infection control ================= there are two tiers of precautions to prevent the transmission of infectious agents, standard precau

INFECTION CONTROL
=================
There are two tiers of precautions to prevent the transmission of
infectious agents, Standard Precautions and Transmission-based
Precautions. Standard Precautions are to be observed with all patients
in all healthcare settings regardless of the suspected or confirmed
presence of an infectious agent. Transmission-Based Precautions are to
be observed with certain patients who are known or suspected to be
infected with or colonized with infectious agents, including
epidemiologically important agents.
Revised Centers for Disease Control and Prevention (CDC) guidelines on
isolation precautions have been issued for all healthcare settings.
Most of these principles will apply to the Local Health Department
(LHD) setting, but there have been few studies of transmission risks
in healthcare settings other than hospitals. The June 2007 CDC
Guideline for Isolation Precautions: Preventing Transmission of
Infectious Agents in Healthcare Settings 2007 replaces the 1996 CDC
guidelines.
1.
Standard Precautions
All clinical personnel should observe Standard Precautions for all
patients as part of a routine strategy for infection control in
healthcare settings. Clinicians, nurses, laboratory technicians, and
phlebotomists routinely encounter blood and body fluids during the
course of examination and testing. All blood and body fluids are
potentially infected with many different infectious agents such as
Human Immunodeficiency Virus (HIV), hepatitis B or hepatitis C.
Standard Precautions are used to prevent the transmission of these
agents among patients and healthcare personnel.
a.
Standard Precautions are implemented when blood, vaginal
secretions, semen, or other body fluids (excluding sweat) will be
encountered, regardless if they contain visible blood or not. They
are also to be utilized when contact with non-intact skin or
mucous membranes are anticipated.
b.
Personal Protective Equipment (PPE) must be appropriate for the
type of Health Care Worker (HCW) - patient interaction anticipated
and may include latex or vinyl gloves, gowns, masks, and
protective eyewear.
c.
Health Care Workers should always wear gloves when…
===================================================
*
Touching blood and body fluids.
*
Touching mucous membranes (i.e. inside mouth, rectum, vagina)
*
Touching any non-intact skin (or when the health care worker’s
skin is not intact).
*
Handling items or surfaces soiled by blood or other body fluids
when processing blood or any body fluid specimen.
d.
Hands should be washed before and after the examination, before
gloving, and before leaving the examination room.
e.
Gloves must be changed after contact with each patