparation is discussed in Section B4.3.2. B1.1.2 When should hand hygiene be performed?Hands can become contaminated with infectious agents through contact with a patient, patient surroundings, the environment, or other healthcare workers. Cross-contamination can occur from one site to another in the same patient, between healthcare worker and patient, between patient or healthcare worker and the environment, or between healthcare workers. Practicing hand The 5 moments for hand hygieneThe '5 moments for hand hygiene' developed by the World Health Organization (WHO 2009) and adopted by Hand Hygiene Australia (Grayson et al 2009):
The 5 moments for hand hygieneFigure B1.2: The 5 moments for hand hygieneNote Hand hygiene is also performed after the removal of gloves.Source: Grayson et al (2009). While Figure B1.2 illustrates application of the 5 moments in an acute-care setting, the 5 moments are still generally applicable to other healthcare settings including primary care. The key emphasis in any setting is to perform hand hygiene before and after any procedure, and after each consultation with a patient. Recommendation1 Routine hand hygiene - Grade B Hand hygiene must be performed before and after every episode of patient contact. This includes:
Hand hygiene must also be performed after the removal of gloves. In addition to the 5 moments, hand hygiene should be performed in a range of non-clinical situations (see Table B1.1). Table B1.1: Non-clinical situations when hand hygiene should be performed
B1.1.3 What product should be used?Existing guidelines (WHO 2009; Boyce & Pittet 2002; Pratt et al 2007; Canada Standards and Guideline Core Committee 2008; PIDAC 2008) and literature reviews (Pittet & Boyce 2001; Picheansathian 2004; Rotter 2004; Nicolay 2006; Larmer et al 2008; Grayson et al 2009) agree that hand hygiene using alcohol-based hand rubs is more effective against the majority of common infectious agents on hands than hand hygiene with plain or antiseptic soap and water. One advantage of alcohol-based hand rubs is that they are easily accessible at point of care. They have (Grayson et al 2009):
The range of antimicrobial activity in alcohol-based hand rubs varies with the alcohol compound (ethanol, isopropanol or n‑propanol) used. Different alcohol species have different levels of activity (60% v/v n-propanol is approximately equivalent to 70% v/v isopropanol and to 80% v/v ethanol) and many commercial formulations consist of blends of different alcohol species. Most published clinical studies that have demonstrated reductions in HAIs with the use of alcohol-based hand rubs have been associated with products that contain at least 70% alcohol (isopropanol), 0.5% chlorhexidine and a skin emollient (Grayson et al 2009). However the efficacy of alcohol-based hand hygiene products is affected by a number of factors including the type of alcohol used, concentration of alcohol, contact time, volume of product used, and whether the hands are wet when the product is applied. These factors are generally assessed through testing standards for skin disinfectants, for which TGA is the regulatory body responsible for approving products for use in Australia. Plain soaps act by mechanical removal of microorganisms and have no antimicrobial activity. They are sufficient for general social contact and for cleansing of visibly soiled hands. They are also used for mechanical removal of certain organisms such as C. difficile and norovirus. When C. difficile and non-enveloped viruses are suspected or known to be present, use of alcohol-based hand rubs alone may not be sufficient to reduce transmission of these organisms. Alcohol-based hand rubs are effective at removing vegetative forms of C. difficile, but not effective at removing spores (Maiwald 2009). If gloves are worn during the care of patients in settings where C. difficile or non-enveloped viruses are suspected or known to be present, spore contamination of the hands will be minimal and alcohol-based hand rub remains the agent of choice for hand hygiene ( Johnson et al 1990; Jabbar et al 2010). [41, 42] However, if gloves have not been worn or There is a tendency for antimicrobial soaps to be more effective than plain soaps, although the evidence around this is inconsistent. Antimicrobial soap is associated with skin care issues and it is not necessary for use in everyday clinical practice (Pratt et al 2001; Boyce & Pittet 2002; Pratt et al 2007.) Neutral hand-wipe products may be considered in instances where hygienic access to soap and water is not readily available, such as in community care settings. Alcohol-based hand rubs are also suitable for use in resource-limited or remote areas with lack of accessibility to sinks or other facilities for hand hygiene (including clean water, towels etc.). Choosing an alcohol-based handrubIt is necessary to choose products:
Healthcare worker acceptance of alcohol-based hand rub is a crucial factor in the success of any program to improve hand hygiene practice. Several studies showed that user acceptability and skin tolerability tend to be determined by the overall hand rub composition (for example, consistency as gel or rub, texture, fragrance) and by emollient additives, but both are largely independent of a formulation's antimicrobial activity (Rotter et al 1991; Kramer et al 2002a; Girard et al 2006; WHO 2009). Even where emollient agents are present in the product, ready access to a moisturising skin-care product is essential (see Section B1.1.5). The selected alcohol-based hand rubs, soaps and moisturising lotions should be chemically compatible, to minimise skin reactions and ensure that the decontaminating properties of the hand hygiene product are not deactivated. It is advisable to purchase hand hygiene and hand-care products from a range made by a single manufacturer, as this ensures compatibility between the products. Different healthcare workers and healthcare settings have different preferences, and the choice between a gel or liquid needs to be evaluated on an individual basis (Maiwald & Widmer 2007; Pittet 2007). In some healthcare facilities, it may be useful to offer both liquid and gel alongside each other, in order to provide a choice that suits a wide range of healthcare workers (Pittet 2007; Traore et al 2007, Girard R et al 2006). Some studies have noted that gel formulations have generally significantly less antimicrobial activity than liquid alcohol-based hand rub formulations, even if the total alcohol content is similar (Pietsch 2001; Kramer et al 2002b; Picheansathian 2004). The Hand Hygiene Australia Manual (Grayson et al 2009) outlines the following alcohol-based hand rub features as important in influencing acceptability, as well as ready accessibility at each bedside and in all patient-care areas:
There is some evidence to suggest that gels are preferred to solutions (WHO 2009), however it is important for staff to evaluate products themselves before implementation where possible. Even where emollient agents are present in the product, ready access to a moisturising skin-care product is essential. All hand hygiene products should be chemically compatible. It is advisable that hand hygiene and hand-care products are from a range made by a single manufacturer, as this ensures compatibility between the products. Other issues associated with alcohol-based hand rubsOther factors that should be considered when choosing products include cost issues, availability, convenience and functioning of dispenser, and ability to prevent contamination. Consideration should also be given to occupational health and safety issues associated with alcohol-based hand rubs. Alcohols are flammable, and healthcare workers handling alcohol-based preparations should respect safety standards. Accidental and intentional ingestion and dermal absorption of alcohol-based Recommendation2 For all routine hand hygiene practices in healthcare settings, use alcohol-based hand rubs that:
3 Choice of hand hygiene product when hands are visibly soiled If hands are visibly soiled, hand hygiene should be performed using soap and water (Grade B). 4 Hand hygiene for Clostridium difficile and non-enveloped viruses Hand hygiene should be performed using soap and water when Clostridium difficile or non-enveloped viruses such as norovirus are known or suspected to be present and gloves have not been worn. After washing, hands should be dried thoroughly with single-use towels (GPP). TechniqueEffective hand hygiene relies on appropriate technique as much as on selection of the correct product. Inappropriate technique can lead to failure of hand hygiene measures to appropriately remove or kill microorganisms on hands, despite the superficial appearance of having complied with hand hygiene requirements. Key factors in effective hand hygiene and maintaining skin integrity include (Boyce & Pittet 2002):
Table B1.2: Use of alcohol-based hand rub
Table B.1.3: Using soap (including antimicrobial soap) and water
B1.1.4 Other aspects of hand hygieneAs intact skin is a natural defence against infection, cuts and abrasions reduce the effectiveness of hand hygiene practices. Breaks or lesions of the skin are possible sources of entry for infectious agents (Larson 1996) and may also be a source of them. Similarly, the presence of fingernail disease may reduce the efficacy of hand hygiene and result in the transmission of pathogens (WHO 2009). To reduce the risk of cross-transmission of infectious agents, cuts and abrasions should be covered The type and length of fingernails can have an impact on the effectiveness of hand hygiene (Boyce & Pittet 2002; Lin et al 2003). Artificial or false nails have been associated with higher levels of infectious agents, especially Gram-negative bacilli and yeasts, than natural nails (Pottinger et al 1989; Passaro et al 1997; Foca et al 2000; Hedderwick et al 2000; Moolenaar et al 2000; Parry et al 2001; Boyce & Pittet 2002; Gupta et al 2004; Boszczowski et al 2005). Fingernails should therefore be kept short (for example, the length of the finger pad) and clean, and artificial fingernails should not be worn. Studies have also demonstrated that chipped nail polish may support the growth of organisms on the fingernails (Grayson et al 2009). It is good practice to not wear nail polish, but if it must be used it should not be chipped and should be removed every 4 days (AORN 2007). Although there is less evidence concerning the impact of jewellery on the effectiveness of hand hygiene, rings can interfere with the technique used to perform hand hygiene resulting in higher total bacterial counts (Boyce & Pittet 2002). Hand contamination with infectious agents is increased with ring wearing (Boyce & Pittet 2002; Trick et al 2003), although no studies have related this practice to healthcare worker-to-patient transmission. The consensus recommendation is to strongly discourage the wearing of watches, rings or other jewellery during health care; however if jewellery must be worn in clinical areas it should be limited to a plain band (for example, wedding ring) and this should be moved about on the finger during hand hygiene practices. In high-risk settings such as operating suites/rooms, any jewellery, even a plain band, should not be worn. Each healthcare facility should develop policies on the wearing of jewellery, artificial fingernails or nail polish by healthcare workers. B1.1.5 Hand careThe main type of skin irritation associated with hand hygiene, irritant contact dermatitis, includes symptoms such as dryness, irritation, itching and sometimes cracking and bleeding. Allergic contact dermatitis is rare and represents an allergy, which may be to some ingredient in a hand hygiene product. Generally, alcohol-based hand rubs cause significantly less skin reaction or irritation than hand hygiene with plain or antiseptic soaps (Pittet & Boyce 2001). Expert opinion concludes that (Pratt et al 2001; Boyce & Pittet 2002; Grayson et al 2009):
Use of hand creamAn emollient hand cream should be applied regularly, such as after performing hand hygiene before a break or going off duty, and when off duty. Hand hygiene technique should be reviewed if skin irritation occurs. If the irritation persists or if it caused by a particular soap, antiseptic agent or alcohol-based product, the person with designated responsibility for infection control or occupational health should be consulted. B1.1.6 Putting it into practiceIndividual actions for reducing the risk
Involving patients in hand hygieneThe following information may be provided to patients to assist them in becoming involved in identifying and reducing risks related to poor hand hygiene.
Risk management case study: Hand hygiene in a neonatal intensive care unitThe neonatal intensive care unit in a large regional hospital identifies colonisation or infection with Pseudomonas aeruginosa in a number of infants. Surveillance cultures from other infants in the unit, from the hands of staff on the unit and from possible environmental reservoirs are assessed. The cultures show that an additional three infants are colonised. Cultures of environmental specimens are negative but cultures of three of twenty-four healthcare workers are positive. Of these, two have recently joined the unit and received no education on hand hygiene in orientation and the third has artificial fingernails.
B1.1.7 ResourcesStandardsAORN (2007) Standards, Recommended Practices and Guidelines Legislation
GuidelinesTools and web-based resourcesHand Hygiene Australia's website contains numerous educational resources, tools, and information on implementing hand hygiene programs B1.1.8 ReferencesAORN (2007) Standards, Recommended Practices & Guidelines. Association of periOperative Nurses. Boszczowski I, Nicoletti C, Puccini DM et al (2005) Outbreak of extended spectrum beta-lactamaseproducing Klebsiella pneumoniae infection in a neonatal intensive care unit related to onychomycosis in a health care worker. Pediatr Infect Dis J 24(7): 648–50. Brown TL, Gamon S, Tester P et al (2007) Can alcohol-based hand-rub solutions cause you to lose your driver's licence? Comparative cutaneous absorption of various alcohols. Antimicrobial Agents Chemotherapy 51: 1107–08. Canada Standards and Guideline Core Committee (CHICA) (2008) Hand hygiene. Can J Infect Control 23(114): 116–17. Donskey CJ & Eckstein BC (2009) Images in clinical medicine. The hands give it away. N Engl J Med 360(3): e3. Fendler EJ, Ali Y, Hammond BS et al (2002) The impact of alcohol hand sanitizer use on infection rates in an extended care facility. Am J Infect Control 30(4): 226–33. Foca M, Jakob K, Whittier S et al (2000) Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. N Engl J Med 343(10): 695–700. Girard R, Bousquet E, Carre E et al (2006) Tolerance and acceptability of 14 surgical and hygienic alcohol-based hand rubs. J Hosp Infect 63: 281–88. Grayson L, Russo P, Ryan K et al (2009) Hand Hygiene Australia Manual. Australian Commission for Safety and Quality in Healthcare and World Health Organization. Gupta A, Della-Latta P, Todd B et al (2004) Outbreak of extended-spectrum beta-lactamaseproducing Klebsiella pneumoniae in a neonatal intensive care unit linked to artificial nails. Infect Control Hosp Epidemiol 25(3): 210–15. Hedderwick SA, McNeil SA, Lyons MJ et al (2000) Pathogenic organisms associated with artificial fingernails worn by healthcare workers. Infect Control Hosp Epidemiol 21(8): 505–09. Johnson PD, Martin R, Burrell LJ et al (2005) Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Med J Aust 183(10): 509–14. Kramer A, Bernig T, Kampf G (2002a) Clinical double-blind trial on the dermal tolerance and user acceptability of six alcohol-based hand disinfectants for hygienic hand disinfection. J Hosp Infect 51: 114–20. Kramer A, Rudolph P, Kampf G et al (2002b) Limited efficacy of alcohol-based hand gels. Lancet 359: 1489–90. Larmer PJ, Tillson TM, Scown FM et al (2008) Evidence-based recommendations for hand hygiene for health care workers in New Zealand. N Z Med J 121(1272): 69–81. Larson EL (1996) APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 23(4): 251–69. Larson EL, Early E, Cloonan P et al (2000) An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med 26(1): 14–22. Lin CM, Wu FM, Kim HK et al (2003) A comparison of hand washing techniques to remove Escherichia coli and caliciviruses under natural or artificial fingernails. J Food Prot 66(12): 2296–301. Maiwald M & Widmer AF (2007) Are alcohol gels better than liquid hand rubs? Crit Care 11: 418. Malik RK, Montecalvo MA, Reale MR et al (1999) Epidemiology and control of vancomycin-resistant enterococci in a regional neonatal intensive care unit. Pediatr Infect Dis J 18(4): 352–56. Moolenaar RL, Crutcher JM, San Joaquin VH et al (2000) A prolonged outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit: did staff fingernails play a role in disease transmission? Infect Control Hosp Epidemiol 21(2): 80–85. Nicolay CR (2006) Hand hygiene: an evidence-based review for surgeons. Int J Surg 4: 53–65 Parry MF, Grant B, Yukna M et al (2001) Candida osteomyelitis and diskitis after spinal surgery: an outbreak that implicates artificial nail use. Clin Infect Dis 32(3): 352–57. Passaro DJ, Waring L, Armstrong R et al (1997) Postoperative Serratia marcescens wound infections traced to an out-of- hospital source. J Infect Dis 175(4): 992–95. Picheansathian W (2004) A systematic review on the effectiveness of alcohol-based solutions for hand hygiene. Int J Nurs Pract 10: 3–9. PIDAC (2008) Best Practices for Hand Hygiene in all Health Care Settings. Provincial Infectious Diseases Advisory Committee, Ontario Ministry of Health and Long-Term Care, Toronto. Pietsch H (2001) Hand antiseptics: rubs versus scrubs, alcoholic solutions versus alcoholic gels. J Hosp Infect 48 Suppl A: S33–36. Pittet D, Hugonnet S, Harbarth S et al (2000) Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 356(9238): 1307–12. Pittet D & Boyce JM (2001) Hand hygiene and patient care: pursuing the Semmelweis legacy. Lancet Infect Dis 1: 9–20. Pittet D (2007) Liquid or gel: hand rubbing at the point of care remains the most critical element of hand hygiene promotion. Crit Care 11: 418–19. Pottinger J, Burns S, Manske C (1989) Bacterial carriage by artificial versus natural nails. Am J Infect Control 17(6): 340–44. Pratt RJ, Pellowe C, Loveday HP et al (2001) The epic Project: developing national evidence-based guidelines for preventing healthcare associated infections. phase 1: guidelines for preventing hospital-acquired infections. J Hospital Infection 47 (Supplement): S3–82. Pratt RJ, Pellowea CM, Wilson JA et al (2007) epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. J Hosp Infect 65S, S1–S64. Roberts HS, Self RJ, Coxon M (2005) An unusual complication of hand hygiene. Anaesthesia 60(1): 100–01. Rotter ML (2004) Hand washing and hand disinfection. In: Mayhall CG (ed). Hospital Epidemiology and Infection Control. Lippincott Williams and Wilkins, Philadelphia. pp. 1727–46. Rotter ML, Koller W, Neumann R (1991) The influence of cosmetic additives on the acceptability of alcohol-based hand disinfectants. J Hosp Infect 18 Suppl B: 57–63. Ryan MAK, Christian RS, Wohlrabe J (2001) Handwashing and respiratory illness among young adults in military training. Am J Preventative Med 21: 79–83. Traore O, Hugonnet S, Lubbe J et al (2007) Liquid versus gel handrub formulation: a prospective intervention study. Crit Care 11: R52 Trick WE, Vernon MO, Hayes RA et al (2003) Impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital. Clin Infect Dis 36(11): 1383–90. Webster J, Faoagali JL, Cartwright D (1994) Elimination of methicillin-resistant Staphylococcus aureus from a neonatal intensive care unit after hand washing with triclosan. J Paediatr Child Health 30(1): 59–64. WHO (2009) Guidelines on Hand Hygiene in Healthcare. Widmer AE & Dangel M (2004) Alcohol-based handrub: evaluation of technique and microbiological efficacy with international infection control professionals. Infect Control Hosp Epidemiol 25: 207–9 Zafar AB, Butler RC, Reese DJ et al (1995) Use of 0.3% triclosan (Bacti-Stat) to eradicate an outbreak of methicillin-resistant Staphylococcus aureus in a neonatal nursery. B1.2 Personal protective equipmentB1.2.1 What are the risks?Any infectious agent transmitted by the contact or droplet route can potentially be transmitted by contamination of healthcare workers' hands, skin or clothing. Cross-contamination can then occur between the healthcare worker and other patients or healthcare workers, or between the healthcare worker and the environment. Infectious agents transmitted through droplets can also come into contact with the mucous membranes of the healthcare worker. Personal protective equipment (PPE) refers to a variety of barriers, used alone or in combination, to protect mucous membranes, airways, skin and clothing from contact with infectious agents. PPE used as part of standard precautions includes aprons, gowns, gloves, surgical masks, protective eyewear and face shields. Selection of PPE is based on the type of patient interaction, known or possible infectious agents, and/or the likely mode(s) of transmission. There have been few controlled clinical studies evaluating the relationship between the use of PPE and risk of HAIs. However, the use of barriers reduces opportunities for transmission of infectious agents (Pratt et al 2001; Clark et al 2002). PPE also protects patients from exposure to infectious agents in the surrounding environment carried by healthcare workers. This section discusses the routine use of PPE as part of standard precautions. Specific PPE used when transmission-based precautions are applied is discussed in Section B2. The use of PPE during specific procedures is discussed in Section B4. B1.2.2 Decision-making about personal protective equipmentSelection of protective equipment must be based on assessment of the risk of transmission of infectious agents to the patient or carer, and the risk of contamination of the clothing or skin of healthcare workers or other staff by patients' blood, body substances, secretions or excretions. Local policies and current health and safety legislation should also be taken into account (Clark et al 2002). Factors to be considered are:
Appropriate sequences and procedures for putting on and removing PPE[10] are shown in Section B1.2.7. Relevant Australian Standards are listed in B1.2.9. All PPE must meet relevant Therapeutic Goods Administration (TGA) criteria for listing on the Australian Register of Therapeutic Goods (ARTG) or equivalent and should be used in accordance with manufacturer's recommendations. Where to wear PPEPPE is designed and issued for a particular purpose in a protected environment and should not be worn outside that area. Protective clothing provided for staff in areas where there is high risk of contamination (for example, operating suite/room) must be removed before leaving the area. Even where there is a lower risk of contamination, clothing that has been in contact with patients should not be worn outside the patient-care area. Inappropriate wearing of PPE (for example, wearing operating suite/room attire in the public areas of a hospital or wearing such attire outside the facility) may also lead to a public perception of poor practice within the facility. B1.2.3 Aprons and gownsInternational guidelines recommend that protective clothing (apron or gown) be worn by all healthcare workers when (Garner 1996; Pratt et al 2001; Clark et al 2002; Pratt et al 2007):
The type of apron or gown required depends on the degree of risk, including the anticipated degree of contact with infectious material and the potential for blood and body substances to penetrate through to clothes or skin:
Gowns and aprons must be changed between patients. Clinical and laboratory coats or jackets worn over personal clothing for comfort and/or purposes of identity are not considered to be PPE. These items of clothing need to be changed dependant on activity and the extent of exposure to potential pathogens. Aprons/gowns are routinely used upon entering the room of a patient requiring contact precautions. This is discussed in Section B2.2.3. Plastic apronsSingle-use plastic aprons are recommended for general use when there is the possibility of sprays or spills, to protect clothes that cannot be taken off (Garner 1996; Pratt et al 2001; Clark et al 2002; Pratt et al 2007). Unused aprons should be stored in an appropriate area away from potential contamination (Callaghan 1998). GownsGowns are used to protect the healthcare worker's exposed body areas and prevent contamination of clothing with blood, body substances, and other potentially infectious material (Boyce et al 1994; Boyce et al 1995; Hall 2000; Kohn et al 2004). Considerations in choosing a a type of gown (for example, long or short-sleeved) that is appropriate for the activity are:
If a fluid-resistant full body gown is required, it is always worn in combination with gloves, and with other PPE when indicated. Full coverage of the arms and body front, from neck to the mid-thigh or below, ensures that clothing and exposed upper body areas are protected. Table B1.4 Characteristics of aprons/gowns
* Some gown types can be re-used. Reusable gowns need to be laundered or reprocessed according to AS/NZS4146—2000 Laundry Practice Removing aprons and gownsRemoval of aprons and gowns before leaving the patient-care area (for example, in the room or anteroom) prevents possible contamination of the environment outside the patient's room. Aprons and gowns should be removed in a manner that prevents contamination of clothing or skin. The outer, 'contaminated', side of the gown is turned inward and rolled into a bundle, and then discarded into a designated container for waste or linen to contain contamination (see Section B1.2.7). Recommendation5 Wearing of aprons/gowns - Grade C Aprons or gowns should be appropriate to the task being undertaken. They should be worn for a single procedure or episode of patient care and removed in the area where the episode of care takes place. B1.2.4 Face and eye protectionThe mucous membranes of the mouth, nose and eyes are portals of entry for infectious agents, as are other skin surfaces if skin integrity is compromised (for example, by acne, dermatitis) (Sartori et al 1993; Rosen 1997; Keijman et al 2001; Hosoglu et al 2003). Face and eye protection reduces the risk of exposure of healthcare workers to splashes or sprays of blood and body substances (Dancer 1999; Pratt et al 2001; Clark et al 2002) and is an important part of standard precautions. Procedures that generate splashes or sprays of blood, body substances, secretions or excretions require either a face shield or a mask worn with protective eyewear (CDC 1978; Davidson et al 1995; Gehanno et al 1999; Scales et al 2003; Seto et al 2003; Fowler et al 2004; Loeb et al 2004; ADA 2008). Face and eye protection is worn as part of transmission-based precautions as discussed in Sections B2.2.3, B2.3.3 and B2.4.3. Table B1.5: Use of face and eye protection as part of standard precautions
Surgical masksSurgical masks are loose fitting, single-use items that cover the nose and mouth. They are used as part of standard precautions to keep splashes or sprays from reaching the mouth and nose of the person wearing them. They also provide some protection from respiratory secretions and are worn when caring for patients on droplet precautions. Surgical masks differ from P2 respirators, as outlined in Table B1.6. Table B1.6: Properties of different types of mask
Surgical masks can be placed on coughing patients to limit potential dissemination of infectious respiratory secretions from the patient to others (see Section B2.3.3). Considerations when using a surgical mask include:
Children should wear a specifically designed child mask and their oxygen saturation should be monitored. Eye protectionGoggles with a manufacturer's anti-fog coating provide reliable, practical eye protection from splashes, sprays, and respiratory droplets from multiple angles. Newer styles of goggles fit adequately over prescription glasses with minimal gaps (to be efficacious, goggles must fit snugly, particularly from the corners of the eye across the brow). Other types of protective eyewear include safety glasses with side-shield protection, which are widely used in dentistry and other specialties that use operating microscopes (ADA 2008). While effective as eye protection, goggles and safety glasses do not provide splash or spray protection to other parts of the face. Personal eyeglasses and contact lenses are not considered adequate eye protection. Face shieldsSingle-use or reusable face shields may be used in addition to surgical masks, as an alternative to protective eyewear. Compared with other forms of protective eyewear, a face shield can provide protection to other parts of the face as well as the eyes. Face shields extending from chin to crown provide better face and eye protection from splashes and sprays; face shields that wrap around the sides may reduce splashes around the edge of the shield. Removing face and eye protectionRemoval of a face shield, protective eyewear and surgical mask can be performed safely after gloves have been removed and hand hygiene performed. The ties, earpieces and/or headband used to secure the equipment to the head are considered 'clean' and therefore safe to touch with bare hands. The front of a mask, protective eyewear or face shield is considered contaminated. Cleaning reusable face and eye protectionReusable face shields and protective eyewear should be cleaned according to the manufacturer's instructions, generally with detergent solution, and be completely dry before being stored. If they are to be disinfected, they should be disinfected using either a TGA-registered instrument grade disinfectant - low level, or by heat as per AS/NZS 4187:2003. Recommendation6 Use of face and protective eyewear for procedures - Grade C A surgical mask and protective eyewear must be worn during procedures that generate splashes or sprays of blood, body substances, secretions or excretions into the face and eyes. B1.2.5 Gloves Gloves can protect both patients and healthcare workers from exposure to infectious agents that may be carried on hands (Duckro et al 2005). As part of standard precautions, they are used to prevent contamination of healthcare workers' hands when (Siegel et al 2007):
The capacity of gloves to protect healthcare workers from transmission of bloodborne infectious agents following a needlestick or other puncture that penetrates the glove barrier has not been determined (Siegel et al 2007). Gloves are an essential component of contact precautions (in particular for patients with MROs) (see Sections B2.2.3 and B3.1.2) and may also be used as part of droplet precautions (see Section B2.3.3). How and when should gloves be worn?As with all PPE, the need for gloves is based on careful assessment of the task to be carried out, the related risk of transmission of microorganisms to the patient; and the risk of contamination of the healthcare worker's clothing and skin by the patient's blood and body substances (Pratt et al 2001; Clark et al 2002). Risk assessment includes consideration of:
When gloves are worn in combination with other PPE, they are put on last (see Section B1.2.7). When should gloves be changed?International guidance suggests that changing of gloves is necessary: between episodes of care for different patients, to prevent transmission of infectious material (Pratt et al 2001; Siegel et al 2007) during the care of a single patient, to prevent cross-contamination of body sites (CDC 1995; Boyce & Pittet 2002) if the patient interaction involves touching portable computer keyboards or other mobile equipment that is transported from room to room (Siegel et al 2007). Prolonged and indiscriminate use of gloves should be avoided as it may cause adverse reactions and skin sensitivity (Pratt et al 2001; Clark et al 2002). Hand hygiene should be performed before putting on gloves and after removal of gloves. Single-use gloves should not be washed, but discarded. Recommendations7 Wearing of gloves - Grade GPP Gloves must be worn as a single-use item for:
Gloves must be changed between patients and after every episode of individual patient care. 8 Sterile gloves - Grade GPP Sterile gloves must be used for aseptic procedures and contact with sterile sites. The selection of glove type for non-surgical use is based on a number of factors (Korniewicz et al 1994; Bolyard et al 1998; Korniewicz & McLeskey 1998; Ranta & Ownby 2004):
Facility policies for creating a latex-free environment should also be taken into account. Table B1.7: Selection of glove type
Sources: Derived from Kotilainen et al 1989; Korniewicz et al 1989; Korniewicz et al 1993; Rego & Roley 1999; Pratt et al 2001; Korniewicz et al 2002; Sehulster & Chinn 2003; Siegel et al 2007; Queensland Health 2010. LatexLatex allergy is a reaction to certain proteins in latex rubber. The amount of latex exposure needed to produce sensitisation or an allergic reaction is unknown. However, current understanding of latex allergy is as follows (NIOSH 1998):
Healthcare workers with latex allergies should inform their managers to ensure that their work areas can be latex free. If latex gloves are used, they should be non-powdered due to the risks associated with aerosolisation and an increased risk of latex allergies. Removing and disposing of glovesGloves (other than utility gloves) should be treated as single-use items. They should be put on immediately before a procedure and removed as soon as the procedure is completed. When removing gloves, care should be taken not to contaminate the hands. After gloves have been removed, hand hygiene should be performed in case infectious agents have penetrated through unrecognised tears or have contaminated the hands during glove removal (Olsen et al 1993; Tenorio et al 2001; Boyce & Pittet 2002). Gloves must not be washed for subsequent re-use—infectious agents cannot be removed reliably from glove surfaces and continued glove integrity cannot be ensured. Glove re-use has been associated with transmission of methicillin-resistant Staphylococcus aureus (MRSA) and Gramnegative bacilli (Doebbeling et al 1988; Maki et al 1990; Olsen et al 1993). Gloves should be disposed of as soon as they are removed, with disposal complying with local policies and standards. B1.2.6 Other items of clothingTies and lanyardsThere is some evidence to suggest that lanyards and neckties may play a role in transmission of infection but it is difficult to demonstrate the precise role (Kotsanas et al 2008). FootwearFootwear suitable for the duties being undertaken must be worn and preferably be designed to minimise the risk of injury from dropped sharps. UniformsIn areas of clinical practice where there is a high risk of repeated exposure to blood and other body substances, it is recommended that uniforms be worn as well as the appropriate PPE. While some studies show that uniforms and white coats become progressively contaminated during clinical care, no studies have demonstrated that uniforms transmit infectious agents or lead to HAIs (Loveday et al 2007). Uniforms should be washed daily. There is no evidence to suggest that home laundering is inferior to commercial reprocessing of uniforms (Loveday et al 2007). B1.2.7 Sequence for putting on and removing PPETo reduce the risk of transmission of infectious agents, PPE must be used appropriately. The following table outlines sequences and procedures for putting on and removing PPE. Hand hygiene must be performed before putting on PPE and after removing PPE. Table B1.8 Putting on and removing PPE
Source: Adapted from CDC Isolation Precautions. * Surgical masks can be removed at the point of care. To remove a P2 respirator, perform hand hygiene and step outside the room or into an anteroom before removing and disposing of the respirator in a closed container and performing hand hygiene again. Note that for surgical procedures and dentistry, the sequence for putting on PPE differs. In these situations, masks and protective eyewear are applied first prior to hand preparation. Gown and gloves are then put on. (see Section B4.3.2). B1.2.8 Putting it into practiceIndividual actions for reducing the risk
Involving patients in their care The following information may be provided to patients to assist them in becoming involved in identifying and reducing risks related to the use of PPE.
Risk management case study: Glove use and hand hygiene in office-based practiceFollowing an audit of healthcare-associated infections in the practice and comparison of the results with Division benchmarks, a GP identifies a higher than usual rate of Staphylococcus aureus cross-transmission in her practice. The practice comprises three GPs and a part-time practice nurse. Practice policy is that staff members use gloves for patient contact, changing gloves between patients. There is no recommendation in the policy for hand hygiene between different care activities for the same patient or after removing gloves.
B1.2.9 ResourcesStandardsGloves
Masks
Protective eyewear
Gowns
Legislation/codes of practice
Tools and web-based resources Latex allergy B1.2.10 ReferencesADA (2008) Guidelines for Infection Control. Adelaide: Australian Dental Association. Bhalla A, Pultz NJ, Gries DM et al (2004) Acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospi≠talized patients. Infect Control Hosp Epidemiol 25(2): 164–67. Bolyard EA, Tablan OC, Williams WW et al (1998) Guideline for infection control in healthcare personnel, 1998. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 19(6): 407–63. Boyce JM & Pittet D, Healthcare Infection Control Practices Advisory C, Force HSAIHHT (2002) Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 51: 1–45. Boyce JM, Jackson MM, Pugliese G et al (1994) Methicillin-resistant Staphylococcus aureus (MRSA): a briefing for acute care hospitals and nursing facilities. The AHA Technical Panel on Infections Within Hospitals. Infect Control Hosp Epidemiol 15(2): 105–15. Boyce JM, Mermel LA, Zervos MJ et al (1995) Controlling vancomycinresistant enterococci. Infect Control Hosp Epidemiol 16(11): 634–37. Callaghan I (1998) Bacterial contamination of nurses' uniforms: a study. Nursing Standard 13:37–42. CDC (1978) Nosocomial meningococcemia. MMWR 27: 358. Clark L, Smith W, Young L (2002) Protective Clothing; Principles and Guidance. London: Infection Control Nurses Association. Dancer SJ (1999) Mopping up hospital infection. J Hosp Infect 43: 85–100. Davidson IR, Crisp AJ, Hinwood DC et al (1995) Eye splashes during invasive vascular procedures. Br J Radiol 68(805): 39–41. Doebbeling BN, Pfaller MA, Houston AK et al (1988) Removal of nosocomial pathogens from the contaminated glove. Implications for glove reuse and handwashing. Ann Intern Med 109(5): 394–98. Duckro AN, Blom DW, Lyle EA et al (2005) Transfer of vancomycin-resistant enterococci via health care worker hands. Arch Intern Med 165(3): 302–07. Fowler RA, Guest CB, Lapinsky SE et al (2004) Transmission of severe acute respiratory syndrome during intubation and mechanical ventilation. Am J Respir Crit Care Med 169(11): 1198–202. Garner JS (1996) Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infection Control Hosp Epidemiol 17: 53–80 and Am J Infection Control 24: 24–52. Gehanno JF, Kohen-Couderc L, Lemeland JF et al (1999) Nosocomial meningococcemia in a physician. Infect Control Hosp Epidemiol 20(8): 564–65. Hall CB (2000) Nosocomial respiratory syncytial virus infections: the “Cold War” has not ended. Clin Infect Dis 31(2): 590–96. Hosoglu S, Celen MK, Akalin S et al (2003) Transmission of hepatitis C by blood splash into conjunctiva in a nurse. Am J Infect Control 31(8): 502–04. Hunt A, Kelkar P, Reed CE et al (2002) Management of occupational allergy to natural rubber latex in a medical centre: the importance of quantitative latex allergen measurement and objective follow-up. Allergy Clin Immunol 110: S94–106. Keijman J, Tjhie J, Olde Damink S et al (2001) Unusual nosocomial transmission of Mycobacterium tuberculosis. Eur J Clin Microbiol Infect Dis 20(11): 808–09. Kohn WG, Collins AS, Cleveland JL et al (2004) Guidelines for Infection Control in Dental Health- Care Settings 2003. J Am Dent Assoc 135(1):33-47. http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5217a1.htm Korniewicz DM & McLeskey SW (1998) Latex allergy and gloving standards. Semin Perioper Nurs Korniewicz DM, El-Masri M, Broyles JM (2002) To determine the effects of gloves stress, type of material (vinyl, nitrile, copolymer, latex) and manufacturer on the barrier effectiveness of medical examination gloves. Am J Infection Control 30: 133–38. Korniewicz DM, Kirwin M, Cresci K et al (1993) Leakage of latex and vinyl exam gloves in high and low risk clinical settings. Am Ind Hyg Assoc J 54(1): 22–26. Korniewicz DM, Kirwin M, Cresci K et al (1994) Barrier protection with examination gloves: double versus single. Am J Infect Control 22(1): 12–15. Korniewicz DM, Laughon BE, Butz A et al (1989) Integrity of vinyl and latex procedure gloves. Nurs Res 38(3): 144–46. Kotilainen HR, Brinker JP, Avato JL et al (1989) Latex and vinyl examination gloves. Quality control procedures and implications for health care workers. Arch Intern Med 149(12): 2749–53. Kotsanas D, Scott C, Gillespie EE et al (2008) What's hanging around your neck? Pathogenic bacteria on identity badges and lanyards. MJA 2008; 188: 5–8. Loeb M, McGeer A, Henry B et al (2004) SARS among critical care nurses, Toronto. Emerg Infect Dis 10(2): 251–55. Loveday HP, Wilson JA, Hoffman PN et al (2007) Public perception and the social and microbiological significance of uniforms in the prevention and control of healthcare-associated infections: an evidence review. Br J Infect Control 8: 10. Maki DG, McCormick RD, Zilz MA et al (1990) A MRSA outbreak in an SICU during universial precautions: new epidemiology for nosocomial MRSA. Abstract # 473 Presented at the 30th Annual Meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), Chicago, Illinois October 21–24, 1990. NIOSH (1998) Latex Allergy: A Prevention Guide. National Institute for Occupational Safety and Health Publication Number 98-113. United States Centers for Disease Control and Prevention. Olsen RJ, Lynch P, Coyle MB et al (1993) Examination gloves as barriers to hand contamination in clinical practice. JAMA 270(3): 350–53. Pratt RJ, Pellowe C, Loveday HP et al (2001) The epic Project: developing national evidence-based guidelines for preventing healthcare associated infections. phase 1: guidelines for preventing hospital-acquired infections. J Hosp Infect 47 (Supplement): S3–82. Pratt RJ, Pellowea CM, Wilson JA et al (2007) epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. J Hosp Infect 65S, S1–S64. Queensland Health (2010) Infection Control Guidelines. p5. Ranta PM & Ownby DR (2004) A review of natural-rubber latex allergy in health care workers. Clin Infect Dis 38(2): 252–56. Rego A & Roley L (1999) In-use barrier integrity of gloves: latex and nitrile superior to vinyl. Am J Infect Control 27(5): 405–10. Rosen HR (1997) Acquisition of hepatitis C by a conjunctival splash. Am J Infect Control 25(3): Sartori M, La Terra G, Aglietta M (1993) Transmission of hepatitis C via blood splash into conjunctiva. Scand J Infect Dis 25(2): 270–71. Scales D, Green K, Chan AK et al (2003) Illness in intensive-care staff after brief exposure to severe acute respiratory syndrome. Emerg Infect Dis 9(10): 1205–10. Seto WH, Tsang D, Yung RW et al (2003) Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet 361(9368): 1519–20. Siegel JD, Rhinehart E, Jackson M et al (Health Care Infection Control Practices Advisory Committee) (2007) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007. United States Centers for Disease Control and Prevention. Tenorio AR, Badri SM, Sahgal NB et al (2001) Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant enterococcus species by health care workers after patient care. Clin Infect Dis 32(5): 8269(s). B1.3 Handling and disposing of sharpsB1.3.1 What are the risks?The use of sharp devices exposes healthcare workers to the risk of injury and potential exposure to bloodborne infectious agents, including hepatitis B virus, hepatitis C virus and human immunodeficiency virus (HIV) (CDC 2001; Do et al 2003). Sharps injuries can occur in any healthcare setting, including non-hospital settings such as in office-based practices, home health care and long-term care facilities. Injuries most often occur (CDC 2008):
There are many possible mechanisms of injury during each of these periods. Hollowbore needles are of particular concern, especially those used for blood collection or intravascular catheter insertion, as they are likely to contain residual blood and are associated with an increased risk for bloodborne virus transmission. Non-hollowbore sharps such as glass vials and butterfly needles have also been involved in sharps incidents (ASCC 2008). Table B1.9: Examples of sharps associated with sharps injuries in healthcare settings
A survey of occupational exposures in Australian nurses (ASCC 2008) found that in the 12 months prior to the survey, 11.2% of nurses had sustained at least one needlestick or other sharps injury. Eliminating workplace hazard and risk is a fundamental principle of all occupational health and safety (OH&S) legislation in Australia. To limit the risk of sharps injuries, the hierarchy of controls method is a well recognised approach to prevent sharps injuries (CDC 2008; NOHSC (2010 [2003]). The first priority is to eliminate and reduce the use of needles and other sharps where possible. Next is to isolate the hazard, thereby protecting an otherwise exposed sharp, through the use of an engineering control. When these strategies are not available or will not provide total protection, the focus shifts to work-practice controls and PPE. An organisational approach to reducing sharps injuries is discussed in Section C1.5.2 and sharps injuries and post-exposure prophylaxis (PEP) in Section C6.3. B1.3.2 Handling of sharpsAll healthcare workers should take precautions to prevent injuries caused by needles, scalpels and other sharp instruments or devices: during procedures; when cleaning used instruments; during disposal of used needles; and when handling sharp instruments after procedures. Standard measures to avoid sharps injuries include handling sharp devices in a way that prevents injury to the user and to others who may encounter the device during or after a procedure. Examples include (CDC 2008):
The extent to which gloves protect healthcare workers from transmission of bloodborne infectious agents following a needlestick or other puncture that penetrates the glove has not been determined (Siegel et al 2007). Although gloves may reduce the volume of blood on the external surface of a sharp (Mast et al 1993), the residual blood in the lumen of a hollowbore needle would not be Recommendations9 Safe handling of sharps - Grade D Sharps must not be passed directly from hand to hand and handling should be kept to a minimum. Needles must not be recapped, bent or broken after use. B1.3.3 Disposal of single-use sharpsAny person who has used a disposable sharp instrument or equipment must be responsible for its safe management and immediate disposal after use. After they are used, single-use syringes and needles, scalpel blades and other sharp items should be placed in an appropriate container. These containers should be clearly labelled, puncture and leak proof, and conform to AS4031 or AS/NZ 4261. The containers should be located at the point of use or, if this is not possible, as close as practical to the use area. Reusable sharps requiring transport to a reprocessing area must be placed in a puncture-resistant lidded container. Sharps containers must be appropriately placed so that they are out of reach of children. They should also be placed in a secure position or mounted on the wall to prevent tipping. There are numerous safety devices available that assist with safe removal and disposal of sharps (eg scalpel blade removers). Local protocol and procedures need to be developed to outline their appropriate use. Table B1.10: Reducing risks if a sharps injury is sustained
Recommendation10 Disposal of single-use sharps - Grade D The person who has used the single-use sharp must be responsible for its immediate safe disposal. Used disposable sharps must be discarded into an approved sharps container at the point-of-use. These must not be filled above the mark that indicates the bin is three-quarters full. B1.3.4 Safety-engineered devicesA broad range of devices has been designed with built-in safety features that reduce the risk of injury involving a sharp. Examples include devices such as syringes with guards, sliding sheaths, shielded, blunting or retracting needles, blunt suture needles and surgical blades with protective covers. The use of devices with safety-engineered protective features (for example, safety or retractable devices) was mandated in the US in 2000 and is thought to have reduced the rate of incidence of needlestick injuries ( Jagger et al 2008). Their use has recently been mandated in the UK and Europe, but not yet in Australia. Further research is required on their efficacy in reducing sharps Needleless devicesNeedleless devices do not use needles for procedures such as the collection or withdrawal of body substances after initial venous or arterial access is established, or administering medication or fluids. Since their adoption in healthcare facilities, needleless devices have contributed to a decrease in percutaneous injuries among healthcare workers ( Jagger et al 2008). While it is difficult to assess the overall effect of needleless devices because of the wide variety of devices and systems that are in use, some studies have shown an increased risk of bloodstream infections (BSI) among patients (Rupp et al 2007; Salgado et al 2007). Unfamiliarity with the use of these complex devices, together with inadequate disinfection procedures, may contribute to increased BSI rates. The CDC recommends that (O'Grady et al 2002):
Disinfection of needleless connectors with chlorhexidine/alcohol or povidone-iodine has been shown to significantly reduce external contamination (Casey et al 2003). Retractable devicesThe use of retractable safety devices on sharps has been associated with a significant reduction in needlestick injury in healthcare settings (Rogues et al 2004; Tuma & Sepkowitz 2006), although their direct impact is difficult to determine because their introduction is often accompanied by other interventions (for example, training and education, overarching hospital policies Retractable technology is only one example of the broad range of safety-engineered medical devices that have been designed and produced to assist in reducing the risk of occupational exposure to bloodborne pathogens in healthcare. Implementation of safety-engineered devices must be accompanied by appropriate training and education for healthcare workers in the use of the new technology to achieve successful reduction in percutaneous injury rates (Tuma & Sepkowitz 2006). B1.3.5 Putting it into practiceIndividual actions for reducing the risk
Involving patients in their care The following information may be provided to patients to assist them in becoming involved in identifying and reducing risks related to the handling and disposal of sharps.
Risk-management case study: Prevention of stick injury during surgery at a university hospitalAs part of the revision of infection control policies at a university hospital, an analysis of the risk of percutaneous blood and body substance exposure during surgical procedures was undertaken. Separate analyses were conducted for different device types and for different members of the surgical team. Surgeons and first assistants were at highest risk for injury, suffering more than half of injuries in the operating room, followed by scrub nurses and technicians, anaesthetists and circulating nurses. Rates of stick injury increased with estimated blood loss and surgery duration. Suture needle injuries were the most common and mostly occurred during wound closure. A considerable number of injuries also occurred while passing sharp instruments hand to hand. As many as one-third of devices that caused injuries came in contact with the patient after the injury to the healthcare worker. However, only a small proportion of injuries to surgeons (0.5%) involved hollowbore vascular access needles, which are defined as 'high risk'. Source: Based on Myers et al (2008) and Bergauer & Heller (2005).
B1.3.6 ResourcesStandards
Legislation/codes of practice
Tools and web-based resourcesCDC (2008) Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program. United States Centers for Disease Control. B1.3.7 ReferencesASCC (2008) Occupational Exposures in Australian Nurses: Report of the Project. Australian Safety and Compensation Council. Bergauer R & Heller PJ (2005) Strategies for preventing sharps injuries in the operating room. Surg Clin N Am 85: 1299–305 Casey AL, Worthington T, Lambert PA et al (2003) A randomized, prospective clinical trial to assess the potential infection risk associated with the PosiFIow needleless connector. J Hosp Infect 54(4): 288–93. CDC (2001) Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. United States Centers for Disease Control and Prevention. MMWR 50(RR-11): 1–52. CDC (2008) Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program. United States Centers for Disease Control and prevention. Do AN, Ciesielski CA, Metler RP et al (2003) Occupationally acquired human immunodeficiency virus (HIV) infection: national case surveillance data during 20 years of the HIV epidemic in the United States. Infect Control Hosp Epidemiol 24(2): 86–96. Jagger J, Perry J, Gomaa A et al (2008) The impact of U.S. policies to protect healthcare workers from bloodborne pathogens: the critical role of safety-engineered devices. J Infect Public Health 1(2): 62–71. Mast ST, Woolwine JD, Gerberding JL (1993) Efficacy of gloves in reducing blood volumes transferred during simulated needlestick injury. J Infect Dis 168(6): 1589–92. Myers DJ, Epling C, Dement J et al (2008) Risk of sharp device-related blood and body fluid exposure in operating rooms. Infect Control Hosp Epidemiol 29(12): 1139–48. NOHSC (2010 [2003]) National Code of Practice for the Control of Work-Related Exposure to Hepatitis and HIV (Blood-Borne) Viruses. 2nd ed. Canberra: Australian Government National Occupational Health and Safety Commission. O'Grady NP, Alexander M, Dellinger EP et al (2002) Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 51(RB-10): 1–29. Pratt RJ, Pellowea CM, Wilson JA et al (2007) epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. J Hosp Infect 65S: S1–S64. Rogues AM, Verdun-Esquer C, Buisson-Valles I (2004) Impact of safety devices for preventing percutaneous injuries related to phlebotomy procedures in health care workers. Am J Infect Control 32(8): 441–44. Rupp ME, Sholtz LA, Jourdan DR et al (2007) Outbreak of bloodstream infection temporally associated with the use of an intravascular needleless valve. Clin Infect Dis 44(11): 1408–14. Salgado CD, Chinnes L, Paczesny TH et al (2007) Increased rate of catheter-related bloodstream infection associated with use of a needleless mechanical valve device at a long-term acute care hospital. Infect Control Hosp Epidemiol 28(6): 684–88. Siegel JD, Rhinehart E, Jackson M et al (Health Care Infection Control Practices Advisory Committee) (2007) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007. United States Centers for Disease Control and Prevention. Tuma S & Sepkowitz KA (2006) Efficacy of safety-engineered device implementation in the prevention of percutaneous injuries: a review of published studies. Healthcare Epidemiol 42: 1159. Whitby M, McLaws M, Slater K (2008) Needlestick Injures in a major teaching hospital: the worthwhile effect of hospital wide B1.4 Routine management of the physical environmentB1.4.1 What are the risks?Infectious agents can be widely found in healthcare settings and there is a body of clinical evidence, derived from case reports and outbreak investigations, suggesting an association between poor environmental hygiene and the transmission of infectious agents in healthcare settings (Garner & Favero 1986; Dancer 1999). Transmission of infectious agents from the environment to patients may occur through direct contact with contaminated equipment, or indirectly, for example, in the acute-care setting, via hands that are in contact with contaminated equipment or the environment and then touch a patient (Dancer 2008). Environmental surfaces can be safely decontaminated using less rigorous methods than those used on medical instruments and devices. The level of cleaning required depends on the objects involved and the risk of contamination—for example, surfaces that are likely to be contaminated with infectious agents (for example, shared clinical equipment) require cleaning between patient uses, which is more often than general surfaces and fittings. However, all surfaces require regular cleaning. Thorough cleaning of all surfaces is necessary after spills and between patient uses of a room or patient-care area, especially in acute-care settings. Intensive care units and isolation areas require additional levels of cleaning, especially where there is a risk of MRO transmission (see Section B2.2). B1.4.2 Routine environmental cleaningGeneral surfaces can be divided into two groups—those with minimal hand contact (for example, floors and ceilings) and those with frequent skin contact ('frequently touched' or 'high risk' surfaces). The methods, thoroughness and frequency of cleaning and the products used are determined by risk analysis and reflected in healthcare facility policy. Frequently touched surfaces in patient-care areas should be cleaned using a detergent solution and more frequently than surfaces with minimal hand contact. Infection control professionals typically use a risk-assessment approach to identify frequently touched surfaces and then coordinate an appropriately thorough cleaning strategy and schedule with the housekeeping staff. When MROs are suspected or known to be present, routine cleaning is intensified and the use of a detergent solution is followed by the use of a disinfectant so that surfaces are cleaned twice (see Section B3.1.2). Cleaning schedulesThe recommendations outlined for cleaning should be justified by the risk of transmission of infection within a particular healthcare facility. All organisations should have a documented cleaning schedule that outlines clear responsibilities of staff, a roster of duties and the frequency of cleaning required and the products that should be used to clean specific areas. Organisations should also facilitate job or task-specific education and training by accredited bodies for general and special cleaning of the physical environment. If cleaning is outsourced to cleaning service providers, all cleaning service delivery procedures should be documented, including details of how the cleaning service will be undertaken. The procedures must include the following (VCSUG 2009).
The risk of transmission of particular infections should be assessed and the cleaning schedule should be adjusted if a known infectious agent is present (for example, an outbreak of C. difficile requires surfaces to be disinfected with sodium hypochlorite after cleaning with detergent [HPS 2008]). CleaningMost hard surfaces can be adequately cleaned with warm water and detergent as per manufactures instructions. Allowing the cleaned surface to dry is an important aspect of cleaning. Minimal touch surfaces A detergent solution (diluted as per manufacturer's instructions) is adequate for cleaning general surfaces (for example, floors, walls), as well as non-patient-care areas (for example, administrative offices). Damp mopping is preferable to dry mopping for routine cleaning (Andersen et al 2009). Walls and blinds in patient-care areas should be cleaned with detergent solution when they are visibly dusty or soiled. Window curtains should be regularly changed in addition to being cleaned when soiled or exposed to MROs. Sinks and washbasins should be cleaned with a detergent solution on a regular basis as set by facility policy. Frequently touched surfaces Surfaces that are in close proximity to the patient and frequently touched surfaces in the patientcare areas should be cleaned more frequently than minimal touch surfaces. Examples include doorknobs, bedrails, over-bed tables, light switches, tabletops and wall areas around the toilet in the patient's room. Frequently touched surfaces can be cleaned with a detergent solution designed for general purpose cleaning. The exact choice of detergent will depend on the nature of the surface and the likely degree of contamination. Detergent-impregnated wipes may be used to clean single pieces of equipment and small surface areas. This method is not normally used for general ward cleaning and should not be considered a replacement for clean cloths and detergent solution. Recommendation11 Routine cleaning of surfaces - Grade GPP Clean frequently touched surfaces with detergent solution at least daily, and when visibly soiled and after every known contamination. Clean general surfaces and fittings when visibly soiled and immediately after spillage. Use of disinfectants In acute-care settings where there is uncertainty about the nature of soiling on the surface (for example, blood or body fluid contamination versus routine dust or dirt) or the presence of MROs (including C. difficile) or other infectious agents requiring transmission-based precautions (for example, pulmonary tuberculosis) is known or suspected, surfaces should be physically cleaned with a detergent solution, followed or combined with a TGA-registered disinfectant with label claims specifying its effectiveness against specific infectious organisms. This process must involve either:
In office-based practice and less acute patient-care areas (for example, long-term care facilities), the risk of contamination, mode of transmission and risk to others should be used to determine whether disinfectants are required. Processes for routine cleaningFigure B1.3: Processes for routine cleaningHigh-level disinfectants or liquid chemical sterilants are not appropriate for general cleaning; such use is counter to manufacturers' instructions for these hazardous chemicals. Instrument disinfectants should not be used for surface disinfection. Alcohol should not be used to disinfect large environmental surfaces, given the risk of additional hazards such as flammability. Technologies in this area are evolving and new technologies may replace the need for cleaning chemicals and disinfectants. Some current examples include ultramicrofibre cloths (Moore & Griffin 2006; Rutala 2007; Bergen et al 2008; Wren 2008) and hydrogen peroxide mist (Shapey 2008). More research is needed in these areas to assess the scope of organisms removed or killed and the practical application of these technologies. Shared clinical equipmentWhile shared clinical equipment comes into contact with intact skin only and is therefore unlikely to introduce infection, it can act as a vehicle by which infectious agents are transferred between patients (Microbiological Advisory Committee to the Department of Health 2006). Examples of possible contaminated surfaces on shared medical equipment include knobs or handles on Surface barriers (for example, clear plastic wrap, bags, sheets, tubing or other materials impervious to moisture) help prevent contamination of surfaces and equipment. Surface barriers on equipment (for example, air water syringes, bedboards, computer keyboards) need to be placed carefully to ensure that they protect the surfaces underneath and should be changed and cleaned between patients. If surface barriers are unable to be used, cleaning clinical surfaces including equipment still applies. Recommendation12 Cleaning of shared clinical equipment - Grade GPP Clean touched surfaces of shared clinical equipment between patient uses, with detergent solution. Exceptions to this should be justified by risk assessment. 13 Surface barriers - Grade GPP Use surface barriers to protect clinical surfaces (including equipment) that are:
Exceptions to this should be justified by risk assessment. Cleaning implements and solutionsPart of the cleaning strategy is to minimise contamination of cleaning solutions and cleaning tools. Proper procedures for effective use of mops, cloths, and solutions should be followed:
Table B1.11: Choosing cleaning/disinfection products
CarpetCarpets in public areas and in general patient-care areas should be vacuumed daily with well-maintained equipment fitted with high efficiency particulate air (HEPA) filters to minimise dust dispersion (see also Section C6.2.3). After a spill has been removed as much as possible (see Section B1.4.3), the carpet should be cleaned using the hot water extraction method, which is recognised by AS/NZS 3733:1995 to minimise chemical and soil residue. Carpets should undergo thorough cleaning on a regular basis as set by facility policy, using a method that minimises the production of aerosols, leaves little or no residue and is recommended by Australian Standards and manufacturer's recommendations. Checking, auditing and environmental samplingHealthcare facilities use a variety of systems to ensure that cleaning standards are met. These include checklists, colour coding to reduce the chance of cross infection, cleaning manuals, model cleaning contracts, infection control guidance, and monitoring strategies. Some states and territories have cleaning standards that are applied to healthcare facilities regardless of whether cleaning services are contracted or performed in-house. Auditing of cleaning is mostly done through visual checking; however, this does not recognise that microorganisms are invisible to the naked eye (Dancer 2008). Currently, more objective methods of assessing surface cleanliness and benchmarking (such as black-spot auditing and detection of bacterial load with ATPase) are being investigated. Routine microbiological sampling of the environment to determine the effectiveness of cleaning has considerable limitations, including detection of specific classes of organisms (with exclusion of others), inconsistency and unpredictability of 'patient shedding' and other causes of environmental contamination, variation of effects of residual detergent/ disinfectants, and variations in sampling techniques and testing. These limitations make interpreting the results very difficult (Button 2006; Mutters et al 2009; Rohr et al 2009) and routine environmental sampling is therefore not recommended. However, there may be a role for environmental sampling in the management of specific situations and as part of a holistic risk-management approach (for example, an outbreak situation or unidentified cause of infections). B1.4.3 Management of blood and body substance spillsPrompt removal of spots and spills of blood and body substance followed by cleaning and disinfection of the area contaminated is a sound infection control practice and meets occupational health and safety requirements (Sehulster & Chinn 2003). Process of spills managementStrategies for decontaminating spills of blood and other body substances (for example, vomit, urine) differ based on the setting in which they occur and the volume of the spill:
The B1.12 table demonstrates appropriate processes when managing spills. Appropriate PPE should be worn at all times. If spillage has occurred on soft furnishings, a detergent solution can be used to clean the area thoroughly. Do not clean soft furnishings with a disinfectant such as sodium hypochlorite. Soft furnishings can also be wet vacuumed. Following cleaning of soft furnishings, every effort must be made to air the room to allow drying of the furnishing before reuse. Alcohol solutions should not be used to clean spillages (HPS 2006). Table B1.12: Management of blood or body substance spills
The use of sodium hypochlorite is not necessary for routinely managing spills but it may be used in specific circumstances. There is evidence supporting the use of sodium hypochlorite to inactivate various bloodborne and gastrointestinal viruses, and bacteria such as C. difficile (HPS 2008). The consideration to use sodium hypochlorite should be based on risk assessment of the environment, the spill, risk of transmission of disease, and the surface area and potential hazards with using the product. If a disinfectant is required, particularly during the implementation of transmission-based precautions, a TGA-registered hospital grade disinfectant must be used. The disinfectant chosen should have label claims against the organism of concern. Recommendation14 Site decontamination after spills of blood or other potentially infectious materials - Grade C Spills of blood or other potentially infectious materials should be promptly cleaned as follows:
Use of chemical disinfectants such as sodium hypochlorite should be based on assessment of risk of transmission of infectious agents from that spill. Spill kitA spill kit should be readily available in each clinical area and should include a scoop and scraper, single-use gloves, protective apron, surgical mask and eye protection, absorbent agent, clinical waste bags and ties, and detergent. All parts should be disposable to ensure that cross-contamination does not occur. B1.4.4 Putting it into practiceIndividual actions for reducing the risk
Involving patients in their care Patients are an integral part of the risk-management process. Following are points of advice to assist patients in becoming involved in identifying and reducing risks related to routine hospital hygiene.
Risk-management case study: Spills management in a busy paediatric wardA visitor to the paediatric ward in a small regional hospital notices that the child in the next bed is vomiting and has diarrhoea. The ward is extremely busy and the two nurses on duty are fully occupied. The child's mother has cleaned up any spills, but there are still traces of vomit on the bedside table. Later the visitor notices that equipment is being placed on this table. When there is a lull in activity in the ward, the visitor approaches one of the nurses and mentions what she has noticed. The nurse is grateful for the advice and the quiet period is used for more thorough cleaning of surfaces around the vomiting child. The nurse thanks the mother for her assistance and explains to her the importance of thorough cleaning and hand hygiene in the prevention of transmission of infection.
Standards
Legislation/codes of practice
GuidelinesTools and web-based resourcesB1.4.6 ReferencesAndersen B, Rasch M, Kvist J et al (2009) Floor cleaning: effect on bacteria and organic materials in hospital rooms. J Hosp Infect 71(1): 57–65. Bergen LK, Meyer M, Hog M et al (2008) Spread of bacteria on surfaces when cleaning with microfiber cloths. Journal of Hospital Infection 71:132-137. Button S (2006) In: Dixon AM Environmental Monitoring for Cleanrooms and Controlled Environments. CRC Press. Dancer SJ (1999) Mopping up hospital infection. J Hosp Infect 43: 85–100. Dancer SJ (2008) Importance of the environment in methicillin-resistant Staphylococcus aureus acquisition: the case for hospital cleaning. Lancet 8:101–113. Garner JS & Favero MS (1986) CDC Guideline for Handwashing and Hospital Environmental Control, 1985. Infection Control 7: 231–35. HPS (2006) Standard Infection Control Precautions—Literature Review: Control of the Environment. Health Protection Scotland, National Health Service Scotland. HPS (2008) Transmission-based Precautions—Literature Review: Disinfectants. Health Protection Scotland, National Health Service Scotland. Microbiological Advisory Committee to the Department of Health (2006) Sterilisation, disinfection and cleaning of medical equipment. London: Department of Health. ISBN 1-85-839518-6. Moore G & Griffith C (2006) A laboratory evaluation of the decontamination properties of microfiber cloths. Journal of Hospital Infection 64:379-385. Mutters R, Nonnenmacher C, Susin C et al (2009) Quantitative detection of Clostridium difficile in hospital environmental samples by real-time polymerase chain reaction. J Hosp Infect 71(1): 43–48. Rohr U, Kaminski A, Wilhelm M et al (2009) Colonisation of patients and contamination of the patients' environment by MRSA under conditions of single-room isolation. Int J Hygiene & Environmental Health 212(2): 209–15. Rutala WA, Gergen MF, Weber DJ (2007) Microbiologic evaluation of microfiber mops for surface disinfection American J Infect Control 35(9): 569–73. Sehulster LM & Chinn RYW (CDC, HICPAC) (2003) Guidelines for Environmental Infection Control in Health-Care Facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR 52(RR10): 1–42. Shapey, S, Machin K, Levi K et al (2008) Activity of a dry mist hydrogen peroxide system against environmental Clostridium difficile contamination in elderly care wards. J Hosp Infect 70(2): 136–41. VCSUG (2009) Cleaning Standards for Victorian Health Facilities. Victorian Cleaning Standards User Group, Department of Health, Victoria. Wren MW, Rollins MS, Jeanes A et al (2008) Removing bacteria from hospital surfaces: a laboratory comparison of ultramicrofibre and standard cloths. J Hosp Infect 70(3): 265–71. B1.5 Reprocessing of reusable instruments and equipmentThis section gives core principles for reprocessing of reusable instruments and equipment in any healthcare setting. Healthcare facilities should develop local policies and procedures relevant to their setting and may also need to consult relevant Australian standards and discipline-specific guidelines for further advice on reprocessing requirements. B1.5.1 What are the risks?Any infectious agents introduced into the body can establish infection. In all healthcare settings, reusable instruments and equipment should be handled in a manner that will prevent patient, healthcare worker and environmental contact with potentially infectious material. Principles of reprocessing reusable instruments and equipment include (TGA 1998):
B1.5.2 Assessing the degree of riskAny instrument or piece of equipment that is to be reused requires reprocessing—cleaning, disinfection and/or sterilisation. The minimum level of reprocessing required for reusable instruments and equipment depends on the individual situation (that is, the body site and the nature by which the instrument will be used). The approach to disinfection and sterilisation of patient-care items and equipment devised by Spaulding over 30 years ago has been retained and refined and is still successfully used by infection control professionals and others when planning methods for disinfection or sterilisation (Rutala & Weber 2008). The system is based on instruments and items for patient care being Table B1.13: Categories of items for patient care
Computers and personal digital assistants (PDAs) used in patient care should be included in policies for cleaning non-critical items. Although keyboard covers and washable keyboards that can be easily cleaned are in use, the infection control benefit of these items and optimal management B1.5.3 CleaningCleaning is the removal of foreign material (for example, soil and organic material) from objects and is normally accomplished using detergent solution. Cleaning to remove organic material must always precede high-level disinfection and sterilisation of critical and semi-critical instruments and devices as residual proteinaceous material reduces the effectiveness of the disinfection and sterilisation processes. If an item cannot be cleaned, it cannot be disinfected or sterilised. Instruments should be cleaned as soon as practical after use (for example, preferably at the point of use) before soiled materials become dried onto the instruments. Dried or baked materials on the instrument make the removal process more difficult and the disinfection or sterilisation process less effective or ineffective. Instruments that can be disassembled must be disassembled before the cleaning and the disinfection/sterilisation process. Methods of cleaningAutomated Automated cleaners (ultrasonic cleaners and washer-disinfectors) reduce the handling of instruments and are recommended for cleaning basic instruments that can withstand the process.
When a washer-disinfector is used, care should be taken in loading instruments: hinged instruments should be opened fully to allow adequate contact with the detergent solution; stacking of instruments in washers should be avoided; and instruments should be disassembled as much as possible. Manual Cleaning is done manually for fragile or difficult-to-clean instruments and in areas without automatic units. The two essential components of manual cleaning are:
Healthcare workers should wear appropriate PPE for the task—plastic apron, utility gloves and face protection (protective eyewear and mask or face shield). Care should be taken to prevent splashes to mucous membranes or penetration of the skin by sharp instruments. Cleaning agentsThe cleaning solution and style must be appropriate for each instrument and equipment. The manufacturer's instructions will guide the type of cleaning agent required. This is usually neutral pH or mildly alkaline as such solutions generally provide the best material compatibility profile and good soil removal and mildly acidic solutions may damage instruments. Enzymes, usually proteases, are sometimes added to neutral pH solutions to assist in removing organic material such as blood and pus. Cleaning solutions can also contain lipases (enzymes active on fats) and amylases (enzymes active on starches). Enzymatic cleaners are not disinfectants, and proteinaceous enzymes can be inactivated by germicides. As with all chemicals, enzymes must be rinsed from the equipment or adverse reactions could result. Checking effectiveness of cleaningDuring the past few years, data have been published describing use of an artificial soil, protein, endotoxin, X-ray contrast medium, or blood, to verify manual or automated cleaning processes and adenosine triphosphate bioluminescence and microbiologic sampling to evaluate the effectiveness of environmental surface cleaning (Rutala & Weber 2008). However, these are not used routinely in most healthcare facilities. Australian Standards (AS 2945:2002) outline specific test methods to check the effectiveness of cleaning to verify manual and automated processes. At a minimum, all instruments should be individually inspected (with magnification where possible) and be visibly clean. B1.5.4 Disinfection Disinfection is a process that inactivates non-sporing infectious agents, using either thermal (moist or dry heat) or chemical means. Items need to be cleaned before being disinfected. Instruments should be removed from the disinfectant after reprocessing and stored dry. To preserve the surfaces of the instruments, dissimilar metals should be separated before cleaning.
There are three levels of disinfection, depending on the intended use of the instruments. Disinfection is not a sterilising process. Wherever possible, sterilise items to be used in semi-critical sites, or employ single-use items. B1.5.5 SterilisationSterilisation destroys all microorganisms on the surface of an instrument or device, to prevent disease transmission associated with the use of that item. While the use of inadequately sterilised critical items represents a high risk of transmitting infectious agents, documented transmission associated with an inadequately sterilised critical item is rare. This is probably due to the wide
Sterilisation methods are designed to give a sterility assurance level (SAL) of at least 10-6, provided the sterilisation process is validated by the user. Records of sterilisation must also be kept to verify that an appropriate reprocessing system is in place according to state and federal legislation. Details of the documentation required can be found in Australian Standards AS/NZS 4187 and AS/NZS 4815. In this rapidly changing area, reprocessing standards should evolve to accommodate changes in equipment design and emerging technologies in sterilisation. B1.5.6 Storage and maintenanceAll items must be stored in a way that that maintains their level of reprocessing (for example, sterile, high level disinfected). Dry, sterile, packaged instruments and equipment should be stored in a clean, dry environment and protected from sharp objects that may damage the packaging. This is essential for instruments and equipment that are sterile and intended for use on critical sites. Equipment and instrument surfaces should be regularly examined for breaks in integrity that would impair either cleaning or disinfection/sterilisation. Equipment that no longer functions as intended or cannot be properly cleaned and disinfected or sterilised should be repaired or discarded. Table B1.14: General criteria for reprocessing and storage of equipment and instruments in healthcare settings
Notes: Critical items, particularly endoscopes, must be sterilised between patient uses. An invasive procedure is defined as entry into tissues, cavities or organs or repair of traumatic injuries. Source: Rutala & Weber (2008). Further considerationsSteam sterilisation and the other methods listed above are not sufficient for reprocessing items potentially contaminated with certain types of infectious agents. This includes prions, such as cCJD, for which single-use items should be used wherever possible and subsequently destroyed by incineration. This guideline does not provide detailed information on reprocessing of reusable instruments or disease-specific guidance. The Department of Health and Ageing provides further information on infection control issues relating to cCJD. Refer to the Infection Control Guidelines. B1.5.7 Putting it into practiceIndividual actions for reducing risk
Involving patients in their care The following information may be provided to patients to assist them in becoming involved in identifying and reducing risks related to reprocessing of instruments and equipment.
Risk-management case study: Reprocessing of instruments in a dental practiceA patient attends a dental practice for a scaling and cleaning of his teeth. He has moderate periodontal disease with inflamed gingiva (gums). The dentist uses both an ultrasonic scaler (which creates aerosol) and very sharp hand scalers and curettes. Neither the dentist nor the assistant wears a mask. To protect the tongue and cheeks of the patient from being injured by the sharp instruments, a dental mirror is used to retract them. The mirror consists of a handle into which a mirror head is screwed. The handle of the mirror has a corrugated surface so that it doesn't slip. During this procedure the mirror gets covered in blood from the bleeding of the inflamed diseased gums.
B1.5.8 ResourcesCDC (2008) Guideline for the Disinfection and Sterilisation in Healthcare Facilities 2008. Standards
GuidelinesTools and web-based resourcesB1.5.9 ReferencesRutala WA & Weber DJ (HICPAC) (2008) Guideline for Disinfection and Sterilisation in Healthcare Facilities, 2008. United States Centers for Disease Control. TGA (1998) Therapeutic Goods Order No 54 - Standard for Disinfectants and Sterilants (TGO 54). B1.6 Respiratory hygiene and cough etiquetteRespiratory hygiene and cough etiquette should be applied as a standard infection control precaution at all times. Covering sneezes and coughs prevents infected persons from dispersing respiratory secretions into the air. Hands should be washed with soap and water after coughing, sneezing, using tissues, or after contact with respiratory secretions or objects contaminated by Table B1.15: Steps in respiratory hygiene and cough etiquette
Health care/social workers should also assist patients (for example, elderly, children) who need assistance with containment of respiratory secretions. Those who are immobile will need a receptacle (for example, plastic bag) readily at hand for the immediate disposal of used tissues and will need to be offered hand hygiene facilities. Respiratory hygiene and cough etiquette are particularly important for patients on droplet precautions (see Section B2.3). B1.6.1 ResourcesB1.7 Aseptic techniqueAseptic technique protects patients during invasive clinical procedures by employing infection control measures that minimise, as far as practicably possible, the presence of pathogenic microorganisms. B1.7.1 A septic non-touch technique (ANTT)ANTT is a framework for aseptic practice—the principles are intended for use in a range of settings from the operating theatre to the community. Since 1993, the ANTT project has helped implement ANTT through clinical guidelines and a standard implementation process, into hundreds of hospitals and community health organisations in the UK and internationally. As a result, ANTT has become the first standardised method of aseptic technique to exist in multiple hospitals and community care organisations. Hospitals that have implemented ANTT robustly have reported significant improvements in practice that have helped reduce rates of healthcare-associated infection (Rowley & Clare 2009). TerminologyHistorically, the practice of protecting patients from contamination and infection during clinical procedures has generated an inaccurate and confusing paradigm based on the terminology of undefined sterile, aseptic and clean techniques. The use of accurate terminology is important in order to promote clarity in practice. Sterile 'Free from microorganisms' (Weller 1997) Due to the natural multitude of organisms in the atmosphere it is not possible to achieve a sterile technique in a typical healthcare setting. Near sterile techniques can only be achieved in controlled environments such as a laminar air flow cabinet or a specially equipped theatre. The commonly used term, 'sterile technique' i.e. the instruction to maintain sterility of equipment exposed to air, is obviously not possible and is often applied inaccurately. Asepsis 'Freedom from infection or infectious (pathogenic) material' (Weller 1997) An aseptic technique aims to prevent pathogenic organisms, in sufficient quantity to cause infection, from being introduced to susceptible sites by hands, surfaces and equipment. Therefore, unlike sterile techniques, aseptic techniques are possible and can be achieved in typical hospital and community settings. Clean 'Free from dirt, marks or stains' (Mcleod 1991). Although cleaning followed by drying of equipment and surfaces can be very effective it does not necessarily meet the quality standard of asepsis (Ayliffe 2000). However, the action of cleaning is an important component in helping render equipment and skin aseptic, especially when there are high levels of contamination that require removal or reduction. However, to be confident of achieving asepsis an application of a skin or hard surface disinfectant is required either during cleaning or afterwards. Consequently, the aim of any aseptic technique including ANTT, is asepsis. ANTT in practiceANTT is a technique used to prevent contamination of key parts and key sites by microorganisms that could cause infection. In ANTT, asepsis is ensured by identifying and then protecting key parts and key sites by hand hygiene, non-touch technique, using new sterilised equipment and/or cleaning existing key parts to a standard that renders them aseptic prior to use (Rowley et al 2010). Risk assessmentWhile the principles of ANTT remain constant for all clinical procedures, the level of practice will change depending upon a standard ANTT risk assessment. Taking into account the technical difficulty of the procedure and his or her own competence, the healthcare worker assesses whether procedures can be performed without touching key parts and key sites directly. Infective B1.7.2 Core infection control components of ANTTKey part and key site identification and protection Key parts must be identified and protected at all times. Aseptic key parts must only come into contact with other aseptic key parts and/or key sites. Hand hygieneEffective hand hygiene is an essential component of ANTT. In Standard ANTT, hand hygiene should be performed as outlined in Section B1.1. In Surgical ANTT, a surgical hand scrub is required (ICNA 2002) (see Section B4.3.2). It is known that hand hygiene is not always correctly performed and that even correctly performed hand hygiene cannot always remove all pathogenic organisms. Therefore, a non-touch technique—identifying 'key parts' and not touching them directly or indirectly—is a vital component of achieving asepsis. In other words, the safest way to protect a key part is not to touch it, Glove useGloves are single-use items. In ANTT, if it is necessary to touch key parts or key sites directly, sterile gloves are used to minimise the risk of contamination. Otherwise, non-sterile gloves are typically the gloves of choice. Aseptic fieldsEven well cleaned hospitals can be said to be 'dirty'—busy and dynamic environments resident with unusual antibiotic-resistant organisms. Consequently, aseptic fields are important in providing a controlled aseptic working space to help promote or ensure the integrity of asepsis during clinical procedures. It is also important that aseptic fields are fit for purpose. In ANTT, aseptic fields are increased in size and sterilised drapes added on the basis of procedure complexity; for example in IV therapy, 'mobile' aseptic fields such as plastic trays should be large enough and with high sides to provide an adequate working space to contain equipment, sharps and spillages. ANTT employs two types of aseptic field that require different management depending on whether the primary purpose is to promote or ensure asepsis. Critical aseptic fields; ensuring asepsis Critical aseptic fields are used when key parts and/or key sites, usually due to their size or number, cannot easily be protected at all times with covers and caps, or handled at all times by a non-touch technique (such as in PICC line, urinary catheter insertion, complex wound care etc), or when particularly open and invasive procedures demand large aseptic working areas for long durations, as in the operating room. In such cases, the critical aseptic field demands to be managed as a key part (that is, only equipment that has been sterilised can come into contact with it). Such a critical aseptic field demands the use of sterilised gloves and, often, full barrier precautions (Pratt et al 2007). Large main critical aseptic fields are used in Surgical ANTT and as a result, technique is more complicated. A sub-type of a main critical aseptic field is the critical micro aseptic field. Traditional nontouch/clean techniques have protected key parts by syringe caps, sheathed needles, covers or packaging etc. This often-understated approach is given new emphasis in ANTT, because the inside of such caps and covers have been sterilised and thus provide an optimum all-encompassing General aseptic fields; promoting asepsis General aseptic fields are used in Standard ANTT when key parts can easily and optimally be protected by critical micro aseptic fields and a non-touch technique. The main general aseptic field does not have to be managed as a key part and is essentially promoting rather than ensuring asepsis. Subsequently, aseptic technique is considerably simplified and typically involves non-sterile gloves. Use of standard and surgical aseptic non-touch techniqueFigure B1.4: Use of standard and surgical aseptic non-touch technique. Left: Standard ANTT and the use of a general main aseptic field and critical. Right: Surgical ANTT and the use of a main critical aseptic field.Environmental controlPrior to aseptic procedures, healthcare workers must ensure that there are no avoidable nearby environmental risk factors, such as bed making or patients using commodes. SequencingANTT practice is sequenced to ensure an efficient, logical and safe order of procedure events. Section B5.4 provides examples of how to perform ANTT for peripheral and central access intravenous therapy and for wound care. B1.7.3 Surgical or Standard ANTT?Differentiation between Standard and Surgical ANTT is intended to provide clarity and structure to aid understanding, but not polarise practice. ANTT guidelines help standardise practice, technique and equipment levels.
Table B1.16: Use of aseptic non-touch technique for specific procedures
B1.7.4 ReferencesAyliffe G, Fraise A, Geddes A, Mitchell K (2000) Control of Hospital Infection: A Practical Handbook. 4th edition. Butterworth Heinemannn, Oxford. Cotterill S, Evans R, Fraise AP (1996) An unusual source for an outbreak of MRSA on an intensive care unit. J Hospital Infect 32(3): 207–16. Kaler W & Chinn R (2007) A Matter of time and friction. JAVA 12(3): 140–42. ICNA (2002) Hand Decontamination Guidelines. Infection Control Nurses Association. Available from McLeod W (1991) The New Collins Dictionary and Thesaurus. Harper Collins Publishers, Glasgow. Pratt RJ, Pellowea CM, Wilson JA et al (2007) epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. J Hospital Infect (2007) 65S, S1–S64 Roberts K, Smith C, Snelling A et al (2008) Aerial dissemination of clostridium difficile spores. BMC Infectious Diseases 8(7). Available: www.biomedcentral.com/1471-2334/8/7. Rowley S & Clare S (2009) Improving standards of aseptic practice through an ANTT trust-wide implementation process: a matter of prioritisation and care. Brit J Infection Prevention 10(1): IV Supplement. Rowley S, Clare S, Macqueen A et al (2010) ANTTv2 An updated practice framework for aseptic technique. Brit J Nursing 19(5). Weller B (ed) (1997) Encyclopedic Dictionary of Nursing and Health Care. Balliere Tindall, London: 81. B1.8 Waste managementAs there is currently no national definition of clinical waste in Australian, healthcare facilities need to conform to relevant State or Territory legislation and regulations on the management of clinical and related wastes. Healthcare facilities should also refer to AS/NZS 3816. When handling waste:
Regardless of where waste is generated (for example, isolation rooms/patient versus routine patient-care areas), the principles of determining whether it is to be treated as clinical or general waste remain the same. B1.8.1 ResourcesStandards
B1.9 Handling of linenHealthcare facilities must have documented polices on the collection, transport and storage of linen. Healthcare facilities that process or launder linen must have documented operating policies consistent with AS/NZS 4146. All used linen should be handled with care to avoid dispersal of microorganisms into the environment and to avoid contact with staff clothing. The following principles apply for linen used for all patients (that is, whether or not transmission-based precautions are required):
Clean linen must be stored in a clean dry place that prevents contamination by aerosols, dust, Patient items Domestic-type washing machines must only be used for a patient's personal items (not other linen). Washing must involve the use of an appropriate detergent and hot water. If hot water is not available, only individual patient loads can be washed at one time. Clothes dryers should be used for drying. B1.9.1 ResourcesStandards
B2 Transmission-based precautionsSummary
Patient care tipWhen transmission-based precautions are applied during the care of an individual patient, there is potential for adverse effects such as anxiety, mood disturbances, perceptions of stigma and reduced contact with clinical staff. Clearly explaining to patients why these precautions are necessary may help to alleviate these effects. Evidence supporting practice The majority of the recommendations in this section have been adapted from:[11] Further review of the evidence concerning certain aspects of implementation of transmission-based precautions allowed the development of recommendations and good practice points specific to the Australian context. Literature reviews conducted as part of the development of these guidelines or that were released during the guideline development process identified the following:[12]
B2.1 Application of transmission-based precautionsB2.1.1 What are the risks?Transmission of infectious agents can occur in a number of ways.
Transmission of infectious agentsFigure B2.1: Transmission of infectious agents. Source: Courtesy of Northern Ireland region infection prevention manual, Department of Health, Social Services and Public Safety.B2.1.2 When are transmission-based precautions applied?Transmission-based precautions are applied to patients suspected or confirmed to be infected with agents transmitted by the contact, droplet or airborne routes. The combination of measures used in transmission-based precautions depends on the route(s) of transmission of the infectious agent involved, as outlined in Sections B2.2, B2.3 and B2.4 below. In the acute-care setting, this will involve a combination of the following measures:
For diseases that have multiple routes of transmission, more than one transmission-based precaution category is applied. Whether used singly or in combination, transmission-based precautions are always applied in addition to standard precautions. Transmission-based precautions remain in effect for limited periods of time until signs and symptoms of the infection have resolved or according to recommendations from infection control professionals specific to the infectious agent (see Section B5.2, page 165). The mode of transmission of infectious agents is the same in primary care or office-based practice as it is in the acute-care setting. However, the risk of transmission may differ due to the population groups and the nature of care provided. Considering the following will help to establish the risk of infection in primary care and office-based practice:
In developing policies and procedures for a healthcare facility it is useful to refer to discipline specific guidelines to inform practice on specialised areas. An overview of risk-management principles and processes is given in Section A2. B2.1.3 Environmental cleaningIn acute-care areas where the presence of infectious agents requiring transmission-based precautions is suspected or known, surfaces should be physically cleaned with a detergent solution. A TGA-registered hospital-grade disinfectant should then be used (for example, 2-step clean or 2-in-1 clean) as outlined in Section B1.4.2). In office-based practice and non-acute-care areas (for example, long-term care facilities), the risk of contamination, mode of transmission and risk to others should be used to determine whether disinfectants are required. Crockery and utensils used by patients on transmission-based precautions do not require containment and should be treated in the same manner as those used for non-infectious patients (that is, washed in a dishwasher). Disposable crockery and utensils are not necessary. This section does not provide specific guidance on cleaning. Section B5.1 provides guidance on frequency of cleaning of specific items in low, medium and high-risk settings. Further information on the considerations required when developing cleaning schedules is provided in Section B1.4.2. B2.2 Contact precautionsB2.2.1 What are the risks?There is clear evidence that certain infectious agents are transmitted by direct or indirect contactcduring patient care. Direct transmission occurs when infectious agents are transferred from one person to another person without a contaminated intermediate object or person. For example, blood or other body substances from an infectious person may come into contact with a mucous membrane or breaks in the skin of another person (Rosen 1997; Beltrami et al 2003). Indirect transmission involves the transfer of an infectious agent through a contaminated intermediate object (fomite) or person. Contaminated hands of healthcare workers have been shown to be important contributors to indirect contact transmission (Boyce & Pittet 2002; Bhalla et al 2004; Duckro et al 2005). Other opportunities for indirect contact transmission include:
Direct or indirect contact transmission of microorganisms during patient care is responsible for the majority of healthcare-associated infections in patients and healthcare staff. B2.2.2 When should contact precautions be implemented?Contact precautions are used when there is a risk of direct or indirect contact transmission of infectious agents (for example, MRSA, C. difficile, or highly contagious skin infections/infestations) that are not effectively contained by standard precautions alone (see Section B1). The requirements for contact precautions are summarised on page 110. Information about which precautions to apply for specific conditions is given in Section B5.2 (see page 165). Recommendation15 Implementation of contact precautions - Grade GPP In addition to standard precautions, implement contact precautions in the presence of known or suspected infectious agents that are spread by direct or indirect contact with the patient or the patient's environment. B2.2.3 How should contact precautions be applied?The key aspects of applying contact precautions relate to:
Hand hygiene and PPEEffective hand hygiene is particularly important in preventing contact transmission and the 5 moments for hand hygiene outlined in Section B1.1.2 should be followed at all times. When the presence of C. difficile or non-enveloped viruses is known or suspected, use of alcohol-based hand rubs alone may not be sufficient to reduce transmission of these organisms (see Section B1.1.3). Putting on both gloves and gown upon entering the patient-care area helps to contain infectious agents, especially those that have been implicated in transmission through environmental contamination (for example, VRE, MRSA, C. difficile, norovirus and other intestinal tract pathogens, respiratory syncytial virus) (Hall & Douglas 1981; CDC 1995; Evans et al 2002; Bhalla et al 2004; Donskey 2004; Duckro et al 2005; Wu et al 2005). Considerations in selecting a gown appropriate to the situation are outlined in Section B1.2. A surgical mask and protective eyewear must be worn if there is the potential for generation of splashes or sprays of blood and body substances into the face and eyes. Recommendation16 Hand hygiene and personal protective equipment to prevent contact transmission - Grade C When working with patients who require contact precautions:
Single-use or patient-dedicated equipmentStandard precautions concerning patient-care equipment (see Section B1.5) are very important in the care of patients on contact precautions. If patient-care devices (for example, blood pressure cuffs, nebulisers, mobility aids) are shared between patients without being reprocessed between uses, they may transmit infectious agents (Brooks et al 1992; Desenclos et al 2001; Rutala & Weber 2008). Recommendation17 Patient-care equipment for patients on contact precautions - Grade C Use patient-dedicated equipment or single-use non-critical patient-care equipment. If common use of equipment for multiple patients is unavoidable, clean the equipment and allow it to dry before use on another patient. Patient placementA single-patient room is recommended for patients who require contact precautions. Rooms with ensuites and anterooms are preferred (see also C6). Other points relevant to patient placement include the following:
When a single-patient room is not available, consultation with infection control professionals is recommended to assess the various risks associated with other patient placement options (for example, cohorting). If it is necessary to place a patient who requires contact precautions in a room with a patient who is not infected or colonised:
Transfer of patientsLimiting transfer of a patient on contact precautions reduces the risk of environmental contamination. If transfer within or between facilities is necessary, it is important to ensure that infected or colonised areas of the patient's body are contained and covered. Contaminated PPE should be removed and disposed of and hand hygiene performed before the patient is moved. Clean PPE should be put on before the patient is handled at the destination. Risk-management case study: Klebsiella pneumoniae sepsis in a neonatal unitDuring a 7-month period, seven infants in a neonatal unit developed septicaemia from multiresistantextended spectrum β lactamase producing Klebsiella pneumoniae, and two babies died. Molecular typing revealed that four of the strains were identical; not all isolates were available for typing. Screening of all babies was not carried out, as it was expected that many would already be colonised, and that babies whose gut was colonised by the bacteria would be the source of infection through the hands of healthcare workers. The outbreak was brought under control by in-service education and improvement of hand hygiene compliance, and wearing of single-use gloves when babies' nappies were being changed. Nurses were declared to be the advocates for the babies, and the nurse caring for each baby was responsible for ensuring that all attending personnel perform hand hygiene before and after handling the baby, with non-compliance being reported to the infection control team. Source: Based on Royle et al (1999).
B2.3 D roplet precautionsB2.3.1 What are the risks?A number of infectious agents are transmitted through respiratory droplets (that is, large-particle droplets >5 microns in size) that are generated by a patient who is coughing, sneezing or talking. Transmission via large droplets requires close contact as the droplets do not remain suspended in the air and generally only travel short distances. There is also the potential for infectious agents transmitted by the droplet route to be transmitted by contact. Droplet precautions are based on evidence that shows that:
B2.3.2 When should droplet precautions be implemented?Droplet precautions are intended to prevent transmission of infectious agents spread through close respiratory or mucous membrane contact with respiratory secretions. Because these microorganisms do not travel over long distances, special air handling and ventilation are not required. Infectious agents for which droplet precautions are indicated include respiratory syncytial virus (RSV) and meningococcus. The requirements for droplet precautions are summarised on page 110. Information about which precautions to apply for specific conditions is given in Section B5.2 (see page 165). Recommendation18 Implementation of droplet precautions - Grade C In addition to standard precautions, implement droplet precautions for patients known or suspected to be infected with agents transmitted by respiratory droplets that are generated by a patient when coughing, sneezing or talking. B2.3.3 How should droplet precautions be applied?The key aspects of applying droplet precautions relate to:
Hand hygiene and personal protective equipmentDroplet transmission is, technically, a form of contact transmission and some infectious agents transmitted by the droplet route may also be transmitted by contact (Siegel et al 2007). Hand hygiene is therefore an important aspect of droplet precautions and the 5 moments for hand hygiene outlined in Section B1.1.2 should be followed. There is insufficient evidence to support the use of P2 respirators for reducing the risk of infections transmitted by the droplet route. Although surgical masks do not protect the wearer from infectious agents that are transmitted via the airborne route, surgical masks that meet Australian Standards are fluid resistant and protect the wearer from droplet contamination of the nasal or oral mucosa (DoHA 2006). The mask is generally put on upon room entry, with hand hygiene practiced before putting on the mask and after taking off the mask. More studies are needed to improve understanding of droplet transmission under various circumstances. The CDC isolation guidelines (Siegel et al 2007) specify that masks should be put on when the healthcare worker is 'a short distance from a patient', giving a distance of 1 metre around the patient as an example of what is meant by this, but also stating that it may be prudent to put on a mask upon entry into the patient's room, especially when the patient has violent, frequent coughing and sneezing or when exposure to emerging or highly virulent pathogens is likely. There is insufficient evidence to recommend the routine use of protective eyewear with individuals on droplet precautions, unless there is a risk of splashes or spray to the mucosa (see Section B1.2). Goggles provide reliable eye protection from respiratory droplets from multiple angles. Emerging evidence on droplet transmission will be monitored as a part of the ongoing review process. Recommendation19 Personal protective equipment to prevent droplet transmission - Grade C When entering the patient-care environment, put on a surgical mask. Placement of patients on droplet precautionsPlacing patients on droplet precautions in a single-patient room reduces the risk of patient-to-patient transmission. When single-patient rooms are in short supply, the following principles apply in decision-making on patient placement:
If it becomes necessary to place patients who require droplet precautions in a room with a patient who does not have the same infection:
In all cases, the importance of respiratory hygiene and cough etiquette should be explained to patients on droplet precautions (see Section B1.6). In primary care and other office-based practice, examples of appropriate implementation of droplet precautions include segregation in waiting rooms for patients with violent or frequent coughing, and the availability of tissues, alcohol-based handrub and a waste bin so that patients can practice respiratory hygiene and cough etiquette. Recommendation20 Placement of patients requiring droplet precautions - Grade GPP Place patients who require droplet precautions in a single-patient room. Transfer of patients on droplet precautionsWhen transfer of a patient on droplet precautions within or between facilities is necessary, there is the potential for other patients and healthcare workers to come in contact with infectious agents when the patient coughs or sneezes. This can be addressed by asking the patient to wear a mask while they are being transferred and to follow respiratory hygiene and cough etiquette. Children should wear a correctly fitting mask when they are outside an isolation room. The child's oxygen saturation should be monitored. Risk-management case study: Influenza in a long-term care facilityA cluster of cases of influenza occurred in a long-term care facility, which were observed after a group activity involving dancing was held in the dining room prior to the midday meal. It was observed that a number of residents who had been unwell had attended the group activity and had sat at the dining tables. Due to the lack of waste receptacles in the dining room, used tissues were placed on the dining room tables. It was also noticed that a number of residents remained in the vicinity of the dining room post activity as their rooms were a short distance from the dining room. The shared bathrooms were at the other end of the corridor so it was not known whether hand hygiene was performed prior to meals or the event. Residents reported signs and symptoms consistent
B2.4 Airborne precautionsB2.4.1 Why are airborne precautions important?Certain infectious agents are disseminated through airborne droplet nuclei or small particles in the respirable size range that remain infective over time and distance. Airborne precautions are based on evidence that shows that:
B2.4.2 When should airborne precautions be implemented?Airborne precautions prevent transmission of microorganisms that remain infectious over time and distance when suspended in the air. These agents may be inhaled by susceptible individuals who have not had face-to-face contact with (or been in the same room as) the infectious individual. Infectious agents for which airborne precautions are indicated include measles (rubeola), chickenpox (varicella) and M. tuberculosis. The requirements for airborne precautions are summarised on page 110. Information about which precautions to apply for specific conditions is given in Section B5.2 (see page 165). Recommendation21 Implementation of airborne precautions - Grade C In addition to standard precautions, implement airborne precautions for patients known or suspected to be infected with infectious agents transmitted person-to-person by the airborne route. B2.4.3 How should airborne precautions be applied?The key aspects of applying airborne precautions relate to:
Specialist procedural areas should refer to their discipline-specific guidelines for detailed advice on applying airborne precautions relevant to the field of practice. Personal protective equipmentWhen there is a high probability of airborne transmission due to the infectious agent or procedure, sound scientific principles support the use of P2 respirators to prevent transmission (see also Table B1.6; page 52). Respirators are designed to help reduce the wearer's respiratory exposure to airborne contaminants such as particles, gases or vapours. P2 respirators are appropriate for the majority of airborne precautions encountered in healthcare facilities. The need for PPE varies with the condition in question and the immune status of the healthcare worker. For example, staff members known to be immune to the relevant infectious agent are not required to wear a P2 respirator. For high-risk procedures such as bronchoscopy where the risk of droplet and airborne infection is high, a P2 respirator should be worn if the infectious status of the patient is unknown or unconfirmed. P2 respirators – fit testing and checkingIn order for a P2 respirator to offer the maximum desired protection it is essential that the wearer is properly fitted and trained in its safe use. A risk-management approach should be applied to ensure that staff working in high-risk areas are fit tested and are aware of how to perform a fit check. Fit testingThe purpose of fit testing is to identify which size and style of P2 respirator is suitable for an individual, and to ensure that it is worn correctly. It also provides an opportunity to ensure healthcare workers are properly trained in the correct use of the mask. Fit testing should be performed:
Employers must ensure that their employees have the medical ability to wear a respirator. Medical evaluations are required for both positive pressure and negative pressure respirators. There are two types of facial fit test—qualitative and quantitative. Qualitative fit tests are fast and simple but can be influenced by the wearer. Quantitative fit tests require the use of specialised equipment used by a trained operator. AS/NZS 1715:2009 outlines the method by which fit testing is conducted. Fit checking Healthcare workers must perform fit checks every time they put on a P2 respirator to ensure it is properly applied. No clinical activity should be undertaken until a satisfactory fit has been achieved. Fit checks ensure the respirator is sealed over the bridge of the nose and mouth and that there are no gaps between the respirator and face. Healthcare workers must be informed about how to perform a fit check. The procedure for fit checking includes (see Figure B2.2):
The manufacturer's instructions for fit checking of individual brands and types of P2 respirator should be referred to at all times. Healthcare workers who have facial hair (including a 1–2 day beard growth) must be aware that an adequate seal cannot be guaranteed between the P2 respirator and the wearer's face. Process for putting on a P2 respiratorFigure B2.2: Process for putting on a P2 respirator. Source: Courtesy of DHS VictoriaWearing a P2 respiratorConsiderations when using a P2 respirator include (DoHA 2006):
Respirators should be removed outside the patient-care area and disposed of in a closed receptacle (Siegel et al 2007). Recommendation22 Personal protective equipment to prevent airborne transmission - Grade D Wear a correctly fitted P2 respirator when entering the patient-care area when an airbornetransmissible infectious agent is known or suspected to be present. Patient placementWhen patients have a confirmed or suspected airborne-transmissible condition or if nebulisation is to be performed, it is important to place them in an area that can be contained (for example, placing them in a single room and, providing it is tolerated, asking them to wear a surgical mask while not in a single room, until advised to remove it by attending staff). It is important that the door to the room remains closed and that, where possible, only staff or visitors who are immune to the specific infectious agent enter the room. Non-immune staff should be provided with appropriate PPE. While there is a paucity of evidence to confirm their effectiveness, the use of correctly serviced/maintained negative pressure rooms may reduce the transmission of airborne infection within healthcare settings (Siegel et al 2007). Visitors should be restricted and screened by nursing staff, with visitors' names recorded either in a log book or in the case notes. Recommendation23 Placement of patients requiring airborne precautions - Grade GPP Patients on airborne precautions should be placed in a negative pressure room or in a room from which the air does not circulate to other areas. Exceptions to this should be justified by risk assessment. Transfer of patientsIf transfer of the patient outside the negative pressure room is necessary, asking the patient to wear a correctly fitted surgical mask while they are being transferred and to follow respiratory hygiene and cough etiquette, as well as covering any skin lesions associated with the condition (for example, chickenpox [varicella]) will reduce the risk of cross-transmission. Children should wear a correctly fitting mask when they are outside an isolation room. The child's oxygen saturation should be monitored. Risk-management case study: M. tuberculosis among immunocompromised patients attending outpatient servicesAn investigation into the healthcare-associated transmission of M. tuberculosis followed reports of two epidemiologically linked patients (Patient 1 and Patient 2) with haematologic malignancies and active pulmonary TB. Subsequently it was found that four oncology patients had spent more than an hour in the same room as Patient 1. Patient 1's pulmonary TB was not diagnosed for 3 months as clinical findings were attributed to lower respiratory tract infection from other infectious agents or adverse effects of oncology treatments. Patient 1 was not placed on airborne precautions during this period. The investigation found that delayed TB diagnosis in Patients 1 and 2 ultimately resulted in the transmission of M. tuberculosis to 19 patients and staff at three hospitals and a residential facility. Source: Based on Malone et al (2004).
Measles (rubeola) control in general practiceThe case study in Section A2.2 outlines a risk assessment approach to airborne precautions in the primary care setting. B2.5 Putting it into practiceIndividual actions for reducing risk
Involving patients in their careThe following information may be provided to patients to assist them in becoming involved in identifying and reducing risks.
Table B2 1: Application of standard and transmission-based precautions
Notes: A - Essential component of transmission-based precautions B - surgical mask required if infectious agent isolated in sputum C - As required – Gloves to be worn whenever there is the potential of direct or indirect contact with blood or body substances Gowns to be worn for procedures when there is the potential of direct or indirect contact to body substances Face and eye protection to be worn when there is the potential of exposure to splashes or sprays to mucosa (including during aerosol-generating procedures) * - Visitors should be given instruction about correct procedures when transmission-based precautions are applied and given appropriate resources to support them in meeting these requirements. # - If staff or visitor HAVE HAD chickenpox / measles in the past or vaccination for these diseases, mask, gown and gloves are not required Environmental cleaning has not been addressed in this table but it is an essential component of infection prevention and control. For further guidance please refer to section B1.4 For more detail on specific diseases please refer to Section B5.2. Source: Adapted from The Canberra Hospital Inpatient Isolation Guidelines B2.6 ResourcesStandards
Tools and web based resourcesB2.7 ReferencesAiello AE & Larson EL (2002) What is the evidence for a causal link between hygiene and infections? Lancet Infect Dis 2(2): 103–10. Beltrami EM, Kozak A, Williams IT et al (2003) Transmission of HIV and hepatitis C virus from a nursing home patient to a health care worker. Am J Infect Control 31(3): 168–75. Bhalla A, Pultz NJ, Gries DM, et al (2004) Acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospitalized patients. Infect Control Hosp Epidemiol 25(2): 164–67. Boyce JM & Pittet D (2002) Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 51(RR-16): 1–45. Brooks SE, Veal RO, Kramer M et al (1992) Reduction in the incidence of Clostridium difficileassociated diarrhea in an acute care hospital and a skilled nursing facility following replacement of electronic thermometers with single-use disposables. Infect Control Hosp Epidemiol 13(2): 98-103. CDC (1995) Recommendations for preventing the spread of vancomycin resistance. Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep 44 (RR12): 1–13. Desenclos JC, Bourdiol-Razes M, Rolin B et al (2001) Hepatitis C in a ward for cystic fibrosis and diabetic patients: possible transmission by springloaded finger-stick devices for self-monitoring of capillary blood glucose. Infect Control Hosp Epidemiol 22(11): 701–07. DoHA (2006) Interim Infection Control Guidelines for Pandemic Influenza in Healthcare and Community Settings. Commonwealth of Australia. Donskey CJ (2004) The role of the intestinal tract as a reservoir and source for transmission of nosocomial pathogens. Clin Infect Dis 39(2): 219–26. Duckro AN, Blom DW, Lyle EA et al (2005) Transfer of vancomycin-resistant enterococci via health care worker hands. Arch Intern Med 165(3): 302–07. Evans MR, Meldrum R, Lane W et al (2002) An outbreak of viral gastroenteritis following environmental contamination at a concert hall. Epidemiol Infect 129(2): 355–60. Feigin RD, Baker CJ, Herwaldt LA et al (1982) Epidemic meningococcal disease in an elementary-school classroom. N Engl J Med 307(20): 1255–57. Gaillat J, Dennetière E, Raffin-Bru M et al (2008) Summer influenza outbreak in a home for the elderly: application of preventive measures. J Hosp Infection 70(3): 272–77. Gralton J & McLaws ML (2010) Protecting healthcare workers from pandemic influenza: N95 or surgical masks? Critical Care Med 38(2): 657–67. Hall CB & Douglas RG, Jr (1981) Modes of transmission of respiratory syncytial virus. J Pediatr 99(1): 100–03. Hamburger M & Robertson OH (1948) Expulsion of group A haemolytic streptococci in droplets and droplet nuclei by sneezing, coughing and talking. Am J Med 4:690. Jefferson T, Del Mar C, Dooley L et al (2009) Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review. BMJ 339:b3675. doi: 10.1136/bmj.b3675. Malone JL, Ijaz K, Lambert L et al (2004) Investigation of healthcare-associated transmission of Mycobacterium tuberculosis among patients with malignancies at three hospitals and at a residential facility. Cancer 101(12): 2713–21. Perry C, Marshall R, Jones E (2001) Bacterial contamination of uniforms. J Hosp Infect 48(3): 238–41. Pittet D & Boyce JM (2001) Hand hygiene and patient care: pursuing the Semmelweis legacy. Lancet Infect Dis 1: 9–20. Rosen HR (1997) Acquisition of hepatitis C by a conjunctival splash. Am J Infect Control 25(3):242-7. Royle J, Halasz S, Eagles G et al (1999) Outbreak of extended spectrum β lactamase producing Klebsiella pneumoniae in a neonatal unit. Arch Dis Child Fetal Neonatal Ed 80: F64–F68. Rutala WA & Weber DJ (HICPAC) (2008) Guideline for Disinfection and Sterilisation in Healthcare Facilities, 2008. United States Centers for Disease Control and Prevention. Siegel JD, Rhinehart E, Jackson M et al (Health Care Infection Control Practices Advisory Committee) (2007) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007. United States Centers for Disease Control and Prevention. Wu HM, Fornek M, Kellogg JS et al (2005) A Norovirus Outbreak at a Long-Term-Care Facility: The Role of Environmental Surface Contamination. Infect Control Hosp Epidemiol 26(10): 802–10. Zachary KC, Bayne PS, Morrison VJ et al (2001) Contamination of gowns, gloves, and stethoscopes with vancomycinresistant enterococci. Infect Control Hosp Epidemiol 22(9): 560–64. B3 Management of multi-resistant organisms and outbreak situationsSummary
Patient-care tipWhen a patient is infected or colonised with an MRO or involved in an outbreak, there is potential for adverse effects such as anxiety, mood disturbances, perceptions of stigma and reduced contact with clinical staff. Clearly explaining to patients the measures being undertaken and why they are necessary may help to alleviate these effects. Evidence supporting practiceThe majority of the recommendations in this section have been adapted from United States Centers for Disease Control and Prevention (CDC) Management of Multidrug-Resistant Organisms in Healthcare Settings (2006).[13] Further review of the evidence concerning the management of MROs allowed the development of recommendations and good practice points specific to the Australian context. Literature reviews conducted as part of the development of these guidelines or that were released during the guideline development process identified the following:
B3.1 Management of multi-resistant organismsB3.1.1 What are the risks?MROs, which are predominantly bacteria, are resistant to multiple classes of antimicrobial agents. Antibiotic resistance increases the morbidity and mortality associated with infections, and contributes to increased costs of care due to prolonged hospital stays and other factors, including the need for more expensive drugs (Struelens 1998). A major cause of antibiotic resistance is the exposure of a high-density, high-acuity patient population in frequent contact with healthcare workers to extensive antibiotic use, along with the attendant risk of cross-infection (Gold & Moellering 1996; Christiansen et al 2008). For the purpose of these guidelines, MROs are taken to include:
A two-level approach is necessary for the prevention and control of MROs. This involves implementation of:
In the event of an MRO outbreak, investigation and control/containment should be conducted as outlined in Section B3.2. The best practices in these guidelines are based on the assumption that healthcare settings already have basic infection prevention and control systems in place. If this is not the case, healthcare settings will find it challenging to implement the practices recommended for the management of MRSA and VRE. These settings must work with organisations that have infection prevention and control expertise, such as academic health science centres, regional infection control networks, public health units that have professional staff certified in infection prevention B3.1.2 Core strategies for MRO prevention and controlSuccessful control of MROs is based on a combination of interventions. These involve continued rigorous adherence to hand hygiene, appropriate use of PPE and implementation of specific transmission-based precautions (isolation of infected or colonised patients, increased environmental cleaning and patient-dedicated equipment) until patients are culture-negative for a target MRO or have been discharged from the facility. In non-acute healthcare settings, general measures of infection control (particularly hand hygiene by both patients and healthcare workers) may be enough to prevent transmission. However, contact precautions, such as gowns and gloves, may be necessary if the patient is heavily colonised or there is known continuing transmission. Local guidelines and circumstances should determine practice in settings where the patient population is vulnerable (Matlow & Morris 2009). Organisational measures—such as staff education on prevention and management of MRO transmission, antibiotic stewardship program, and appropriate response to active surveillance cultures—are discussed in Part C. Hand hygieneMROs can be carried from one person to another via the hands of a healthcare worker. Contamination can occur during patient care or from contact with environmental surfaces in close proximity to the patient, particularly when patients have diarrhoea and the reservoir of the MRO is the gastrointestinal tract. Effective hand hygiene is therefore the most important measure to prevent and control the spread of MROs. Alcohol-based hand rub of at least 70% v/v ethanol or equivalent has been shown to be effective against MRSA and VRE (Picheansathian 2004). Personal protective equipmentBoth direct patient contact (for example, routine patient care) and indirect contact (for example, involving environmental contamination) can lead to contamination of the healthcare worker's hands and clothing. Appropriate use of gloves has been found to be as effective a strategy as patient isolation in containing MROs, particularly when isolation may not be feasible (Trick et al 2004; Bearman et al 2007). Glove use is more effective when combined with wearing of gowns (Puzniak et al 2002; Srinivasan et al 2002; Hayden et al 2008). Section B1.2.3 provides guidance on the selection of an appropriate gown and Section B1.2.5 on selection of gloves. IsolationPlacing colonised or infected patients in single rooms, cohort rooms or cohort areas as a component of a multifaceted infection control policy can reduce acquisition rate and infection with MROs in acute-care settings. Cohorting patients with the same strain of MRO has been used extensively for managing outbreaks of specific MROs, including MRSA, VRE, extended spectrum beta-lactamase (ESBL)-producing bacteria, and Pseudomonas aeruginosa. However, it is not always appropriate to cohort patients with the same MRO species if they have a different resistance mechanism or phenotype (for example, if one has a community-acquired strain of likely panton-valentine leukocidin (PVL)-positive MRSA and the other has a hospital-acquired strain of MRSA). In long-term care facilities, isolation and cohorting may not be possible, so hand hygiene with appropriate routine use of gloves for individual resident and environmental contact is preferred (Trick et al 2004). Due to the varying nature of healthcare facilities, it is not feasible to provide a generic policy on the movement of patients with MROs. This needs to occur at a local level and be relevant to the patient's treatment plan. These policies should not limit access to treatment and should consider the social implications of managing a patient with an MRO. Environmental cleaningIn acute-care areas where the risk of patient vulnerability and risk of cross infection due to the presence of an MRO is high, contact precautions should be followed. This will require all patient surrounds and frequently touched objects (for example, bedrails, trolleys, bedside commodes, doorknobs, light switches or tap handles, ensuite facilities) to be cleaned with a suitable detergent and disinfected with a TGA-registered hospital grade disinfectant. As outlined in Section B1.4 this process must involve either:
Sole reliance on a disinfectant without mechanical/manual cleaning is not recommended. Patient equipmentStandard precautions concerning patient-care equipment are very important in the care of patients with MROs. Patient-care devices (for example, electronic thermometers) may transmit infectious agents if devices are shared between patients. To reduce the risk of transmission, disposable or patient-dedicated equipment is preferred. Section B1.5 provides more detailed information on reusable instruments and equipment. MonitoringMonitoring of the incidence of target MRO infection and colonisation should continue after these interventions are implemented. If rates do not decrease, more interventions may be needed to reduce MRO transmission as outlined in Section B3.1.3. Recommendation24 Implementation of core strategies in the control of MROs (MRSA, MRGN, VRE) - Grade C Implement transmission-based precautions for all patients colonised or infected with an MRO, including:
Patient-care tipWhen patients are placed on transmission-based precautions due to infection or colonisation with an MRO, efforts should be made to ensure patients continue to receive adequate medical care, and to counteract potential psychological adverse effects of isolation such as anxiety and depression, and feeling of stigmatisation. B3.1.3 Organism-specific approachWhen the incidence or prevalence of MROs is not decreasing despite implementation of the core strategies outlined above, further measures to control transmission need to be considered. A risk management approach focuses on:
Further measures may include:
ScreeningCurrently there is no consensus nationally or internationally about the most appropriate manner to conduct screening for MROs. Control measures specific to local factors should be determined and endorsed by the healthcare facility management structure, and the screening protocols for MROs should be influenced by the:
As a minimum standard to reduce the risk of transmission of MROs, it is recommended that the following approaches to screening be implemented. Expert direction and resources allocation is required for effective MRO screening. The decision to screen for VRE and MRGN is optional and should be made on the basis of local epidemiology, necessity for screening and resource factors. The following tables provide guidance for screening based on patient risk factors for these organisms. Other risk groups may be defined by local experience, based on screening initiatives or outbreak epidemiology. For example some facilities have found that screening patients who are recent hospital admissions from international facilities into Australian facilities have increasingly been shown to be positive for MRGN. While this is an area for future research, currently, healthcare facilities could consider screening these patients on admission, particularly in areas where MROs are found to be prevalent in transferred patients. Table B3.1: Suggested approach to screening for MRSA
Table B3.2: Suggested approach to screening for VRE and MRGN dependent on local acquisition rates
MRO clearanceBased on the 2005 Multi-Resistant Organism Screening and Clearance Recommendations[14] the following criteria should be satisfied prior to certifying that a patient has cleared a particular MRO:
Some patients with VRE may appear to 'clear' with time but relapse with antibiotic therapy. Where VRE or MRGN are prevalent, admission and interval screening in specialised units is an important way to detect new or relapsed VRE or MRGN colonisation. These criteria are based on evidence related to MRSA. It is recognised that there is variation in clearance methods between jurisdictions, but currently there is insufficient evidence to recommend the most effective method of demonstrating clearance of a particular MRO. This is an area that warrants further research. The important issue appears to be sampling the patient on more than two occasions separated in time. This period should not be less than 3 weeks but is typically months. Examples of successful approachesWith an incidence rate of 1.09 per 100,000 population in 2006, Western Australia (WA) has consistently reported low rates of acquisition of MRSA compared to other states in Australia (Ferguson 2007). Tables B3.3 and B3.4 provide examples of approaches that have been successful in reducing rates of cross-transmission in hospitals in WA. It is acknowledged that approaches will vary across jurisdictions, depending on the setting (for example, available resources and access to laboratory techniques). Table B3.3: Example of a successful strategy to prevent endemicity of MRSA in a tertiary hospital in WA
Table B3.4: Example of a successful strategy to prevent endemicity of VRE in a tertiary hospital in WA
B3.1.4 Antibiotic stewardship [15]Over the last 40 years, the prevalence of MROs such as MRSA has risen alarmingly, initially mainly in hospitals but now increasingly in the community. There is good evidence that overall rates of antibiotic resistance correlate with the total quantity of antibiotics used, as determined by the number of individuals treated, prior exposure and the average duration of each treatment course. Some antibiotics promote the development of resistance more readily than others, depending in part on the breadth of their antibacterial spectrum. In individuals, the risk of colonisation and infection with MROs correlates strongly with previous antibiotic therapy. Unnecessary antibiotic use for self-limiting or non-infective illness and inappropriate antibiotic choice, dose or duration of therapy drives the selection of resistant bacteria, disrupts normal bacterial flora and increase the risk of colonisation with resistant organisms. There is a lag period between acquisition of an MRO and its detection; during this period, the infection may spread between patients if risk factors for acquisition are not considered carefully. Clinicians may be under pressure to prescribe broad-spectrum agents against likely pathogens in an environment where MROs are common, thereby further increasing the development of resistant organisms. As many as 25–50% of antibiotic regimens prescribed in hospitals may be inappropriate. The reasons for the continued unnecessary and/or inappropriate use of antibiotics, in the face of increasing antibiotic resistance and availability of well-established evidence-based treatment guidelines, are varied. Antibiotic stewardship programs involve a systematic approach to optimising the use of antibiotics (see Section C5). Effective hospital antibiotic stewardship programs have been shown to decrease antibiotic use and improve patient care. Along with infection control, hand hygiene and surveillance, antibiotic stewardship is considered a key strategy in local and national programs to decrease MROs and HAIs. B3.1.5 Risk-management case study: VRE outbreak in a large tertiary-care referral hospitalTwo months after the first index case of VRE was detected in the intensive care unit of a large teaching hospital, 68 patients had become either infected or colonised with an epidemic strain of vanB vancomycin-resistant Enterococcus faecium, despite standard infection control procedures. Subsequently, 169 patients in 23 wards were found to be colonised with a single strain of vanB vancomycin-resistant E. faecium. Introducing additional control measures rapidly brought the outbreak under control. Hospital-wide screening found 39 previously unidentified colonised patients, with only 7 more non-segregated patients being detected in the next 2 months. The outbreak was terminated within 3 months due to a well-resourced, multifaceted approach. Source: Based on Christiansen et al (2004).
B3.2 Outbreak investigation and managementWhen there are more cases of infection with the same organism than would normally be expected in one area or period of time, this constitutes an outbreak. An outbreak may be defined as:
Commonly detected outbreaks involve:
This section gives principles and overall guidance for managing an outbreak. For specific guidance on particular infections, please refer to national guidelines related to management of that infection. B3.2.1 Outbreak investigation and managementA suspected outbreak may be identified by a healthcare worker, by laboratory personnel, or by state/territory health authorities conducting routine surveillance or investigating reports of illness and from reportable disease notifications. When an outbreak is detected, the healthcare facility's infection control management system should be notified and an outbreak control team formed relevant to the size and seriousness of the outbreak and the healthcare facility involved. There may also be a requirement to notify the state/territory public health unit. The responsibility for investigation and the extent of investigations will vary according to the outbreak type and circumstances. It is important to investigate an outbreak immediately, as the availability and quality of microbiological evidence and epidemiological data diminishes rapidly with time between illness and investigation. An outbreak management plan should be developed based on local policy and consultation between the infection control professional, healthcare workers, patients, facility management and state/territory health authorities as appropriate. Such a plan is multifactorial and its implementation is typically overseen by a person with designated responsibility for infection control, such as an infection control professional, clinical microbiologist or infectious diseases physician. The outbreak response may differ according to the nature of disease, the virulence of the organism and the vulnerability of the patients concerned, however the principles that underlie an outbreak investigation are similar: identification of the aetiological agent; the route(s) of transmission; exposure factors and the population at risk. Table B3.5 outlines the process of outbreak investigation and corresponding management. In practice many steps are taken more or less simultaneously, while the results of investigations and implementation of strategies to contain and control will vary with the availability and timeliness of information and seriousness of the outbreak. In primary care there may be a limited ability to investigate an outbreak, which will be generally conducted by public health authorities once they have been notified. All outbreaks, however minor, should be investigated promptly and Table B3.5: Steps in an outbreak investigation
B3.2.2 Infection control strategies to control/contain an outbreakGood governance and administrative or managerial support are crucial to support outbreak management (see Section C1). The healthcare worker's role in outbreak management will include:
The specific precautions required for each infectious agent are listed in Section B5.2 Environmental cleaningFrequency and efficiency of environmental cleaning should be increased above the standard for the area to ensure any contaminants are removed (see Section B5.1 on page 161 for guidance on cleaning in high-risk situations). A targeted cleaning regime may be introduced and continued for the duration of the outbreak dependent on the mode of transmission of the infectious agent. Consideration should be given to whether the surrounding environment will need to be disinfected in addition to being cleaned. Patient isolationThe isolation of infected patients—through allocation of single rooms or cohorting of patients—is important when managing an outbreak. Infected patients should be isolated using single rooms, cohorting and negative-pressure rooms if available and as advised by an infection control professional or person with designated responsibility for infection control. Standardised transmission-based precautions signage should identify the isolation room and include the necessary precautions to be adopted. The door should be kept closed for patients on airborne precautions. Single roomSingle-patient rooms are always indicated for patients placed on airborne precautions and are preferred for patients who require contact or droplet precautions. In the event of an outbreak, single-patient rooms are preferred for all modes of transmission. When there is only a limited number of single-patient rooms, they should be prioritised for patients who have conditions that facilitate transmission of infectious material to other patients (for example, draining wounds, stool incontinence, uncontained secretions) and for those who are at increased risk of acquisition and adverse outcomes resulting from infection (for example, immunosuppression, open wounds, indwelling catheters, anticipated prolonged length of stay, total dependence on healthcare workers for activities of daily living). Cohorting Cohorting patients who are colonised or infected with the same strain confines their care to one area and prevents contact with other patients. Cohorts are created based on clinical diagnosis, microbiologic confirmation when available, epidemiology, and mode of transmission of the infectious agent. It is generally preferred not to place severely immunosuppressed patients in patient-care areas with other patients. Cohorting allows more efficient use of staff. Cohorting has been used for managing outbreaks of MROs and pandemic influenza, and modelling studies provide additional support for cohorting patients to control outbreaks. Placement of large numbers of patients In the event of an outbreak or exposure involving large numbers of patients who require airborne precautions, an infection control professional should be consulted before patient placement. Appropriate measures may include:
Restricting movement within the facilityRestricting movement of patients during an outbreak reduces the risk of further transmission. If transfer within the facility or transport to another facility is necessary, advice should be sought from an infection control professional. If an infected or colonised patient must be moved the transport service and/or receiving area or facility should be notified of the nature of the patient's infection or colonisation. It is important to:
Contaminated PPE should be removed and disposed of and hand hygiene performed before the patient is moved. Clean PPE should be put on before the patient is handled at the destination. Exclusion policiesExclusion policies may also be implemented to restrict the spread of disease throughout a healthcare facility. This could include:
In an outbreak of viral gastroenteritis, healthcare workers should not return to work until diarrhoea and vomiting have ceased for 2 days. It is extremely important that healthcare workers comply with appropriate hand hygiene methods and stringent infection control practices upon return to work, given that some studies have shown prolonged viral shedding. Notifications and contact tracingAll healthcare facilities should have systems in place to ensure timely reporting of notifiable diseases to the relevant state/territory health department. As patients may present to a healthcare facility and be later confirmed to have a transmissible disease state/territory health authorities need to be notified to enable tracing of contacts of the infected patient in order to initiate appropriate counselling, quarantine and post-exposure prophylaxis. Healthcare facilities may need to identify staff on duty and other patients present who may have been exposed to the infectious patient and be at risk. CommunicationOne of the important aspects of the outbreak management process is the written and oral communication of findings to the appropriate authorities, the appropriate health professionals and the public. This communication is based on the type and severity of the outbreak. During an outbreak it is important to provide education to the key stakeholders and clinicians about the organism, its mode of transmission and its behaviour in disease. Within a healthcare facility, effective communication could consist of:
Patient-care tipPatients, their families, and visitors may experience concern or fear or may feel they are not being given enough information in an outbreak situation. Clearly explaining the process of outbreak management and the importance of infection control measures may assist them in understanding the situation and improve compliance with infection control directives. B3.2.3 Applying transmission-based precautions during an outbreakSuccessful outbreak management is based on a combination of transmission-based precautions. Specific interventions will be determined by the infection control professional, based on the mode of transmission of the infectious agent. These include:
B3.2.4 Risk-management case study: Norovirus in a long-term care facilityA patient from a self-contained unit within a long-term care facility is transferred to a hospital unit with dehydration resulting from diarrhoea. The infectious agent involved is identified as norovirus. The facility is contacted and advised to implement contact and droplet precautions, but these can only be implemented in the main facility and the following day the patient's neighbour is also admitted with diarrhoea. When he and a third patient within the hospital unit are also confirmed as having norovirus, the three patients are isolated in single rooms with ensuites. Healthcare workers caring for the patients pay particular attention to hand hygiene and appropriate use of PPE. No further cases are identified. Investigation reveals low levels of hand hygiene among residents in the units. An education program is developed and provided to assist in preventing further infections.
B3.3 Putting it into practiceIndividual actions for reducing the risk
Involving patients in their careThe following information may be provided to patients to assist them in understanding outbreak management.
B3.4 ResourcesB3.4.1 Multi-resistant organismsGuidelinesB3.4.2 Outbreak managementGuidelines
B3.5 ReferencesBearman GML, Marra AR, Sessler CN et al (2007) A controlled trial of universal gloving versus contact precautions for preventing the transmission of multidrugresistant organisms. Am J Infection Control 35(10): 650–55. Christiansen KJ, Tibbett PA, Beresford W et al (2004) Eradication of a large outbreak of a single strain of vanB vancomycin-resistant Enterococcus faecium at a major Australian teaching hospital. Infect Control Hosp Epidemiol 25(5): 384–90. Christiansen K, Coombs G, Ferguson J et al (2008) Microbial resistance. In: Cruickshank M, Ferguson J, editors. Reducing Harm to Patients from Health Care Associated Infection: The Role of Surveillance. Australian Commission on Safety and Quality in Health Care. Ferguson J (2007) Healthcare-associated methicillin-resistant Staph aureus (MRSA) control in Australia and New Zealand - 2007 Australasian Society for Infectious Diseases (ASID) Conference forum convened by Healthcare Infection Control Special Interest Group (HICSIG). Aust Infection Control 12(2) 60–66. Gold H & Moellering R (1996). Antimicrobial-drug resistance. NEJM 335(19): 1445–53. Hayden MK, Blom DW, Lyle EA et al (2008) Risk of hand or glove contamination after contact with patients colonised with Vancomycin-resistant enterococcus or the colonised patients' environment. Infection Control Hosp Epidemiol 29(2): 149–54. Herwaldt LA (1999) Control of methicillin-resistant Staphylococcus aureus in the hospital setting. Am J Med 106(5A): 11S–18S; discussion 48S–52S. Matlow AG & Morris SK (2009) Control of antibiotic-resistant bacteria in the office and clinic. CMAJ 180 (10). Nathwani D, Morgan M, Masterton RG et al (2008) Guidelines for the UK practice for the diagnosis and management of methicillin-resistant Staphyloccus aureus (MRSA) infections presenting in the community. British Society for Antimicrobial Chemotherapy Working Party on Community-Onset MRSA. J Antimicrob Chemother 61: 976–94. Picheansathian W (2004) A systematic review on the effectiveness of alcohol-based solutions for hand hygiene. Int J Nurs Pract 10: 3–9. PIDAC (2007) Best practices for Infection Prevention and Control of Resistant Staphylococcus aureus and Enterococci in All Health Care Settings Canada 2007. Provincial Infectious Diseases Advisory Committee Pop-Vicas AE & D'Agata EMC (2005) The rising influx of multidrug-resistant gram-negative bacilli into a tertiary care hospital. Clin Infect Dis 40: 1792–98. Puzniak LA, Leet T, Mayfield J et al (2002) To gown or not to gown: the effect on acquisition of vancomycin-resistant enterococci. Clinical Infectious Diseases 35: 18–25. Srinivasan A, Song X, Ross T et al (2002) A prospective study to determine whether cover gowns in addition to gloves decrease nosocomial transmission of vancomycin-resistant enterococci in an intensive care unit. Infection Control Hosp Epidemiol 23(8): 424–28. Struelens MJ (1998). The epidemiology of antimicrobial resistance in hospital acquired infections: problems and possible solutions. BMJ 317(7159): 652–54. Trick WE, Weinstein RA, DeMarais PL et al (2004) Comparison of routine glove use and contactisolation precautions to prevent transmission of multidrugresistant bacteria in a long-term care facility. J Am Geriatrics Society 52(12): 2003–09. B4 Applying Standard and Transmission-Based Precautions During ProceduresSummaryMedical and dental procedures increase the risk of transmission of infectious agents between patients and healthcare workers.
Patient-care tipPatients and their carers should be offered clear, consistent information and advice through all stages of their care. This should include the risks of procedure-related infections, what is being done to reduce them and how they are managed. This section outlines processes for risk identification and the application of standard and transmission-based precautions for certain procedures. It is not intended to provide guidance on performing procedures, but outlines the principles involved in the delivery of care that reduce the risk of transmission of infection during the insertion and maintenance of therapeutic devices and for surgery. Evidence supporting practiceThe advice in this section has been adapted from:[16]
Further review of the literature conducted for these guidelines provided additional evidence on infection control measures required in the use of intravascular devices.[17] B4.1 Taking a Risk-Management Approach to ProceduresAll procedures involve some risk of infection. Minimising the infection risk associated with a procedure should be an integral part of considering the overall risks and benefits of that procedure to the patient. The aim should be to perform the procedure with the lowest level of perceived infection risk that will meet the treatment goals for that patient. When performing the procedure, associated infection risks should be identified and minimised. In developing local policies for a healthcare facility, it is useful to refer to guidelines developed to inform practice in performing specialised procedures. B4.1.1 Classifying proceduresProcedures can be classified according to the level of perceived risk, by applying the principles of Spaulding's criteria for assessing the risk of medical instruments and equipment according to their intended use (see Section B1.5). Table B4.1: Level of risk to patients from different types of procedures
B4.1.2 Appropriate use of devicesAppropriate use of devices is integral to reducing the risk of procedures. Single-use or single-patient items should be used wherever practical, and items designed for single use must not be used for multiple patients. Healthcare workers should be aware of situations where cross-contamination may occur during routine procedures. Healthcare workers must adhere to infection control principles, including safe injection practices and aseptic technique for the preparation and administration of parenteral medications. Single-dose vialsMedications or solutions that come into contact with normally sterile tissue should be sterile. The most effective way to avoid cross-infection via injection of medication is through the use of single-dose vials or ampoules and single-use sterile injecting equipment. Single-dose vials or ampoules, or prefilled syringes, should be used wherever these are available. These include the use of a sterile, single-use needle and syringe for each injection given, and adherence to practices that prevent contamination of injection equipment and medication. Multi-dose vialsThe Australian Drug Evaluation Committee (ADEC) has advised that injectable products packaged in multi-dose vials should not be used except where products such as insulin are intended solely for the exclusive use of an individual patient (ADEC 2005). In these particular cases, specific protocols should be in place to ensure the products are used for those individuals only, and there is adherence to practices that prevent contamination of injection equipment and medication. Currently some injectable products (for example, Bacillus Calmette-Guérin [BCG] and botulinum toxin) are only available in multi-dose vials. When single-dose vials or ampoules are not available, there is a high risk of cross-contamination if injectable products are used on multiple patients. Steps should be taken to ensure these become available in single dose vials, however the risk of infectious disease transmission may be mitigated by (Siegel et al 2007):
The use of multi-dose vials has been associated with the transmission of infectious diseases including HIV (Katzenstein et al 1999), hepatitis B (Hutin et al 1999; Dumpis et al 2003; Samandari et al 2005), hepatitis C (Widell et al 1999; Massari et al 2001; Trasancos et al 2001; Kokubo et al 2002; Silini et al 2002; Dumpis et al 2003; Germain et al 2005; Verbaan et al 2008), Staphylococcus aureus (Kellaway et al 1928), and Streptococcus pyogenes (Stetler et al 1985; Olson et al 1999). International agencies such as the CDC and WHO recommend that single-dose vials be used for parenteral additives or medications whenever possible, especially when medications will be administered to multiple patients (Hutin et al 2003; Siegel et al 2007). There may be some exceptional circumstances where for short periods (for example, a few months) multi-dose vials may be the only way to deliver vaccines or drugs to a large proportion of the population in a timely fashion. An example would be when a health emergency is declared because of an infection that has a high associated mortality and rapid spread (for example, smallpox outbreak) and when there may be a delay in single-dose vaccines or drugs becoming available for a period of time. Table B4.2: Summary of processes for appropriate use of devices
B4.1.3 The care bundle approachThe Institute for Healthcare Improvement (IHI) in the US developed a structured 'care bundle' approach to help healthcare workers consistently deliver the safest possible care for patients undergoing treatments with inherent risks. A bundle is a set of evidence-based practices that, when performed collectively and reliably, improve patient outcomes. Many bundle elements are well-established practices, combined in a structured protocol that is agreed upon and is the responsibility of the whole clinical team. Bundle characteristics include the following.
Examples of care bundles are given in each section of this chapter. These can be used to monitor, assess and improve performance as well as to increase consistency of care. Existing care bundles can be used as a tool and be developed by each facility to meet its needs. For more information, refer to the IHI website. B4.2 Therapeutic DevicesTherapeutic devices include catheters inserted for drainage (for example, urinary catheter), for intravascular access (for example, central venous line), for mechanical ventilation (for example, intubation) and for feeding (for example, enteral feeding tube). Indwelling devices provide a route for infectious agents to enter the body. Aseptic insertion and careful maintenance of devices is critical to reducing infection risk. Therapeutic medical devices are a common source of HAIs in intensive care units. Pneumonia, urinary tract infections and bloodstream infection account for around 70% of intensive care unit HAIs, and most of these are associated with invasive devices (Cruickshank & Ferguson 2008). Table B4.3: Key concepts in minimising the risk of infection related to the use of invasive devices
Information on use of aseptic non-touch technique (ANTT) for specific procedures (including therapeutic devices) can be found in Section B1.7 and Section B5.4. An indwelling urinary catheter is a flexible tubular instrument passed into the bladder either through the urethra or though the abdominal wall above the symphysis pubis. They are used to empty the contents of the bladder in patients with acute urine retention or peri-operatively, and for urinary measurements in critically ill patients. What are the risks?Bacterial infections associated with urinary catheterisation gain access to the urinary tract either through:
Catheterising patients places them at significant risk of acquiring a urinary tract infection. The risk of infection is associated with the method and duration of catheterisation, the quality of catheter care and host susceptibility. The longer a urinary catheter is in place, the greater the risk of infection. Between 15 and 25% of patients in hospital may receive short-term indwelling urinary catheters, and about 5% of residents in long-term care facilities (O'Grady et al 2002; draft 2009). Around 20% of HAIs are urinary tract infections, and a large proportion of these are catheter-associated urinary tract infections (CAUTIs) (Smyth et al 2008). Up to 97% of urinary tract infections in intensive care units have been associated with indwelling catheters (Cruickshank and Ferguson 2008). Minimising the risk from indwelling urinary devicesLimiting catheter use and minimising duration are primary strategies in reducing the risk of CAUTI. Healthcare facilities should have documented policies regarding insertion, maintenance and surveillance of indwelling urinary catheters. Facilities should clearly outline the indications for catheter insertion. Healthcare workers performing catheterisation should be trained and competent in the technique and familiar with policies and procedures for insertion, maintenance and changing regimes of indwelling urinary devices. Insertion
Maintaining the system
Patient care
Documentation and surveillance
Patient-care tipGiven the risk of urinary tract infection associated with urinary catheterisation, it is important that patients and relatives understand about infection prevention, are aware of the signs and symptoms of urinary tract infection and know how to access expert help if difficulties arise. Table B4.4: Summary of processes for urethral catheter insertion and maintenance
Table B4.5: CAUTI maintenance bundleAn example of a bundle procedure for maintenance of urinary catheters is to:
These practices can be measured and used to monitor performance by the clinical team. B4.2.2 Intravascular access devicesIndwelling intravascular access devices (catheters) provide a route for:
Intravascular devices (IVDs) are catheters that are usually inserted into peripheral veins (for example, small veins in the arms). Peripheral arterial devices are also used for some patients. Central venous catheters are inserted into larger veins within the chest and abdomen. They generally remain in place for longer than peripheral vein catheters.
IVD insertion is the most commonly performed invasive healthcare procedure with approximately 14 million IVDs used in Australia each year (Collignon 1994; ABS 2008). What are the risks?IVDs provide potential routes for infectious agents to cause local infection or to enter the bloodstream. As a result, despite their important role in diagnostic and therapeutic care, IVDs are a potential source of HAIs, the most severe form being bloodstream infections (BSI) associated with the insertion and maintenance of central venous access devices. There are about 5,000 cases of IVD-related BSI a year in Australia (Collignon 1994; ABS 2008). IVD-related BSIs are associated with significant mortality, worsen the severity of the patient's underlying ill health, prolong the period of hospitalisation and increase the cost of care. There is risk of infection when the device is inserted and while it remains in situ. The risks inherent in insertion of IVDs include bypassing the skin, which is such an important barrier against microorganisms gaining entry to sterile sites such as the bloodstream, and leaving a foreign body in the patient for several days or longer which is likely to become colonised by microorganisms. Potential sources for indwelling device contaminationFigure B4.1: Potential sources for indwelling device contamination. Source: Illustration used with permission from Professor Dennis Maki.
Table B4.6: Risk factors for IVD-related BSI
The microorganisms that colonise catheter hubs and the skin adjacent to the insertion site are the source of most IVD-related BSI. Coagulase-negative staphylococci, particularly Staphylococcus epidermidis, are the most frequently implicated microorganisms. Other microorganisms commonly involved include Staphylococcus aureus, Candida species and enterococci. Prolonged duration of peripheral IV catheters greatly increases the risk of infection – while only 1–2% of peripheral catheters remain in place for longer than 2 days, these are associated with 90% of IVD-related BSIs (Collignon P, unpublished study). Minimising the risk from intravascular access devicesTo minimise the risk to patients, IVDs should only be used when absolutely necessary. They must be removed as soon as they are no longer needed or alternative means are available to deliver appropriate care (for example, oral drugs instead of IV delivery). Prevention of catheter-related BSI requires a set of infection control measures (see care bundles box below). Decision-making about IVDsDecision-making about IVDs should involve the consideration of:
If a central venous access catheter is necessary, it must be inserted under maximal barrier precautions (that is, similar to surgical procedures). The femoral site of insertion should be avoided (Hamilton and Foxcraft 2008). Table B4.7: Central venous catheter decision tree for adults
Source: The Canberra Hospital. Evidence supporting practice [18]Site preparation
Insertion of IVDs
Maintenance
Choice of dressings
Changing dressings
Device replacement
Replacement of administration sets
Patient-care tipBefore discharge from hospital, patients and their carers should be provided with education, supported by written instructions, on the management and care of an indwelling device, including the prevention of infection. Table B4.8: Summary of processes for insertion, maintenance and replacement of intravascular access devices
Figure B4.2: PPE and maximal barrier precautions for IVD insertionIVD care bundlesThere are numerous care bundles in use on the management of central and peripheral vascular devices. Information on bundles and their implementation is discussed in Section B4.1.3. Before implementing a care bundle it is important to identify current practice in the particular area. Gaps in service provision need to be identified, analysed and systematically addressed through the implementation of the bundle. Examples available bundles include:
B4.2.3 VentilationCertain patients require mechanical ventilatory support by endotracheal tube or tracheostomy. Common medical indications include acute lung injury, chronic obstructive lung disease and acute respiratory acidosis. What are the risks?Ventilator-associated pneumonia (VAP) is a type of hospital-acquired pneumonia that can occur in up to 25% of all people who require mechanical ventilation. VAP is a common cause of morbidity and mortality with crude death rates of 5 to 65% as well as increased healthcare costs. VAP can develop at any time during ventilation, but occurs more often in the first few days after intubation, because the intubation process itself contributes to the development of VAP. VAP primarily occurs because microorganisms colonise the endotracheal or tracheostomy tube and are embolised into the lungs, often in patients who may have underlying lung or immune problems. Bacteria may enter the lungs with procedures such as bronchoscopy. Minimising the risks of VAPMany practices have been demonstrated to reduce the incidence of VAP and its associated burden of illness. The first consideration should always be whether intubation is necessary. Physical strategies
Positional strategies
Pharmacologic strategies
VAP care bundlesThere a numerous care bundles in use on the management and prevention of VAP. Information on bundles and their implementation is discussed in Section B4.1.3. Before implementing a care bundle it is important to identify current practice in the particular area. Gaps in service provision need to be identified, analysed and systematically addressed through the implementation of the bundle. Examples of available bundles include: B4.2.4 Enteral feeding tubesEnteral feeding is usually prescribed for patients in hospital requiring artificial nutrition support for 7 to 10 days and long-term feeding/ home enteral tube feeding may be considered for patients needing artificial nutrition support for more than 30 days. What are the risks?Contamination of feeds is a key concern in both the hospital and community setting, with contamination largely occurring during the preparation or administration of feeds and being linked to serious clinical infection. Minimising the risks of enteral feeding tubesMost evidence concerning enteral feeding relates to gastrostomy or percutaneous endoscopic gastrostomies (PEG feeds). However, the principles outlined here are also applicable to nasogastric and jejunostomy feeding.
Patient-care tipPatients and carers should be educated in techniques of hand hygiene, enteral feeding and the management of the administration system before being discharged from hospital. Table B4.10: Summary of processes for using enteral feeding tubes
B4.3 Surgical ProceduresThe discussion in this section applies to all surgical procedures regardless of setting. While there is less evidence for surgical procedures in office-based practice than in hospitals, the same principles apply. Notes Unless otherwise specified, this section is drawn from NICE (2008) Prevention and Treatment of Surgical Site InfectionB4.3.1 What are the risks?The microorganisms that cause surgical-site infections are usually derived from patients (endogenous infection), being present on their skin or from a surgical opening in the body. Exogenous infection occurs when microorganisms from instruments or the operating environment contaminate the site at operation, when microorganisms from the environment contaminate a traumatic wound, or when microorganisms gain access to the wound after surgery, before the skin has sealed. The risk of surgery-related infection is increased by factors that:
B4.3.2 Minimising the risk of surgical proceduresPractices to prevent surgical-site infections are aimed at minimising the number of microorganisms introduced into the operative site, for example by:
This section gives general guidance on preventing surgical infection. More detailed information can be found in the NICE surgical-site infection guidelines (NICE 2008). Patient-care tipPatients and carers require clear, consistent information and advice throughout all stages of their care, including:
An integrated care pathway helps to communicate this information to both patients and all those involved in their care after discharge. Patients should always be informed if they have been given antibiotics. Hand hygiene for surgerySurgical hand preparation should reduce the release of skin bacteria from the hands of the surgical team for the duration of the procedure in case of an unnoticed puncture of the surgical glove that releases bacteria to the open wound. Surgical hand preparation must eliminate the transient and reduce the resident flora. There are special surgical scrub formulations available for use, although any product used within Australia should preferably be approved by the TGA. Current WHO guidelines recommend the use of an alcohol-based formulation for preoperative surgical hand preparation given its superior antimicrobial efficacy compared to other methods (WHO 2009; Widmer 2010). Specific policies and procedures on products and methods of surgical hand preparation should be developed locally. PPE for surgical and dental proceduresFor surgical procedures and dentistry, the sequence for putting on PPE differs from that outlined in Section B1.2. In these situations, masks and protective eyewear are applied first prior to hand preparation. Gown and gloves are then put on. Double-gloving (wearing two sets of gloves) is becoming more common, especially for surgery where sharp surfaces are formed (such as orthopaedic or dental surgery). A second pair of gloves protects the inner pair, without apparently affecting surgical performance (Tanner & Parkinson 2006). A glove liner between the two pairs of gloves reduces breaks to the inner glove even further, and extra-thick gloves seem to be as good as two pairs (Tanner & Parkinson 2006). Information on use of Surgical aseptic non-touch technique (ANTT), and on Standard ANTT for wound care, can be found in Section B1.7 and Section B5.4. B4.3.3 Considerations pre-procedure
B4.3.4 Considerations during a surgical procedure
Table B4.12: Summary of processes during a surgical procedure
B4.3.5 Considerations post-procedure
Table B4.13: Summary of processes following a surgical procedure
B4.4 Putting in into PracticeThis table outlines the use of standard precautions for a range of procedures. It is assumed that there is no known or suspected infection. Decision-making about the level of protection required involves a risk assessment of the procedure to be performed; for example, usual wound irrigation is unlikely to require surgical mask and eye protection in primary care, but may be required more often in the hospital setting. Table B4.14: Checklist of standard precautions for procedures
* Including most dental implants, surgical removal or exposure of completely impacted teeth or tooth fragments, vital endodontics, surgical periodontics, maxillo-facial surgery. B4.5 ResourcesB4.5.1 Intravascular devicesGuidelinesResourcesB4.5.2 Indwelling urinary cathetersGuidelinesB4.5.3 Ventilation-associated pneumoniaGuidelinesB4.5.6 Enteral feedingGuidelinesB4.5.7 Surgical-site infectionGuidelinesStandardsB4.5.8 Patient education tools and resources on devicesB4.6 References
B5 Supplementary InformationB5.1 Recommended Routine Cleaning Frequencies for Clinical, Patient and Resident Areas in Acute SettingsThe following table outlines the recommended minimum frequencies for routine cleaning of various items in healthcare facilities. It is applicable to all settings (although some items may not be relevant to all settings) and is presented by level of risk as per the key below. The table has been developed to provide a benchmark guide to best-practice cleaning schedules. Facilities should develop and implement a local cleaning schedule and policy that suits their environment, and consider regular monitoring and mechanisms to deal with specific organisms and outbreak situations. For guidance on cleaning of spills, see Section B1.4.3.
Source: Adapted from NHS national specifications for cleanliness launched in April 2001; Wales WHC (2003) 59 – National Standards of Cleanliness for NHS Trusts, Welsh Assembly Government, June 2003; NHS Estates - NHS Estates. Standards of cleanliness in the NHS: a framework in which to measure performance outcomes. Leeds: NHS Estates; 2003. Available at: B5.2 Type and Duration of Precautions for Specific Infections and ConditionsType and duration of precautions for specific infections and conditions (PDF 225KB) B5.3 Exposure Prone ProceduresExposure prone procedures (EPPs) are invasive procedures where there is potential for direct contact between the skin, usually finger or thumb of the healthcare worker, and sharp surgical instruments, needles, or sharp tissues (for example, fractured bones), spicules of bone or teeth in body cavities or in poorly visualised or confined body sites, including the mouth of the patient. During EPPs, there is an increased risk of transmitting bloodborne viruses between healthcare workers and patients. EPP categoriesThe nature of the EPP performed by the healthcare worker can be categorised according to level of risk of transmission, in increasing order of magnitude.
Source: DH/HP/GHP3. HIV Infected Health Care Workers: Guidance on Management and Patient Notification. London; 2005 Advice on EPPs in specific areas of clinical careAccident and emergency (AandE)AandE staff members who are restricted from performing EPPs should not provide pre-hospital trauma care. These staff should not physically examine or otherwise handle acute trauma patients with open tissues because of the unpredictable risk of injury from sharp tissues. Cover from colleagues who are allowed to perform EPPs would be needed at all times to avoid this eventuality. Other EPPs which may arise in an AandE setting would include:
(See also Anaesthetics, Biting, Paramedics and Resuscitation) AnaestheticsEndotracheal intubation, use of a laryngeal mask and procedures performed purely percutaneously are not exposure prone. The only procedures currently performed by anaesthetists which would constitute EPPs are:
The insertion of a chest drain may or may not be considered to be exposure prone depending on how it is performed. Procedures where, following a small initial incision, the chest drain with its internal trochar is passed directly through the chest wall (as may happen e.g. with a pneumothorax or pleural effusion) and where the lung is well clear of the chest wall, would not be considered to be exposure prone. However, where a larger incision is made, and a finger is inserted into the chest cavity (for example, with a flail chest) and where the healthcare worker could be injured by the broken ribs, the procedure should be considered exposure prone. Modern techniques for skin tunnelling involve wire guided techniques and putting steel or plastic trochars from the entry site to the exit site where they are retrieved in full vision. Therefore skin tunnelling is no longer considered to be exposure prone (see also Arterial cutdown). Arterial cutdownAlthough the use of more percutaneous techniques has made arterial or venous cutdown to obtain access to blood vessels an unusual procedure, it may still be used in rare cases. However, as the operator's hands are always visible, it should no longer be considered exposure prone. BitingStaff working in areas where there is a significant risk of being bitten should not be considered to be performing EPPs. Bone marrow transplantsNot exposure prone. CardiologyPercutaneous procedures including angiography/cardiac catheterisation are not exposure prone. Implantation of permanent pacemakers (for which a skin tunnelling technique is used to site the pacemaker device subcutaneously) may or may not be exposure prone. This will depend on whether the operator's fingers are or are not concealed from view in the patient's tissues in the presence of sharp instruments during the procedure (see also Arterial cutdown). DentistryThe definition for exposure-prone procedures for dentistry is currently under review. The guideline will be updated once this issue is resolved. Ear, nose and throat surgery (otolaryngology)ENT surgical procedures generally should be regarded as exposure prone with the exception of simple ear or nasal procedures, and procedures performed using endoscopes (flexible and rigid) provided fingertips are always visible. Non-exposure prone ear procedures include stapedectomy/stapedotomy, insertion of ventilation tubes and insertion of a titanium screw for a bone anchored hearing aid. EndoscopySimple endoscopic procedures (for example, gastroscopy, bronchoscopy) have not been considered exposure prone. In general there is a risk that surgical endoscopic procedures (for example, cystoscopy, laparoscopy – see below) may escalate due to complications that may not have been foreseen and may necessitate an open EPP. The need for cover from a colleague who is allowed to perform EPPs should be considered as a contingency (see also Biting). General practiceSee Accident and Emergency, Biting, Minor Surgery, Midwifery/Obstetrics, Resuscitation Gynaecology (see also laparoscopy)Open surgical procedures are exposure prone. Many minor gynaecological procedures are not considered exposure prone, examples include dilatation and curettage (Dand C), suction termination of pregnancy, colposcopy, surgical insertion of depot contraceptive implants/devices, fitting intrauterine contraceptive devices (coils), and vaginal egg collection provided fingers remain visible at all times when sharp instruments are in use. Performing cone biopsies with a scalpel (and with the necessary suturing of the cervix) would be exposure prone. Cone biopsies performed with a loop or laser would not in themselves be classified as exposure prone, but if local anaesthetic was administered to the cervix other than under direct vision (that is, with fingers concealed in the vagina), then the latter would be an EPP (category 1). Haemodialysis/HaemofiltrationSee Renal Medicine Intensive careIntensive care does not generally involve EPPs on the part of medical or nursing staff LaparoscopyThese are mostly non-exposure prone because fingers are never concealed in the patient's tissues. Exceptions are: if main trochar inserted using an open procedure, as for example in a patient who has had previous abdominal surgery. Also exposure prone if rectus sheath closed at port sites using J-needle, and fingers rather than needle holders and forceps are used. In general there is a risk that a therapeutic, rather than a diagnostic, laparoscopy may escalate due to complications, which may not have been foreseen necessitating an open EPP. Cover from colleagues who are allowed to perform EPPs would be needed at all times to avoid this eventuality. Midwifery/obstetricsSimple vaginal delivery, amniotomy using a plastic device, attachment of foetal scalp electrodes, infiltration of local anaesthetic prior to an episiotomy and the use of scissors to make an episiotomy cut are not exposure prone. The only EPPs routinely undertaken by midwives are repairs following episiotomies and perineal tears: category 1 in the case of first-degree lacerations; category 2 in the case of second, third and fourth degree lacerations. Repairs of third and fourth degree tears are normally undertaken by medical staff members who may include general practitioners assisting at births in a community setting. Minor surgeryIn the context of general practice, minor surgical procedures such as excision of sebaceous cysts, skin lesions, cauterisation of skin warts, aspiration of bursae, cortisone injections into joints and vasectomies do not usually constitute EPPs. Sharps occupational exposureHealthcare workers need not refrain from performing EPPs pending follow up of occupational exposure to a BBV infected source. The combined risks of contracting a BBV from the source patient and then transmitting this to another patient during an EPP is so low as to be considered negligible. However in the event of the worker being diagnosed with a BBV, such procedures should cease in accordance with this guidance. NursingGeneral nursing procedures do not include EPPs. The duties of operating room nurses should be considered individually. Instrument nurses do not generally undertake EPPs. However, it is possible that nurses acting as first assistant may perform EPPs (see also Accident and Emergency, Renal Medicine/Nursing, and Resuscitation). Obstetrics/MidwiferySee Midwifery/Obstetrics. Obstetricians perform surgical procedures, many of which will be exposure prone according to the criteria. Operating room techniciansGeneral duties do not normally include EPPs. OphthalmologyWith the exception of orbital surgery, which is usually performed by maxillo-facial surgeons (who perform many other EPPs), routine ophthalmological surgical procedures are not exposure prone as the operator's fingers are not concealed in the patient's tissues. Exceptions may occur in some acute trauma cases, which should be avoided by EPP restricted surgeons. OptometryThe training and practice of optometry does not require the performance of EPPs. OrthodonticsSee Dentistry OrthopaedicsEPPs
Non-EPPs
PaediatricsNeither general nor neonatal/special care paediatrics has been considered likely to involve any EPPs. Paediatric surgeons do perform EPPs (see also Arterial cutdown). ParamedicsIn contrast to other emergency workers, a paramedic's primary function is to provide care to patients. Paramedics do not normally perform EPPs. However, paramedics who would be restricted from performing EPPs should not provide pre-hospital trauma care. This advice is subject to review as the work undertaken by paramedics continues to develop (see also Accident and Emergency, Biting and Resuscitation). PathologyIn the event of injury to an EPP restricted pathologist performing a post mortem examination, the risk to other workers handling the same body subsequently is so remote that no restriction is recommended. PodiatristsRoutine procedures undertaken by podiatrists who are not trained in and do not perform surgical techniques are not exposure prone. Procedures undertaken by podiatric surgeons include surgery on nails, bones and soft tissue of the foot and lower leg, and joint replacements. In a proportion of these procedures, part of the operator's fingers will be inside the wound and out of view, making them EPPs (see also Orthopaedics). RadiologyAll percutaneous procedures, including imaging of the vascular tree, biliary system and renal system, drainage procedures and biopsies as appropriate, are not EPPs (see also Arterial cutdown). Renal medicineThese procedures are not exposure prone and neither haemofiltration nor haemodialysis constitute EPPs. The working practices of those staff members who supervise haemofiltration and haemodialysis circuits do not include EPPs. ResuscitationResuscitation performed wearing appropriate protective equipment does not constitute an EPP. SurgeryOpen surgical procedures are exposure prone. This applies equally to major organ retrieval because there is a very small, though remote, risk that major organs retrieved for transplant could be contaminated by a healthcare worker's blood during what are long retrieval operations while the patient's circulation remains intact. It is possible for some contaminated blood cells to remain following pre-transplantation preparatory procedures and for any virus to remain intact since organs are chilled to only 10°C (see also Laparoscopy, Minor Surgery). Volunteer healthcare workers (including first aid)The important issue is whether or not an infected healthcare worker undertakes EPPs. Notes: This section has been adapted by the committee from DH/HP/GHP3 (2005) HIV Infected Health Care Workers: Guidance on Management and Patient Notification. London: UK Dept Health. B5.4 Examples of How to Perform Aseptic Non-Touch TechniqueTypically, IV maintenance procedures will be assessed as requiring Standard ANTT with the employment of a main general aseptic field and critical micro aseptic fields. Figure B5.1: Aseptic non-touch technique for peripheral and central access intravenous therapyNotes Unless otherwise specified, this section is drawn from NICE (2003) Prevention of Healthcare-associated Infection in Primary and Community Care. Clean key parts 2% chlorehixidine/70% alcohol wipes is the application of choice (Pratt et al 2007). In addition, the benefit of using friction and allowing key parts to dry has been demonstrated by Kaler and Chinn (2007).Method: A large 2% chlorhexidine and 70% alcohol wipe should be fully unfolded to provide a suitable working surface area. One side of the wipe should be exposed to the user's gloved hand, the other side should be introduced to the hub (non-touch technique) The port tip should be thoroughly wiped hard for 5 seconds – to create friction. This should be repeated 4 times using different parts of the tissue (to remove dirt from the tip). After cleaning the hub clean the sides of the port and line, working away from the port tip. Allowing the hub to air dry promotes asepsis.This technique provides the required level of friction. Using different parts of the wipe ensures any dirt is transferred from the hub to the wipe. The hub must dry before use otherwise it won't be aseptic (if organisms have remained, a wet tip will facilitate their transportation into the patient on injection).
Wound care procedures are highly variable. Typically, a critical main aseptic field is employed and practice is dictated accordingly. Figure B5.2: Aseptic non-touch technique for wound careTable B5.2: Aseptic non-touch technique for wound care
B5.5 General Infection Control ResourcesB5.5.1 International guidelines on infection controlB5.5.2 Policies on infection controlState and Territory department of health infection policies B5.5.3 Legislation/codes of practice
B5.5.4 Commonwealth legislationB5.5.5 Other resourcesPart C: Organisational SupportSummaryFor infection prevention and control to be effective at the clinical level, much organisational support is required. This includes embedding infection control into governance and management structures, initiating procedures (for example, immunisation programs) to ensure that healthcare workers are protected, instituting processes for surveillance that feed into the overall quality control program, implementing systems for ongoing staff education and training, and incorporating infection control into planning for facility design and maintenance. Infection control is a health and safety issue, which means that all those working in the healthcare facility – managers, healthcare workers and support staff – are responsible for providing a safe environment for patients and other staff. Organisational support should aim to ensure that clinical work practices provide patient-centred care – this is not only essential from a safety and quality perspective but out of consideration for patient preferences. This may require consultation with patients and relevant consumer groups in the development of health care services. The information presented in this Part is particularly relevant to managers of healthcare facilities. It outlines responsibilities of management of healthcare facilities, including governance structures that support the implementation, monitoring and reporting of effective work practices. While the focus of the information is acute-care facilities, much of the information is relevant in other healthcare settings. C1 Management and Clinical GovernanceSummaryTo be effective, infection prevention and control must be a priority in every healthcare facility – this requires total commitment at every level of the organisation
C1.1 Clinical Governance in Infection Prevention and ControlAddressing infection prevention and control requires a facility wide program and is everybody's responsibility.Healthcare facilities have a legal responsibility to provide a safe work environment, safe systems of work and a safe environment for patients and visitors.Clinical governance refers to the system by which managers and clinicians in each healthcare facility share responsibility and are held accountable for patient care. This involves minimising risks to patients and staff, and continuously monitoring and improving the quality of clinical care. Preventing transmission of infectious agents should be a priority in every healthcare facility. This will involve action to:
All healthcare workers need to be aware of their individual responsibility for maintaining a safe care environment for patients and other staff. C1.2 Roles and ResponsibilitiesManagement and clinical governance can have a positive impact on the effectiveness of infection prevention and control, by driving continuous quality improvement and promoting a non-punitive culture of trust and honesty (Victorian Quality Council 2004). Studies have found that where clinical governance and management encourage collaboration between healthcare managers and clinicians, change is more likely to be achieved than where there is unilateral governance (Ham 2003). Change is also more likely to be achieved and sustained when the role of patients as partners in their health care is strengthened, and where there is a shared understanding of the role of patients, healthcare workers and organisations in achieving the best possible outcomes (ACSQHC 2008). The roles and responsibilities described below are most relevant to acute health care settings. However, all the roles described in this section are important for effective infection prevention and control and can be readily adapted to other healthcare settings – for example, with the practice principal fulfilling relevant roles and responsibilities of a CEO, and the office manager or other staff representative with an interest in infection prevention and control fulfilling the role of infection control professional (see Section C1.2.4). C1.2.1 Chief Executive Officer/AdministratorThe healthcare facility's CEO or designated equivalent administrator should support and promote infection prevention and control as an integral part of the organisation's culture through the following strategies:
In some Australian states and territories and internationally, performance against infection control indicators is monitored. For example, in Tasmania, a performance monitoring process is in place. The indicators used to monitor performance and progress includes indicators relating to infection prevention and control. C1.2.2 Infection control professionalsInfection control professionals should have the skills, experience and qualifications relevant to their specific clinical setting and be able to:
Infection control professionals are primarily responsible for designing, coordinating, implementing and undertaking ongoing evaluation of the facility's infection prevention and control program and policies, including compliance with the respective state/territory and/or national accreditation, licensing, policy or regulatory requirements. They are also responsible for equipment and product evaluation. Infection control professionals need to be supported by the facility with resources, authority and time to maintain clinical and professional currency (including support for credentialling and have preferably a postgraduate qualification [see Section C3.5.2]). Infection control professionals must be involved in decisions on facility construction and design, patient placement ratios (for example, single rooms, negative pressure rooms) and environmental assessments (see Section C6). The infection control professional's performance should be appraised at least annually, along with negotiation of individual professional development goals, support, opportunities and plan of work. C1.2.3 Infection prevention and control committeeA multidisciplinary IPC Committee should review and guide the healthcare facility's IPC program, strategies and plans. Membership must include, but not be limited to: the CEO or his/ her designate; an executive member with the authority to allocate the necessary resources and take remedial action as needed from time to time; an infection control professional; and one or more medical practitioners (preferably a clinical microbiologist and/or an infectious diseases physician). The meeting frequency and content will depend on the facility's size, case-mix complexity and the infection risk of populations serviced. IPC Committee activity should be measured against an operational plan with set priorities to target within key focus areas. The IPC Committee should have a formal mechanism for regularly considering patients' experiences and feedback and modifying the IPC program accordingly. The IPC Committee should have an organisational communication strategy to facilitate day-to-day activities and reporting activities, which should be able to be escalated in response to an incident or outbreak. Regular and ad-hoc communication processes should exist between the IPC team and relevant public health authorities. Healthcare facilities that do not have access to an IPC committee (or infection control professional) should consult with an infection control professional in a larger health service for program advice and support. C1.2.4 Infection prevention and control processes in office-based practiceIn office–based practice, the processes associated with infection prevention and control will differ although the responsibilities are the same. The principal of the practice is equivalent to the CEO; he or she has overall responsibility for infection prevention and control in the practice and should demonstrate a strong commitment to an agreed infection prevention and control plan based on the identified risks for that practice. Local policies and procedures need to be developed and implemented as part of standard operating procedures. A nominated staff member must take on the role of infection control professional, developing infection prevention and control procedures and overseeing their implementation. This staff member is likely to need additional training and perhaps ongoing external support in managing infection prevention and control issues. Infection prevention and control should be considered at every staff meeting, with discussion of procedures and processes of the practice and any problem areas. C1.3 Infection Prevention and Control ProgramThe IPC program is the means by which infection prevention and control practice is implemented in every part of the healthcare facility. Elements of an IPC program include:
The IPC program may also include antibiotic stewardship initiatives run in conjunction with the pharmacy department/services. C1.3.1 Recommendations including policies and proceduresNational and/or state infection prevention and control recommendations relevant to the facility should be endorsed and their principles applied as necessary according to local need by the IPC Committee. Compliance with these recommendations must be monitored. At a minimum, these recommendations form the basis of the infection control professional's directives, which should be easily accessible in hard copy, electronic or other formats. Suggested topics to be addressed, depending on the facility, include:
C1.3.2 Infection prevention measuresTo implement the measures outlined in infection prevention and control policies and procedures, the facility must have access to an accredited (for example, National Association of Testing Authorities [NATA]) laboratory and pharmacy staff, as well as systems, protocols and resources to:
C1.3.3 Quality improvementSafe and high quality infection prevention and control practices contribute to continual improvements in the quality of healthcare provided in any setting. These practices occur at the organisational, staff and patient levels. IPC programs include principles of quality management, through the use of approaches such as plan-do-study-act that enable processes to be enhanced and improved. It is essential to performance improvement that healthcare workers understand the value of monitoring and evaluating their own clinical practice. Examining patient and carer experiences can provide an insight into their perspectives and allow these to be taken into account in improving the quality of care. Integrating monitoring and review processes into policies and procedures (for example, through infection prevention and control audits) enables data to be collected. Performance indicators can be developed from this, such as surveys on compliance with protocols and monitoring the use of infection prevention and control products. In the acute setting, it is recommended that healthcare facilities support local research regarding specific cases of infection, outbreaks or preventative strategies, and adopt relevant research findings that reduce or prevent healthcare-associated infections. In addition, comprehensive and epidemiologically sound systems, protocols and resources should exist to:
Surveillance and healthcare-associated infection monitoring strategies should be designed and driven according to local activity, performance and trends in the incidence of epidemiologically significant organisms. A useful resource is the ACSQHC Measurement for improvement tool kit, which provides a set of practical methods to measure the safety and quality of clinical health care services. C1.3.4 Resource allocationHealthcare facility managers should ensure that there are sufficient human and fiscal resources available to support all aspects of the IPC program, including:
C1.4 Risk ManagementRisk management is the basis for preventing and reducing harm arising from healthcare-associated infections and underpins the approach to infection prevention and control throughout these guidelines. Within a healthcare facility, a successful approach to risk management includes action at the organisational level (for example providing support for effective risk management through an organisational risk-management policy, staff training and monitoring and reporting) as well as in clinical practice. C1.4.1 Organisational support for risk managementFor risk management within an organisation to be effective there needs to be appropriate infrastructure and culture; a logical and systematic approach to implementing the required steps (outlined in C1.4.2); and embedding of risk-management principles into the philosophy, practices and business processes of an organisation, rather than it being separate activity or focus. Factors that support risk management across the organisation include development of a risk-management policy; staff training in risk management; implementation of a risk register, risk treatment schedule and integrated action plans; monitoring and audit; and risk-management reporting. An infrastructure and environment that encourages two-way communication between management and healthcare workers and among healthcare workers is an important factor in increasing the level of support for and compliance with IPC programs. Management should:
Healthcare workers can contribute to the development of risk-management structures, and are integral to the strategies within these. Strategies to assist individual healthcare workers to reduce risk are included at the end of each section of Part B. C1.4.2 A stepwise approach to risk managementThe Australian/New Zealand Standard on Risk Management (AS/NZS ISO 31000:2009) outlines a stepwise approach to risk management:
An example of the application of this approach is given in Section A2.2. C1.5 Taking an Organisational Systems Approach to Infection Prevention Quality and SafetyAddressing infection prevention and control issues requires a multi-component, facility-wide program and is everybody's responsibility. This section gives an outline of a systematic approach that has been shown to be effective (care bundles), together with examples of the organisational support required at facility level to address two crucial areas of infection prevention and control— reducing sharps injuries to healthcare workers and lowering the incidence in patients of bloodstream infections associated with intravascular devices. C2 to C6 discuss the separate aspects of a systems approach to infection prevention and control. C1.5.1 Care bundles'Care bundling' is an approach developed by the US Institute of Healthcare Improvement (IHI) to improve consistency of practice in healthcare facilities, particularly for conditions and procedures known to increase patients' risk of healthcare-associated infections. While large studies have not yet been undertaken, the approach has been shown to reduce healthcare-associated infections within hospitals and is now used widely, particularly in the US and UK. A 'care bundle' is set of four or five evidence-based processes that aims to tie routine processes together into a cohesive unit that must be adhered to for every patient. The keys to the bundle strategy's success are the standardised and unvarying application of bundle practices, the use of multidisciplinary rounds, and daily tracking and auditing of compliance. Care bundles can be used to monitor care and to feedback care bundle results to clinical staff in order to decrease the rate of healthcare-associated infections related to that condition or that procedure. It is important that bundles are designed, implemented and evaluated with measurement designed for quality improvement rather than research or judgement. Examples of some procedural care bundles are given in Section B4. C1.5.2 Reducing sharps injuriesSafe handling of sharps is discussed in more detail in Section B1.3. A systems approach can support reducing sharps injuries by addressing (CDC 2009):
C1.5.3 Lowering the incidence of IVD-related bloodstream infectionsSection B4.2 outlines infection prevention and control guidance for healthcare workers to follow when inserting a therapeutic device such as a central venous catheter. A range of measures is required for safe use of devices, the first consideration being whether the device is necessary or if a safer alternative could be used. Facility management and the infection prevention and control team have a key role in working with clinical staff to improve the safety of procedures such as IVD insertion, by providing the necessary support and infrastructure. The care bundle (see also Section B4.1) for central venous catheter insertion stipulates the use of hand hygiene, maximal barrier protection, optimal intravascular catheter site selection, topical chlorhexidine for skin disinfection, and daily review to ensure that catheters are removed as soon as they are no longer necessary. Support and infrastructure requirements to facilitate implementation of these measures include:
C2 Staff Health and SafetySummary
C2.1 Roles and ResponsibilitiesIn the course of their duties, healthcare workers can be exposed to infectious agents (for example, through direct contact with an infectious patient, visitor or colleague or indirectly through a contaminated surface or environment [i.e. air] or as the result of a sharps injury). Healthcare workers can also place patients at risk of transmission of infection (for example, if the healthcare worker has an infectious condition that is capable of being transmitted as they perform their duties). To ensure the safety of everyone in the facility, both employers and employees have a responsibility in relation to infection prevention and control and occupational health and safety. C2.1.1 Responsibilities of healthcare facilitiesWorkplace Health and Safety Acts for the various states and territories place a duty of care on employers to ensure workplace health and safety, including where occupational infectious disease hazards exist. As part of its IPC program, each healthcare facility should develop, implement and document effective policies and procedures related to staff health and safety, including strategies to prevent occupational exposure to infection hazards; prevent occupational risks from chemicals or processes used for recommended infection prevention and control activities; and implement healthcare worker immunisation programs for infectious agents they may encounter in the course of their duties. At the start of their employment, all healthcare workers should be informed of the facility's policy on health screening and be counselled, as appropriate, about their work placement in accordance with these policies. As personal and organisational circumstances change over time, reassessment and additional education may be necessary. Similarly, training institutions should inform healthcare students before their course admission about policies and procedures for staff health and safety and their implications, and provide counselling for students who may be prohibited from completing any requirements of their course due to transmissible infections. Healthcare worker's privacy and civil rights must always be respected and not breached. Positive measures should be undertaken to implement and sustain appropriate infection prevention and control. There are five measures of protection:
C2.1.2 Responsibilities of healthcare workersHealthcare workers have an obligation to always follow specific established infection prevention and control policies as part of their contract of employment. This includes reporting their infectious status if it places others at risk as well as any known potential exposures to blood and/or body substances. Failure to follow infection prevention and control policies and procedures may be grounds for disciplinary action. Some states/territories have statutory infection prevention and control requirements for healthcare workers. Healthcare workers with infections should seek appropriate medical care from a doctor qualified to manage their condition. Where there is a risk of a healthcare worker transmitting infection to a patient or other healthcare worker (for example, if he or she is infected with an acute or other transmissible infection, carries a blood borne virus, or has a predisposing skin condition), the healthcare worker should be counselled about work options and either rostered appropriately or provided with equipment, information and facilities to enable him or her to perform their duties without placing others at risk. The appropriate work option will depend on the specific circumstances:
Healthcare workers should be aware of their requirements for immunisation against infectious diseases and maintain personal immunisation records. Healthcare workers in specific circumstances (for example, pregnant healthcare workers) may be particularly susceptible to some infections and should work with occupational health and safety officers to ensure their safety (see Section C2.4). Education about safe work practices is discussed in Section C3. C2.2 Health Status Screening and ImmunisationC2.2.1 Staff health screening policiesBefore beginning employment, all staff should be assessed and offered testing and/or vaccination for specific infectious diseases before being allowed to work in high-risk areas. Particular attention should be paid to immune status, skin conditions and pregnancy in staff, as well as risk factors for specific groups of patients. These conditions may vary according to state/territory specific requirements and recommendations. Routine screening and assessmentRoutine screening at the start of employment occurs in three forms:
These principles for screening and immunisation also apply to any healthcare students, work experience students and volunteers who are likely to be exposed to potential risks. Pre-employment screening and immunisationPre-employment screening and immunisation requirements for healthcare workers can be determined using a risk classification system that assesses the exposure to blood and body substances. Work activities, rather than job title, must be considered on an individual basis when determining risk categorisation. All Category A healthcare workers (see Table C2.1) are required to be able to provide evidence of serological immunity or vaccination history. Acceptable evidence of protection includes a written record of vaccination signed by the provider and/or serological confirmation of protection. This does not include a statutory declaration. Table C2.1: Determining risk categorisation for pre-employment screening and immunisation
Source: Adapted by the Committee from NSW policy Occupational Assessment, Screening and Vaccination Against Specific Infectious Diseases PD2007_006.
C2.2.2 ImmunisationEmployers should take all reasonable steps to ensure that staff members are protected against vaccine-preventable diseases. Where healthcare workers may be at significant occupational risk of acquiring or transmitting a vaccine-preventable disease, a comprehensive occupational vaccination program should be implemented. Such a program should include:
Healthcare facilities should advise healthcare workers of the potential consequences if they refuse reasonable requests for immunisation. Such advice and refusal to comply should be documented. Duties may be modified if healthcare workers have a confirmed infection that may directly affect the risk of transmission of infection during exposure-prone procedures. This is determined at the local facility level. Vaccine refusal, contraindication to vaccination and vaccine non-response may be managed by ensuring appropriate work placements, work adjustments and work restrictions. Recommended vaccinationsThe most recent edition of The Australian Immunisation Handbook (currently NHMRC 2008) provides detailed information on immunisation schedules and vaccines. Staff vaccination programs should comply as much as possible with these schedules, which acknowledge that some circumstances may require special consideration before vaccination. Table C2.2: Recommended vaccinations for all healthcare workers
Source: Australian Immunisation Handbook Pre-vaccination screeningPre-vaccination screening is outlined in Section 1.3.4 of the Australian Immunisation Handbook, including a pre-vaccination checklist.27 Healthcare facilities should have education programs to support their immunisation policy and reinforce the need for compliance. C2.2.3 Staff recordsEmployers and healthcare facilities need to retain details of screening results and immunisations provided, including vaccine preventable disease history, date and results of serology, record of immunisations consented/ refused, date given and batch number, type and brand name of vaccine. Records need to be secure and accessible by authorised personnel when needed, updated when relevant events occur, and maintained in accordance with confidentiality and privacy laws. C2.3 Exclusion Periods for Healthcare Workers with Acute InfectionsEvery healthcare facility should have comprehensive written policies regarding disease-specific work restriction and exclusion, which include a statement of authority defining who can implement such policies. Any employee who has an infectious disease has a responsibility to:
These policies should encourage healthcare workers to seek appropriate preventive and curative care and report their illnesses, medical conditions, or treatments that can render them more susceptible to opportunistic infection or exposures. They should not penalise healthcare workers with loss of wages, benefits, or job status. The overarching principle for exclusion periods is that staff members should not come to work if they have signs or symptoms of a potentially infectious disease. Table C2.3: Staff exclusion periods for infectious illnesses
*Includes giardiasis, Shigella infection, Salmonella infection, Campylobacter infection Source: Adapted from Staying Healthy in Child Care - Preventing infectious diseases in child care - Fourth Edition Good practice pointNorovirus exclusion periods Healthcare workers should not return to work until diarrhoea and vomiting have ceased for 2 days. It is extremely important that healthcare workers comply with appropriate hand hygiene methods and stringent infection prevention and control practices upon return to work, as some studies have shown prolonged viral shedding with this infection. C2.4 Healthcare Workers with Specific CircumstancesHealthcare facilities need to assist healthcare workers experiencing circumstances that place them at greater risk of infection to develop management plans that ensure their well-being. Where a healthcare worker is known to be particularly susceptible to healthcare associated infections, work duties are assessed to ensure that the welfare of that person, patients and other healthcare workers is safeguarded. This may involve appropriate work placements, adjustments or restrictions, or deployment to a role involving less risk. Healthcare workers in this situation may require counselling on what tasks they can perform, what they should avoid and the possible impact of their work on their health. C2.4.1 Pregnant healthcare workersEmployers should provide information on the risks associated with pregnancy and should assist pregnant healthcare workers to avoid infectious circumstances that may present a risk to her or the baby. It is the responsibility of pregnant healthcare workers to advise their doctor and employer of their pregnancy; this information must remain confidential. All pregnant healthcare workers should adhere to standard and transmission-based precautions and ensure that they are appropriately vaccinated. However, pregnant healthcare workers should be given the opportunity to avoid patients with specific infections. For more information, refer to Section 2.3.2 of the Australian Immunisation Handbook. C2.4.2 Immunocompromised healthcare workersHealthcare workers with immune deficiencies are more at risk of acquiring infections. The type of employment they can undertake should include only duties that will minimise their exposure to infections. Predisposing conditions include neutropenia, disseminated malignancy and infections that produce immunodeficiency (for example, HIV). Refer to Section 2.3.3 of the Australian Immunisation Handbook for guidance on the immunisation of immunocompromised healthcare workers. C2.4.3 Healthcare workers with skin conditionsSkin integrity is the ultimate barrier to transmission of infectious agents. When staff members have damaged skin or weeping skin conditions (for example, allergic eczema, psoriasis, exfoliating dermatitis), they may be readily colonised by healthcare associated microorganisms and may become a vehicle for disseminating these organisms. Healthcare workers in this situation should be identified by personal history screening when they start employment, and need to be informed of the risks they may pose to patients. Any damaged skin must be appropriately covered before healthcare workers carry out procedures. Consideration must be given to providing these staff members with appropriate, individual PPE such as specific types of gloves, hand hygiene product and moisturising lotion. C2.5 Exposure-Prone ProceduresExposure prone procedures (EPPs) are invasive procedures where there is potential for direct contact between the skin, usually finger or thumb of the healthcare worker, and sharp surgical instruments, needles, or sharp body parts (for example, fractured bones), spicules of bone or teeth in body cavities or in poorly visualised or confined body sites, including the mouth of the patient. During EPPs, there is an increased risk of transmitting bloodborne viruses between healthcare workers and patients. A list of EPPs is in Section B5.3. The nature of EPPs can be categorised according to level of risk of transmission, in increasing order of magnitude. Table C3: Categories of exposure prone procedures
Source: DH/HP/GHP3. HIV Infected Health Care Workers: Guidance on Management and Patient Notification. London; 2005 C2.5.1 ResponsibilitiesEmployersEmployers must ensure that employees who perform EPPs have access to appropriate information, testing, training, counselling and vaccination programs. Serological testing may be provided by the healthcare facility or healthcare workers may choose to seek testing from outside sources. Healthcare facilities should aim to achieve voluntary compliance and self-disclosure by providing an environment in which healthcare workers know their confidentiality will be maintained. Under current notification requirements, medical practitioners or laboratories must notify the chief medical officer or state/territory health department of cases of HIV, HBV and HCV, by either name or code. A medical practitioner may be legally obliged to bring to the attention of the appropriate registration board any registered professional who is unable to practise competently or who poses a threat to public safety. Healthcare workers who need to modify their work practices because they are carriers of a bloodborne virus should be provided with counselling and, where practical, with opportunities to continue appropriate patient-care activities, either in their current position or in a redeployed position, or to obtain alternative career training. Healthcare workersHealthcare workers who undertake EPPs have a responsibility to know their infectious status with regard to bloodborne viruses such as hepatitis B virus, hepatitis C virus and HIV, and should be given relevant information about the tests available and encouraged to have voluntary testing.
Healthcare workers who carry a bloodborne virus and are not in these categories must not perform EPPs until specialist medical advice has been sought. Healthcare workers who are currently hepatitis B surface antigen (HBsAg) positive and hepatitis B DNA negative or hepatitis C antibody positive and hepatitis C RNA negative must obtain ongoing medical advice regarding their potential infectiousness and the appropriateness of their continued performance of EPPs. Healthcare studentsConditional registration may be required for students who have had to undertake modified training programs. This will require an undertaking that individuals who are known to carry HIV, HCV or HBV will report their infectious status at the start of their training and agree not to perform EPPs. Training courses that require the performance of EPPs should include information, counselling, opportunities for testing and career advice. Training institutions should counsel student healthcare workers carrying bloodborne illness capable of being transmitted through EPPs, against a career in any profession that may involve such procedures. C2.6 Occupational Hazards for Healthcare WorkersNeedlestick and other blood or body substance incidents are the main causes of occupational hazards for healthcare workers, including HIV, HBV and HCV. C2.6.1 Sharps injuriesHealthcare workers face the risk of injury from needles and other sharp instruments during many routine procedures.Injuries most often occur after use and before disposal of a sharp device, during use of a sharp device on a patient and during disposal (CDC 2009). There are many possible mechanisms of injury during each of these periods. Measures to help combat needlestick and other sharps injuries include: training and education on the risks associated with procedures and on the use of needlestick devices; and safer working practices (including adherence to proper handling and disposal procedures and ensuring that disposal containers are not overfilled [see also Section C1.5.1]). The use of devices with safety engineered protective features was mandated in the US in 2000 and has been associated with reduced rates of incidence of needlestick injuries (Jagger et al 2008). Despite difficulties in determining the direct impact of using safety-engineered devices compared to standard devices, safety-engineered devices are an important component in percutaneous injury prevention (Tuma & Sepkowitz 2006). Typically a sharps-injury campaign involves multi-modal strategies. As a result many studies that show a reduction in incidence of needlestick injuries with the use of safety engineered devices have also involved a combination of other intervention measures such as training and education, overarching healthcare facility policies and other technologies (Whitby et al 2008). Australia is the only country with well-developed systems of infection prevention and control and occupational health and safety that has not yet mandated the use of safety or retractable devices. Such mandates exist in the USA, Canada and most recently the European Union, including the UK. The current UK policy recommends the provision of medical devices that incorporate a sharps protection mechanism where there are clear indications that they will provide safe systems of working for healthcare workers. Consideration of economic and social costs, staff preferences, ease of use, and time required to train staff is necessary before widespread implementation of safety-engineered devices in Australia. In the meantime, if a facility chooses to use safety-engineered devices, introduction of the devices must be supported by a comprehensive training and education program. C2.6.2 Managing risk of exposureExposures that might place a healthcare worker at risk of hepatitis B virus, hepatitis C virus, HIV or human T-cell lymphotropic virus type I (HTLV-I) are percutaneous injury (for example, needlestick or cut with a sharp object) or contact of mucous membrane or non-intact skin (for example, exposed skin that is chapped, abraded, or affected by dermatitis) with blood, tissue or other potentially infectious body substances. Each healthcare facility requires a policy on the management of needlestick injuries, and on providing immediate post-exposure advice for sharps injuries and other blood or body substance incidents involving healthcare workers, as generic policies may not be relevant to individual settings (for example, access to care, especially after hours). Treatment protocols include removal of contaminated clothing, thorough washing of the injured area with soap and water; and flushing of affected mucous membranes with large amounts of water. Healthcare workers should be aware that they must report occupational exposures immediately. Post-exposure prophylaxisPost-exposure prophylaxis (PEP) is the medical response given to prevent the transmission of bloodborne pathogens following a potential exposure. PEP includes first aid, counselling including the assessment of risk of exposure to the infection, testing, and depending on the outcome of the exposure assessment, the prescription of antiretroviral drugs, with appropriate support and follow-up (WHO 2008).
Standard guidelines for pre-test counselling or pre-test discussions for HIV, HBV and HCV must be followed when testing the source and the healthcare worker. Specific guidance on PEP can be found in WHO guidelines (WHO 2008) and CDC (2005). The ASHM guidelines are relevant to non-occupational exposure but include references to jurisdictional guidelines for occupational exposure (see Section C7 for links). C3 Education and trainingSummary
C3.1 Universities and Training CollegesAll healthcare workers need to understand the basis and importance of infection prevention and control. Up-to-date information on infection prevention and control basics, policy, procedures, quality assurance and incident monitoring should be included in the curriculum of all undergraduate and postgraduate courses in health-related areas. Universities and training colleges also have an obligation to inform prospective students about the impact that particular infections may have on their ability to complete the course and engage in the full spectrum of clinical practice after graduation (see Section C2). This information should include advice about specific measures, including immunisation, that reduce the risk of acquiring infection. C3.1.1 Education of infection control professionalsWhile some states in Australia have requirements for practising as an infection control professional, there is currently no minimum or standardised educational requirement to practice as an infection control professional, or to coordinate an organisational IPC program. A range of postgraduate education programs are currently available for nurses seeking or establishing a career in infection control in Australia, although the content of these courses is variable. Good practice pointEducation of infection control professionals Postgraduate education gives infection control professionals the necessary expertise to fulfil the role. Specific professional development should be supported at all levels. Case study – Requirements for infection control professionals in Tasmania [21]Senior infection control professionals (for example, at Clinical Nurse Consultant or Clinical Nurse Manager level) must have adequate skills including:
Infection control professionals at clinical nurse or clinical nurse specialist level must:
C3.2 Healthcare Worker EducationHealthcare facilities should provide specific education and training for all healthcare workers and students about infection prevention and control principles, polices and procedures that are relevant to the facility. The aim is to inform and educate healthcare workers about the infectious hazards they will face during their employment, and their role in minimising the spread of infection to others. Special attention should be given to advice about hand hygiene (see Section C3.4). The role of clinical educators in providing this education needs to be supported, as they provide a vital link between teaching and healthcare facilities. At a minimum, all staff (both clinical and non clinical) should be educated about:
This information should be provided in the context of their roles in the organisation or practice, and with a focus on respecting and maintaining patient confidentiality at all times. It should be provided as part of their orientation, with periodic updates and refresher courses as required for their specific jobs. Healthcare workers may also require job or task-specific education and training, such as:
Job-specific training should be provided as part of orientation, when new procedures affect the employee's occupational exposure, before rostering to hazardous areas (for example, caring for patients on airborne precautions in a negative pressure room); and at a minimum, in annual refresher courses. Healthcare workers should be assessed to ensure that they are competent in using and consistently adhering to the specific infection prevention and control practice. Healthcare facilities should maintain records of participation by healthcare workers in infection prevention and control education programs. C3.3 Education StrategiesThe term 'educational strategies' encompasses a wide range of commonly applied interventions that aim to bring about and sustain changes in the practice of healthcare workers. A review was undertaken to inform the development of these guidelines, identifying relevant systematic reviews of educational interventions in general healthcare settings and, more specifically, where education has been used to reduce healthcare associated infections and improve hand hygiene in the workplace. Examples of education activities include:
While the overall findings of the reviews were inconclusive, they did identify some consistent trends:
Education activities can be integrated into staff orientation programs, credentialling packages, annual training and competency testing, implementation of policy and procedure manuals, and in decision support tools available on the facility intranet. The infection control professionals' contact details should be readily available to all staff and included in all resources. E-learning (for example, interactive web-based training) is being used in some states, and may be a useful addition to other education strategies. For example, the Queensland Health Clinician Development Education Service offers interactive flexible on-line learning programs across a wide range of topics, including infection prevention and control, which are available 24 hours a day from work or home. C3.4 Example of Education in Practice - hand hygieneHand hygiene is the most important of the infection prevention and control strategies. According to the Hand Hygiene Australia Manual, healthcare workersmust perform hand hygiene before and after every patient contact to prevent patients becoming colonised with pathogens from other patients and the healthcare facility environment. Emphasis must also be placed on preventing the transfer of organisms from a contaminated body site to a clean body site during patient care. The latest guidelines also recommend hand hygiene after contact with inanimate objects, including medical charts and equipment in the immediate vicinity of the patient. Hand hygiene is a good example of the role of education in efforts to improve infection prevention and control practice. Although the concept of hand hygiene is straightforward, improving hand hygiene practices involves changing attitudes and behaviour among healthcare workers. Numerous barriers to appropriate hand hygiene have been reported, several of which reflect lack of understanding and knowledge (Grayson et al 2009):
As discussed in Section B1.1, the use of alcohol-based hand rub, coupled with changes in the recommended indications for hand hygiene and a change in attitudes and behaviour of healthcare workers provides the best approach to preventing HCAI transmission. C3.4.1 National Hand Hygiene InitiativeRecent hand hygiene programs in Victorian hospitals have led to significantly increased compliance with hand hygiene (Grayson et al 2008; Johnson et al 2005). These were comprehensive culture-change programs involving widespread availability of alcohol-based hand rubs in clinical areas and targeted education of healthcare workers. The National Hand Hygiene Initiative (NHHI) coordinated by ACSQHC is based on the above studies and the WHO '5 moments' program. It aims to implement a national approach to improving hand hygiene and monitoring its effectiveness. In the initiative, healthcare worker education is a key component of a multi-modal intervention strategy, involving basic educational sessions for all healthcare workers, including:
As well as introductory educational sessions, a program of formal regular sessions and updates is recommended, taking the form of specific orientation programs, in-service lectures or special workshops. All education sessions are supported by an online training package, DVD, video demonstrations of each of the five moments, and slide presentations. Other opportunities for education include:
For healthcare workers, a multi-modal approach is also recommended, led by hand hygiene champions who encourage all staff to act as role models for others. Other opportunities include regular scientific presentations at surgical and medical meetings, including Grand Rounds, and regular attendance by infection prevention and control staff at medical ward rounds. All healthcare workers should be regularly assessed for their hand hygiene compliance and be provided with rapid feedback of results (see 3.5.1). Other measures to increase compliance with hand hygiene are discussed in Section C6. C3.5 Patient EngagementInforming patients and carers about infection prevention strategies and taking their experience and feedback into account are pivotal to safe and effective clinical care. Patient engagement is not just about giving information, it is a process of informing, listening and interacting that gives patients the skills and knowledge to be actively involved in their own health care, give feedback and participate in quality improvement activities. Through open, respectful interactions with healthcare workers, patients and carers can be given information and support to ensure that they are able to maintain a safe environment in which they receive their care (for example, information on caring for wounds, basic advice on hand hygiene and spread of infection). Written material (such as brochures and posters) can be used to reinforce verbal discussions with patients as part of their care. Examples of useful instructional materials for patients and visitors include:
Patient engagement is especially important in the event of a gastroenteritis or influenza outbreak or entry into a ward that houses immunosuppressed patients. C3.6 Compliance and AccreditationC3.6.1 AuditingAuditing of healthcare worker behaviour is important for surveillance and accreditation, and to reinforce positive signs of culture change within the facility. Auditing to measure compliance with infection prevention and control policies and procedures can occur through:
Timely feedback is a critical aspect of auditing. In acute-care settings, measurement and feedback generally occurs at ward level. C3.6.2 Accreditation and credentialingAICA (Australian Infection Control Association), the peak national body representing the interests of the specialist practice of infection prevention and control within Australia, recommends certificated credentialing of infection control professionals. This is a self-regulatory process to determine and acknowledge that an individual has demonstrated prescribed competence of the relevant specialist nursing role. C3.6.3 Mentoring, support and networkingWhile there are no formal mentoring programs in place, many infection control professionals provide mentoring to less experienced staff. Mentoring requires the support of health facility administrators, so that it is recognised as being part of healthcare worker core time, but additional to their workload. Mentoring can also take place more broadly, as illustrated in this case study. Mentoring of infection control professionals in TasmaniaThe Tasmanian Infection Prevention and Control Unit established a forum for infection control professionals to get together every two months. All infection control professionals working in acute hospitals are encouraged to join in via video conference. Each forum, three to four infection prevention and control related research papers are presented and discussed. Each infection control professional is expected to present one paper in a 12-month period. Included in the forum is discussion around current issues faced or new developments in the world of infection prevention and control. There are networking and support forums available through AICA and the AICA state and territory affiliated associations, as well as region-based forums, and infection control professionals can also use other informal networks and contacts with other infection control professionals C4 Healthcare-Associated Infection SurveillanceSummary
Many infections can be prevented using approaches based on quality and safety theories such as:
To be successful, all these approaches need to be based on comprehensive information obtained through surveillance – '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' (CDC 2001). All healthcare facilities require healthcare-associated infection surveillance systems – local data collection that results in timely feedback has been shown to reduce infection rates. Note: Unless otherwise specified, this section is drawn from the ACSQHC report Cruickshank M & Ferguson J (eds) (2008) Reducing Harm to patients from Health care Associated Infection: The Role of Surveillance. Australian Commission for Safety and Quality in Health Care. C4.1 Role of Surveillance in Reducing HAISurveillance is important for wider systems of quality management, but the main purpose of collecting reliable data is to improve quality within a service or facility. Collecting such data can provide the impetus for change and make it possible to evaluate the effectiveness of an intervention. For example, monitoring both hand hygiene compliance and the rate of bloodstream infections, and disseminating the information within the facility, can improve hand hygiene practices. Surveillance of healthcare-associated infections draws information about the agent, host, environment and risk factors from a number of data sources:
There is a surveillance cycle, described as 'data collection–data analysis and interpretation–data dissemination' (Rothman et al 1998). All healthcare facilities, including small acute-care facilities and office practices, should collect data on healthcare-associated infections, infection prevention and control breaches, outbreaks of infectious disease and antibiotic resistance. Post-discharge surveillance by community-based healthcare practices should also be considered. The surveillance system used by a healthcare facility depends on the type and size of the facility, its case mix, and the resources available. C4.2 Types of Surveillance ProgramsIt is not feasible to conduct facility-wide surveillance for all events; therefore surveillance is often targeted, with a focus on specific events, processes, organisms, medical devices or high-risk patient populations. Healthcare-associated infectionssurveillance programs may focus on:
There are two main methods of surveillance – process and outcome.Process measurements are usually easier to measure, less ambiguous and more widely applicable than outcome indicators. Process surveillance may be an adjunct to outcome surveillance; alternatively, it can entirely replace outcome surveillance for practices or locations that have too few adverse outcomes for statistical analysis (for example, small facilities where the number of patients at risk of infection may be too small to calculate valid infection rates). C4.2.1 Process surveillanceProcess surveillance involves auditing practice against a certain standard, guideline or policy. As no single intervention will prevent any healthcare-associated infection, packages of evidence-based interventions have been developed and are increasingly being used in process surveillance (for example, care bundles, see also Sections B4 and C1.5). Process measures that are linked by evidence to important outcomes (McKibben et al 2005):
Examples of published process indicators of high value include:
C4.2.2 Outcome surveillanceOutcome surveillance involves measuring adverse events, a proportion of which are preventable. The sensitivity and specificity of event definitions and the reliability of data collection need to be considered when developing methods to detect adverse events. It is important to create a balance between avoiding false positives (specificity) and picking up true positives (sensitivity), given that true positives are rare events in the overall patient population. Certain outcome measures – for example, the incidence of healthcare-associated MRSA bacteraemia – appear to be reliable and have driven practice change, leading to significant improvements in patient safety. Outcome surveillance with laboratory-based data is used in the signal events system that was designed by Queensland and is implemented in Queensland and South Australia (see also Section C5.3). However, Australia currently has no system-wide approach to measurement of patient mortality caused by or associated with HAI. These deaths are unlikely to be reported using existing mechanisms such as adverse event reporting systems. Mortality from infection may be seen as 'anticipated' even though the occurrence of the infection that led to the death was unanticipated. A further challenge in measuring patient deaths is differentiating between patients who die with a healthcare-associated infection and those who die from a healthcare-associated infection or suffer serious injury due to a healthcare-associated infection (that is, attributable injury or death). One new approach is to evaluate such patient deaths to determine whether mortality was unexpected, and then analyse the contributing factors to determine preventable root causes that might be modified in future. In this approach, infection events (usually deaths or BSI) are considered and investigated individually. Although mandated by the UK's National Health Service, evidence of the value of this approach is lacking. C4.2.3 Critical incidentsIf there has been a breakdown in an infection prevention and control procedure or protocol, a 'lookback' investigation may be necessary to identify, trace, recall, counsel and test patients or healthcare workers who may have been exposed to an infection, usually a bloodborne virus. Lookback investigations must be managed with due regard to ethical and legal considerations. In the event of such an incident (for example, failure of sterilisation or disinfection), the local public health unit should be advised immediately.[22] Monitoring of critical incidents and other sentinel events is an important part of surveillance. Root cause analysis of sentinel events is a structured process for identifying the process and contributing factors, exploring and identifying risk reduction strategies and implementing solutions (see Section C1.4.2). C4.3 Data Collection and ManagementSurveillance involves:
The following epidemiologic principles should be applied during healthcare-associated infection surveillance:
Surveillance data for quality improvement must be of high quality. The characteristics that qualify data as evidence for action include (Booth 1995):
Data of this nature are more likely to arise from surveillance processes:
C4.4 Outbreak SurveillanceAn outbreak may be defined as the occurrence of infections at a rate greater than that expected within a specific geographical area and over a defined period of time. Ideally, surveillance systems should facilitate the early detection of outbreaks. Increasingly, microbiological data are being relied on for this purpose, although outbreaks may be detected using other sources such as pharmacy records. In some instances, the occurrence of an outbreak is obvious, such as in an episode of food poisoning that affects both healthcare workers and patients. It is more usual, however, for the outbreak to have an insidious onset that is not immediately apparent. When an outbreak is detected, the infection prevention and control committee should be informed and an outbreak team formed. Depending on the size and severity of the outbreak, it may be necessary to involve occupational health and safety staff, facility administrators, engineers and public health officials. Details on the steps involved in the management of an outbreak are provided in Section B3.2. Legislation requires that the relevant public health authority be informed of outbreaks related to notifiable infections. It may also be prudent to involve public health officers at an early stage, if an outbreak is likely to come to the attention of the media. The principles for investigating outbreaks in healthcare facilities are the same as for community-based outbreaks. There are three basic steps:
The tasks involved in any investigation can be summarised as follows:
In the interests of public safety (and because of the threat of litigation), all outbreaks, however minor, should be investigated thoroughly and the outcomes of such investigations documented. All institutions should therefore have adequate resources for the detection and control of outbreaks. C4.5 Disease Surveillance in Office-Based PracticeAll staff members in office-based practices need to be aware of the possibility that patients will present with suspected or confirmed infectious diseases. For certain diseases, timely notification to the relevant authority will be required, sometimes by telephone. Systems need to be in place so that authorities are able to trace those with whom infectious patients have been in contact. A staff member should be responsible for checking national and state websites for relevant guidelines (RACGP 2006). In most office-based practices, there will not be enough procedures performed to undertake outcome surveillance. Process surveillance can be used to evaluate processes and procedures and to monitor sentinel events. Systems should be in place for monitoring for threats of outbreaks (for example, chickenpox [varicella], measles [rubeola]) and emerging diseases (for example, H1N1, community-acquired MRSA [CA-MRSA]). C4.6 Notifiable DiseasesNotifiable diseases in Australia are listed on the Department of Health website. Certain diseases are listed as quarantinable under the Quarantine Act 1908 (Commonwealth) and its proclamations. These include yellow fever, cholera, plague, rabies and four viral haemorrhagic fevers (Crimean–Congo, Ebola, Lassa and Marburg). Quarantinable diseases are also notifiable and public health authorities in the relevant jurisdiction must notify their Chief Medical Officer. C4.6.1 Notifiable diseasesNotifiable diseases in Australia are listed on the Department of Health website. Certain diseases are listed as quarantinable under the Quarantine Act 1908 (Commonwealth) and its proclamations. These include yellow fever, cholera, plague, rabies and four viral haemorrhagic fevers (Crimean–Congo, Ebola, Lassa and Marburg). Quarantinable diseases are also notifiable and public health authorities in the relevant jurisdiction must notify their Chief Medical Officer. C4.6.2 State and territory health departmentsPublic health legislation in each state and territory mandates the reporting of certain diseases by medical practitioners, hospitals, and/or laboratories to the relevant state or territory Communicable Diseases Unit. Notifications are collected at the state/territory level, and computerised, de-identified records are sent to the Australian Government Department of Health and Ageing for collation into the National Notifiable Diseases Surveillance System (NNDSS) for analysis at a national level. NNDSS was established in consultation with the Communicable Diseases Network Australia (CDNA). Links to state and territory public health legislation can be found on the Department of Health website. C5 Antibiotic StewardshipSummary
Notes: This section is drawn from Cruickshank M & Ferguson J (eds) (2008) Reducing Harm to patients from Health care Associated Infection: The Role of Surveillance. Australian Commission for Safety and Quality in Health Care. For further information on definitions and reporting mechanisms please refer to this report. C5.1 BackgroundThere is a well-documented relationship between prior antibiotic usage and the emergence of bacterial resistance (McGowan 1987).WHO and other international bodies have nominated antibiotic resistance as a major public health concern, and the ACSQHC has established a national Antibiotic Stewardship Program to facilitate the establishment of effective antibiotic stewardship programs at national, state, healthcare facility and community levels. The use of particular antibiotic classes is linked with the emergence and amplification of specific multi-resistant pathogens, particularly C. difficile, MRSA, VRE and multi-resistant Gram-negative organisms. If unchecked, high levels of antibiotic usage increase the number of patients who are colonised or infected with resistant organisms, both in healthcare facilities and in the community (Cosgrove & Carmeli 2003; van de Sande-Bruinsma et al 2008). C5.1.1 In healthcare facilitiesComparison with international data shows that Australian antibiotic usage rates in healthcare facilities are high for some classes of drugs, and there is considerable unexplained variation between hospitals in the use of certain antibiotics, particularly broad-spectrum antibiotics (NAUSP 2007). Month-to-month variation in use of specific antibiotic classes has been shown to correlate closely with subsequent variation in antibiotic resistance (for example, changes in hospital MRSA incidence) (Lopez-Lozano 2000). Problems resulting from inappropriate use of antibiotics apply to both current and future healthcare facility patients due to changes in healthcare facility microbial ecology resulting from the resistance. Additional costs of infections caused by resistant organisms include:
C5.1.2 In the communityIn the 1990s, community antibiotic use in Australia was high compared with other developed nations(McManus et al 1997). Today, multi-resistant bacteria, such as community strains of MRSA (CA-MRSA) and extended-spectrum beta-lactamase-producing Gram-negative bacteria, are causing increasing human morbidity and there is concern that past excessive antibiotic use in the community or in animal production systems (or both) is responsible. National Prescribing Service (NPS) targeting of antibiotic prescribing contributed to a significant decline in antibiotic prescribing between 1999 and 2004 (NAUSP 2008), but this decline has not been sustained. There is currently no comprehensive system to monitor changes in resistance prevalence as a result of altered prescribing patterns. Most monitoring is done at the institutional level, except in Queensland, which has a system for monitoring resistance in its public hospitals. C5.1.3 What is antibiotic stewardship?Antibiotic stewardship aims to optimise antimicrobial use among patients in order to reduce antibioticresistance, improve patient outcomes and safety, and ensure cost-effective therapy. At the healthcare facility level, antibiotic stewardship involves:
C5.2 Antibiotic Stewardship ProgramsIntervention programs that restrict the use of broad-spectrum antibiotics have shown dramatic effects in optimising antibiotic prescribing. Successful antibiotic stewardship programs have been associated with reduced facility resistance rates as well as morbidity, mortality and associated costs of these and some Australian hospitals have also demonstrated significant cost savings through reduction in drug costs. The density of antibiotic use within specialised units such as intensive care units, haematology and oncology units, and solid-organ transplant units is several-fold higher than in other hospital settings. This increased use has been shown to generate high rates of antibiotic resistance; therefore, these areas should be a particular focus for surveillance and intervention. Key requirements of a healthcare facility antibiotic stewardship program are listed in Table C4. Table C4: Key requirements of a healthcare facility antibiotic stewardship programEssential strategies for all healthcare facilities
Case study – effect of an active antibiotic stewardship programA large tertiary teaching hospital in New South Wales has had an active approach to antibiotic stewardship for many years. It is underpinned by locally relevant antibiotic guidelines and enthusiastic staff in the areas of pharmacy, infectious diseases and microbiology. Clinical teams are regularly engaged in guideline review, development and implementation at local and national levels. Specific discussions about patients are prompted by an online anti-infective registration (approval) system, where clinicians who prescribe broad-spectrum agents register the indication for use and are advised on correct dosage. Twice-weekly infectious diseases and microbiology patient rounds take place in ICUs. These frequently lead to changes in antibiotic therapy, generally to early cessation. A drug usage evaluation pharmacist regularly audits antibiotic use for particular agents or clinical syndromes or situations, mainly community-acquired pneumonia and surgical prophylaxis. These audit data are used to provide feedback to clinicians to encourage more appropriate use. Monthly data on usage are supplied to the National Antimicrobial Utilisation Surveillance Program. This allows for benchmarking of intensive care unit and non-intensive care usage against other large Australian hospitals. A study of usage of selected high-cost (predominantly broad-spectrum) antibiotics in 2006 indicated that, for most agents, use in intensive care unit and non-intensive care situations in this hospital was far lower than the national average. Based on purchase cost alone, the net cost difference in 2006 was $278,000 ($59,000 of this was for intensive care unit use). C5.3 Antibiotic Stewardship Surveillance MethodsC5.3.1 Healthcare facilitiesThere are two main methods of antibiotic data collection in healthcare facilities: patient level surveillance and population surveillance.
South Australia and Queensland have programs for state-wide monitoring of antibiotic usage. The National Antimicrobial Utilisation Surveillance Program provides bi-monthly reports on hospital inpatient antibiotic usage to contributing hospitals, and bi-monthly reports to the Australian Department of Health and Ageing. Data are contributed by 50% of principal referral hospitals from six states, which is currently 42% of major city principal referral centres. C5.3.2 CommunityMeasurement of community antibiotic use is generally based on prescription data. In Australia, this is collected from two sources: Medicare Australia records of prescriptions submitted for payment under the Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS); and an estimate of non-subsidised medicines obtained from an ongoing survey of a representative sample of community pharmacies. These data also include antibiotics dispensed to outpatients and discharged patients in most states. C6 Influence of Facility Design on Healthcare-Associated InfectionSummaryThe design of a healthcare facility can influence the transmission of healthcare-associated infections by air, water and contact with the physical environment. Key design features that minimise the transmission of infection include:
C6.1 Facility Design and its Impact on Infection Prevention and ControlInfection prevention and control requirements are critical to the planning of a healthcare facility and need to be incorporated into plans and specifications. All areas of a healthcare facility should be designed, constructed, furnished and equipped to minimise the risk of transmission of infection. In particular, the design and layout of the facility should facilitate the application of standard and transmission-based precautions by all staff. C6.1.1 Evidence on the influence of environmental design on healthcare-associated infectionThere are few randomised controlled trials relevant to the effects of specific design features or interventions on health outcomes. However, from case reports, published literature relating to outbreaks and from a theoretical risk-management perspective, it is clear that the design of buildings can have an impact on rates of HAIs. Reliable patterns across several studies emerged, which were broadly consistent with predictions based on established knowledge and theory concerning environment and healthcare outcomes. However, it is difficult to distinguish the independent effect of any environmental factor, as most changes of the physical environment in healthcare settings alter several environmental factors simultaneously. For example, renovating an intensive care unit with two-bed patient rooms to create single-bed rooms would be likely to alter not only the number of patients per room, but also the ratio of hand-hygiene sinks per bed and possibly the room ventilation or air quality. C6.2 Mechanisms for Influencing Healthcare-Associated Infection Through Environmental DesignMany studies indicate that infection rates are lower when there is very good air and water quality, greater physical separation of patients and greater space per patient (with isolation where appropriate). C6.2.1 Reducing airborne transmissionReservoirs for airborne pathogens include (Ulrich & Wilson 2006):
Airborne transmission has also been implicated in outbreaks of other infections such as Acinetobacter and Pseudomonas spp. (Beggs 2003; Beggs et al 2008). Most pathogens in healthcare settings originate from patients, staff and visitors within the buildings. Other pathogens can enter buildings from outside air through dust that harbours pathogens such as Aspergillus, streptococci or staphylococci (Beggs 2003). There are also less common sources of airborne infections; for example, bird droppings or aerosols from contaminated water in a warm-water therapy pool (Angenent et al 2005). Approaches to airborne transmissionApproaches to reducing airborne transmission include:
In dental practices, engineering rules state there must be separation between inlet air for compressors and air conditioning outlets (ADA 2008). FiltrationAn effective way to prevent infections is to control the source of pathogens. Heating, ventilation and air-conditioning systems control the concentration of airborne particulates in high risk areas, to minimise the risk of infection by means of air pressure, flow control and air filtration (the physical removal of particulates from air). The level of control should be proportional to the risk. In acute healthcare settings, a commonly used approach to filtration is the HEPA filter (Streifel 1999). There is evidence that there is a lower incidence of infection when immunocompromised and other high-acuity patients are housed in HEPA-filtered isolation rooms. HEPA filters must comply with AS 1324 and AS 4260. Ventilation systems and airflow controlOptimal ventilation rates, airflow patterns and humidity can help to minimise the spread of infection.
Maintenance systemsVentilation and airflow control systems need to be maintained regularly by suitably qualified staff according to an agreed maintenance plan, and accurate documented in a maintenance record. Maintaining air quality during construction or renovationEffective control and prevention measures are necessary during construction and renovation within a healthcare facility, because such activities have been frequently implicated in outbreaks of airborne infection. The key to eliminating infections is to minimise the dust generated during the construction activity and to prevent dust infiltration into patient-care areas near the construction. Examples of such measures include installing barriers between patient-care areas and construction/renovation areas, generating negative air pressure for construction/renovation areas relative to patient-care areas, using portable HEPA filters and sealing patient windows. For more information, refer to Public Health Agency of Canada guidelines from 2001, Construction-related Nosocomial Infections in Patients in Health Care Facilities:(link is external)Decreasing the Risk of Aspergillus, Legionella and Other Infections, which contain a risk assessment and preventive measures checklist. C6.2.2 Reducing infections spread through the physical environmentThe prevention of contact-spread infections is of paramount importance in healthcare settings. Contact contamination is generally recognised as the principal transmission route of healthcare acquired infections, including pathogens such as MRSA, C. difficile and VRE, which survive well on environmental surfaces and other reservoirs. Environmental routes of contact-spread infections include direct person-to-person contact and indirect transmission via environmental surfaces. Reducing surface contamination through hand-hygiene complianceHealthcare workers' hands play a key role in both direct and indirect transmission (see Sections B1.1 and C3.4). Given the importance of maximising hand-hygiene compliance, it is absolutely essential that all areas of the facility are designed to facilitate compliance with hand-hygiene requirements. AccessibilityConveniently located alcohol-based product dispensers, sinks and basins can facilitate healthcare worker compliance with hand-hygiene requirements (Grayson et al 2009). Hand-hygiene compliance can be increased by providing a greater number of alcohol-based product dispensers, particularly if they are placed in appropriate locations (where clinical care is provided [e.g. bedside] or where indirect care tasks are performed). Other aspects of design that may increase compliance include automated dispensers of hand-hygiene products, electronic monitoring and computerised voice prompts. Alcohol-based handrub dispensers need to be suitably located out of the reach of children, or in supervised locations. Placement of dispensers must be carefully considered in mental health facilities and alcohol withdrawal units. Further guidance is available from HHA. Consideration needs to be given to ensuring availability of basins for healthcare workers that are separate from patient bathrooms. As well as being installed in all patient-care areas, hand-hygiene facilities should be placed in all areas where careful attention to hygiene is essential, such as kitchens, laundries, pharmacies, laboratories and staff amenities areas (for example, bathrooms, toilets and change rooms). Personal protective equipmentIt is also essential that all areas of the facility are designed to facilitate appropriate use of PPE. All rooms should have dedicated and accessible areas for storage of gowns, aprons, gloves, masks and protective eyewear. C6.2.3 Control of surface contamination through material selectionEase of cleaning should be a key consideration in selecting appropriate floor and furniture coverings. Several design-related factors should be considered to minimise the risk of infection stemming from contaminated surfaces:
Areas that may be in direct contact with blood and body substances (for example, surfaces such as floors and bench tops) need to be made of impervious material that is smooth and easy to clean. Healthcare flooringA wide range of floor covering materials is used in healthcare settings. These include but are not limited to: ceramic tiling, linoleum, rubber, textile floor covering, vinyl, sheet terrazzo, cork, timber laminates, mats and matting, cementinous toppings, seamless coatings and outdoor flooring. Floor coverings have not been generally related to healthcare associated infection. Some studies have identified carpeting as susceptible to contamination by fungi and bacteria (Anderson et al 1982; Boyce et al 1997; Skoutelis et al 1994; Beyer & Belsito 2000). When selecting floor covering for a health care setting consideration needs to be given to the following:
In terms of infection prevention and control, the advantages of hard floor coverings include:
However, carpeting may offer advantages unrelated to infection prevention and control, including noise reduction (Philbin & Gray 2002). Textile floor finishes should not be considered unless there is a comprehensive maintenance and replacement program in place complying with AS/NZS 3733. Care and maintenance of floor covering need to consider manufacturer's recommendations. Carpeting should be avoided in areas where (Sehulster & Chinn 2003):
FurnishingsNoskin et al (2000) identified fabric-covered furniture as a source of VRE infection in hospitals and suggested the use of easily cleanable, nonporous material. A study comparing the performance of a variety of furniture upholstery types with respect to VRE and Pseudomonas aeruginosa (PSAE) contamination (Lankford et al 2006) found that performance was similar across different furniture coverings in terms of reductions in VRE and PSAE after cleaning and the transfer of VRE and PSAE to hands through contact. However, while there were no differences in the ability of different upholstery types to harbour PSAE, the VRE pathogen survived less well or for shorter periods on vinyl (Lankford et al 2006). The CDC/HICPAC guidelines (Sehulster & Chinn 2003) recommend minimising the use of upholstered furniture in areas housing immunocompromised patients. Blinds and curtains should be easy to clean and discourage the accumulation of dust. C6.2.4 Reducing water-borne transmissionCompared with airborne and contact transmission of infection, fewer studies were identified on waterborne transmission in relation to healthcare facility design factors. The literature nonetheless is clear that waterborne infections can be a serious threat to patient safety. Many bacterial and some protozoal microorganisms can proliferate or remain viable in moist environments or aqueous solutions in healthcare settings (Sehulster et al 2004). Contaminated water systems in healthcare settings (such as inadequately treated wastewater) may lead to the pollution of municipal water systems, enter surface or ground water, and affect people in the community (Iversen et al 2004). Sources of water contaminationThe CDC/HICPAC guidelines (Sehulster & Chinn 2003) identify the following categories of environmental routes or sources of waterborne transmission:
Approaches to reducing waterborne transmissionWater supply systemThe water supply system should be designed and maintained with proper temperature and adequate pressure; stagnation and back flow should be minimised and dead-end pipes should be avoided. To prevent the growth of Legionella and other bacteria, the CDC/HICPAC guidelines recommend that healthcare facilities maintain cold water at a temperature below 20°C, store hot water above 60°C, and circulate hot water with a minimum return temperature of 51°C (Sehulster & Chinn 2003). When the recommended standards cannot be achieved because of inadequate facilities that are unable to be renovated, other measures such as chlorine treatment, copper-silver ionisation, or ultraviolet lights are recommended to ensure water quality and prevent infection (Sehulster & Chinn 2003). Point-of-use fixturesWater fixtures such as sinks, faucets, aerators, showers, and toilets have been identified as potential reservoirs for pathogenic microorganisms (Blanc et al 2004; Conger et al 2004; Mineshita et al 2005; Squier et al 2000). Such fixtures produce aerosols that can disperse microbes and they have wet surfaces on which moulds and other microorganisms can proliferate. However, empirical evidence linking these fixtures to HAIs is still limited; no consensus has been reached regarding the disinfection or removal of these devices for general use (Sehulster et al 2004). Regular cleaning, disinfection and preventative maintenance programs should be provided, especially in areas housing immunocompromised patients. Ice machinesIce storage receptacles and ice-making machines should be properly maintained and regularly cleaned. Ice and ice-making machines may be contaminated through improper handling of ice by patients and/or staff. Ice for human consumption should be differentiated from ice for first aid or storage of clinical specimens. Pharmaceuticals or medical solutions should not be stored on ice intended for consumption. Machines that dispense ice are preferable to those that require ice to be removed from bins or chests with a scoop. Ice machines and their dispensers should be flushed and cleaned if they have not been disconnected before anticipated lengthy water disruptions. All ice-storage chests should be cleaned, disinfected, and maintained on a regular basis as per manufacturers instructions. Suggested steps to avoid improper handling of ice include (Sehulster & Chinn 2003):
Water featuresDespite the absence of empirical documentation linking properly maintained fountains to healthcare-acquired infections, the AIA & FGI Guidelines (2006) recommend that fountains not be installed in enclosed spaces in healthcare facilities. C6.3 the Benefits of Single-Bed Rooms for Patient IsolationThe three routes of transmission often overlap, and environmental approaches may influence more than one transmission route. For example, single rooms play a key role in preventing a patient with a contagious or aerial spread infection from infecting others, and also protect immunocompromised patients in nearby patient-care areas from airborne pathogens.
International bodies including the American Institute of Architects recommend that acute-care facilities have 80% single-bed rooms. This recommendation is being implemented in a number of current hospital redevelopments (for example, Royal Canberra Hospital, Royal Perth Hospital) and should be considered during planning for redevelopment of any acute healthcare facility. AnteroomsAnterooms enable visitors and healthcare workers to change into and dispose of appropriate PPE when caring for an infectious patient. Anterooms increase the effectiveness of isolation rooms by reducing the potential escape of airborne infectious particles into the corridor. Ideally the pressure in the anteroom is lower than that of ambient pressure in the adjacent corridor (AusHFG). C6.4 Construction and RenovationInfection prevention and control precautions during construction and renovation should be integrated into the design and documentation of the facility from the beginning of the design stage. It is important that the dust control and infection prevention and control principles developed during the pre-design stage are integrated from the initial stages of design development until the completion of the activity. Identification of the 'at risk' population, knowledge of the transmission route of a likely pathogen and location of the 'at risk' population all need to be taken into account in the planning stages. C6.4.1 Risk managementThe risk-management approach should, as a minimum:
Refer toSection D of the Australasian Health Facility Guidelines (AusHFG) for further guidanceand the definition of infection prevention and control risk, location/area table and infection prevention and control strategies. C7 ResourcesC7.1 Management and Clinical GovernanceC7.2 Staff Health and SafetyOccupational health and safetyPre-employment screening and ImmunisationLegislation/ policyEach state and territory has numerous legislation/ Acts relating to occupational health and safety, workers compensation and the employers responsibility to provide a safe work environment. Immunisation of health care workers is an aspect of occupational health and safety in the health care setting. Each state has its own policies, examples are provided below: Guidelines
Exposure to blood and blood productsLegislation/codes of practice
Each state has its own policies, examples are provided below: Post-exposure prophylaxisGuidelinesC7.3 Education and TrainingC7.4 SurveillancePolicies
Notifiable diseasesC7.5 Antimicrobial StewardshipNational Antimicrobial Utilisation Surveillance Program (NAUSP) C7.6 Facility DesignMore detailed information on facility design is available from the following sources. State and territory department of health policies also provide information. GuidelinesInternational literatureGeneralStandards
C8 References
Appendix 1: Membership and Terms of Reference of the Working CommitteeMembers
Terms of ReferenceThe Infection Control Steering Committee (the Committee) will oversee and provide expertise in the revision of the Infection control guidelines for the prevention of transmission of infectious disease in the health care setting (2004) (the Guidelines).
Appendix 2: Process ReportThe NHMRC was approached by the Australian Commission on Safety and Quality in Health Care (the Commission) in November 2007 to review and update the Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting. These guidelines were produced by the Communicable Diseases Network Australia (CDNA) and released in 2004. The NHMRC revised guideline (the Guideline) aimed to provide a coordinated approach to the management of health care associated infection (HAI) in Australia by supporting the Commission's other HAI priority program initiatives including the:
The NHMRC developed a range of partnerships to support and assist in the guideline development process including the NHMRC's National Institute of Clinical Studies, CDNA, the Office of Health Protection in the Australian Government Department of Health and Ageing, the Commission and guideline users. The project plan for the revision of the guidelines was approved by the NHMRC Acting Chief Knowledge Development Officer on 25 January 2008. The Infection Control Guidelines Steering Committee (the Committee) was established under the NHMRC Act (1992) as a Section 39 committee, and was chaired by Dr Ann Koehler, the South Australian representative of the CDNA. The committee was first established with eight members, comprising of experts in microbiology and infectious disease, public health, Indigenous health as well as jurisdictional representatives and infection control professionals. During 2008, two Committee members resigned from the Committee (Ms Dolly Oleson and Ms Claire Boardman) but an additional five members were appointed to broaden the expertise of the Committee. The Committee from November 2008 until the completion of the project is outlined in Appendix 1. Appointment of technical writersAmpersand Health Science Writing was selected through a Request for Quote process from the NHMRC Technical Writers and Editors Panel. The two key personnel from Ampersand working on this project were Ms Elizabeth Hall and Ms Jenny Ramson, who participated in the forums and Steering Committee meetings to gain an understanding of the issues and the context of the infection control guidelines. ScopeThe Guideline targets clinicians, ancillary staff and administrators across Australia's various health care settings. Initial feedback indicated that the following health care settings should be considered when developing the guidelines:
As a means of addressing this broad scope of practice it was decided that the guidelines would be structured to address the 'core principles' of infection prevention and control and the underpinning key practice principles. The core principle of infection prevention and control is to prevent the transmission of infectious organisms and manage infections if they occur. The underpinning key practice principles include:
It is acknowledged there may be variation in some current practices due to differences in technology, resources and systems supporting a healthcare facility. To address this, a risk-management approach was adopted that considers how factors associated with the transmission of infectious agents can be identified and managed within various health care settings. This approach ensures that common infections such as gastrointestinal viruses and evolving infectious agents such as influenza or antibiotic resistant bacteria can be managed effectively using the principles of infection prevention and control. Preliminary scopingThe initial focus of the project was to liaise with stakeholders across a broad range of healthcare settings to identify the usefulness and applicability of the 2004 guidelines. This was managed through stakeholder surveys and a series of organised forums. The stakeholder survey was developed to allow participants and the organisations they represented to consider the issues prior to attending the forums. The survey was targeted towards state-based infection control professional associations, public health medical officers and the aged care accreditation alliance. This survey was circulated to stakeholders participating in forums to gather feedback on the guidelines and to organisations wishing to provide feedback but unable to attend the forums. Stakeholder forumsStakeholder forums were conducted in Sydney, Canberra and Melbourne in early March 2008, and were facilitated by Carla Cranny and Associates. In all, 59 representatives from various health care settings, the medical device industry, professional associations, health care funders and government agencies attended. The purpose of the forums was to gain feedback from stakeholders in the healthcare setting on the usefulness and applicability of the 2004 guidelines as well as identify gaps and areas of ambiguity in the guidelines. The forums identified:
Priority settingThe stakeholder forums identified several key areas the guidelines need to address. These issues relate to: emerging pathogens; screening and clearance of patients with MRO infections; areas where gaps in evidence resulted in variation in clinical practice; and medical device technology. Using the feedback from the forums, the Committee actively engaged with stakeholders across the healthcare setting to seek feedback on the priority areas the revised infection prevention and control guidelines should address. With significant input from the Australian Infection Control Association, the Committee carefully considered and systematically identified the priority areas of infection prevention and control that need to be addressed by the guidelines. The Committee developed a framework encompassing the broad scope of infection prevention and control activities across the health care setting. Priority areas identified at the forums and by the Committee were placed in the framework and then ranked according to which issues have the greatest impact on infection prevention and control. From this priority-setting exercise, the Committee identified the key issues that required further research. These issues formed the basis for the development of the clinical questions for systematic review. Systematic review of the evidenceThe recommendations for the Guideline were developed using a twofold approach.
Drafting of clinical questions for systematic reviewDr Adele Weston, a member of the NHMRC evidence-based medicine expert panel, attended the 12 May committee meeting to inform the members on the NHMRC systematic review process including how recommendations are drafted from the evidence. The clinical questions commenced being drafted at that meeting using the population, intervention, comparator, outcome, time (PICOT) approach. They were further refined, circulated and discussed via a series of teleconferences before being released in a Request for Tender in July 2008. The questions are outlined below. Table App2.1: Clinical questions for systematic review
The Request for Tender process was ultimately unsuccessful and systematic reviewers were approached using a Request for Quote or Direct Sourcing approach. The systematic reviews were conducted by the following:
A number of clinical questions that were identified as a priority were unable to be conducted due to resource constraints. These included:
Due to a paucity of evidence or low quality evidence some systematic reviews were not used to draft recommendations. These include: effectiveness of environmental cleaning agents;
Recommendations for these areas were drawn from existing guidelines and supported by expert opinion. The education review to identify strategies to improve hand-hygiene compliance was incorporated into Section C Governance structures,which contains no graded recommendations for practice. The systematic reviews for:
were conducted according to approved NHMRC processes and systematic review methodology with a documented search strategy, inclusion and exclusion criteria, critical appraisal methodology and summary of the evidence. These systematic reviews are provided below. The systematic reviewer summarised the questions and sub questions into the NHMRC template, which documents the evidence base (number of studies, level of evidence and risk of bias in the included studies), consistency, clinical impact, generalisability and applicability. Systematic review attachments: The NHMRC template was used by the Steering Committee to draft evidence statements and recommendations corresponding to the summary of evidence provided by the systematic reviewer. These evidence statements and recommendations are summarised below. The grades assigned by the systematic reviewers are documented with the corresponding grades assigned by the Committee. The grades were assigned by the Committee via teleconferences and meetings with the final recommendations and grading also outlined below. Dissenting opinions were noted. Development of recommendations from guidelines and standardsAs a part of the prioritisation process a mapping exercise was conducted to identify relevant guidelines and standards that existed nationally and internationally on infection prevention and control in the health care setting. Links to standards and legislation relevant to infection prevention and control that were identified will be included in Section D: Compliance with legislation and standards. It is envisaged that targeted and public consultation will provide more feedback in this section. For areas of established practice not covered by the systematic review, guidelines developed using rigorous methodology were used to adapt recommendations from for an Australian context. Guidelines were identified by a combination of literature searches, current use in practice and by the ICG Committee. Guidelines were selected according to their currency and clinical relevance and were appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument to assess the rigor with which they had been developed. The AGREE scores were calculated across the six domains and used to identify which guidelines to use. The NHMRC engaged numerous stakeholders identified during the forums and through the Commission to assist with the appraisal of the guidelines. Three reviewers per guideline with appropriate clinical experience in infection prevention and control, infectious diseases or guideline development reviewed each guideline. The reviewers included Committee members, the Commissions' Health Care associated Infection Implementation Advisory Committee and members of the Australian Dental Association. Reviewers were asked to rate an item on a scale of 1 to 4, with 1 being 'strongly disagree' and 4 being 'strongly agree'. Domain scores were calculated by summing up all the scores of the individual items in a domain and by standardising the total as a percentage of the maximum possible score for that domain. Generally, a higher score indicates the guideline rated well against the AGREE criteria. The six domains were:
An overall assessment and recommendation was provided by each reviewer. Guidelines selected to draft recommendations from were:
Relevant recommendations were drawn out of each approved guideline and categorised appropriately by the technical writers. These recommendations were circulated to committee members and additional infection prevention and control representatives in topic subgroups, to prioritise what should be used in the guidelines. Comments were collated by the NHMRC and the technical writers and the recommendations chosen for the guideline were refined at a face-to-face meeting. The approach taken to consensus setting was developed in consultation with NICS and comprised attributes of the Delphi and RAND/UCLA processes. These recommendations were prioritised and then regraded from their original guideline grading to an NHMRC grading based on matching criteria from the original guideline developers. The Committee considered these grades and dissenting comments were noted. The recommendations with their original grading and the assigned NHMRC grading are summarised in Attachment 2c of the full report. A preliminary draft was provided to jurisdictions for feedback in October 2009. A summary of the feedback and NHMRC responses is provided below. Feedback for Preliminary Draft Infection Control National Guidelines - distributed October 2009 (PDF 72KB) GlossaryThis section outlines the way in which certain terms are used in these guidelines.
Abbreviations and Acronyms
_____________________________ Footnotes[1] Membership and terms of reference of the Infection Control Steering Committee are given in Appendix 1. [2] Cruickshank M & Ferguson J (eds) (2008) Reducing Harm to patients from Health care Associated Infection: The Role of Surveillance. Australian Commission for Safety and Quality in Health Care. p3. [3] CDNA (2004) Infection Control Guidelines for the Prevention of Transmission of Infectious Disease in the Health Care Setting. Communicable Diseases Network of Australia.NHMRC (1996) Infection Control in the Healthcare Setting. Guidelines for the Prevention of Transmission of Infectious Diseases. National Health and Medical Research Council. Rescinded. [4] These guidelines were selected based on analysis using the AGREE tool, which ensures that guidelines have been developed in a rigorous, transparent and robust manner. This process is discussed in detail in Appendix 2. [5] Due to a paucity of evidence or low quality evidence some systematic reviews were not used to draft recommendations [6] Siegel JD, Rhinehart E, Jackson M et al (Health Care Infection Control Practices Advisory Committee) (2007) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007. United States Centers for Disease Control and Prevention. http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf [7] This action has a low impact in terms of measles because the virus is spread through airborne transmission. However, use of ABHR can have a high impact in reducing the spread of micororganisms transmitted via contact or droplet routes (eg norovirus, influenza). [8] Available at: http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/com-pubs_ACHR-roles/$File/17537-charter.pdf (for direct download) [9] These guidelines were selected based on analysis using the AGREE tool, which ensures that guidelines have been developed in a rigorous, transparent and robust manner. This process is discussed in detail in Appendix 2. [10] While it is acknowledged that 'donning' and 'doffing' are accepted terms for putting on and removing PPE, in these guidelines plain English terms are used for simplicity and clarity. [11] These guidelines were selected based on analysis using the AGREE tool, which ensures that guidelines have been developed in a rigorous, transparent and robust manner. This process is discussed in detail in Appendix 2. [12] Due to a paucity of evidence or low quality evidence some systematic reviews were not used to draft recommendations. The reports of those reviews that were used are available from the NHMRC upon request. [13] These guidelines were selected based on analysis using the AGREE tool, which ensures that guidelines have been developed in a rigorous, transparent and robust manner. This process is discussed in detail in Appendix 2. [14] http://www.health.gov.au/internet/safety/publishing.nsf/content/a4114b5692d8a24fca2571d8000978d0/$file/ mroscreenjun05.pdf [15] This section is drawn from ACSQHC (2009) National Report on Antibiotic Stewardship. [16] These guidelines were selected based on analysis using the AGREE tool, which ensures that guidelines have been developed in a rigorous, transparent and robust manner. This process is discussed in detail in Appendix 2. [17] The report of this review is available from the NHMRC upon request. [18] Based also on evidence identified through Richard C, Ray-Barruel G (2009). Systematic literature review. [19] Communicable Disease Network Australia Guidelines for Managing Blood-Borne Virus Infection in Health Care Workers 2005, which are currently under review. [20] Previously published guidelines have stated that HCWs must not perform EPPs if they are HBeAg positive and/or hepatitis B DNA positive at high titres. Whether HCWs with any level of hepatitis B DNA should perform EPPs is under review by Australian infectious disease experts. When there is a nationally agreed approach this Guideline will be updated, but in the mean time, HCWs wishing to perform EPPs who are hepatitis B DNA positive should consult their local health authority for advice. [21] As outlined in the Tasmanian Healthcare Associated Infection Prevention Strategy 2009–11 [22] The NHMRC publication Guidelines under Section 95 of the Privacy Act 1988 provides further information on the protection of privacy in relation to the compilation or analysis of statistics for health services management or medical research. |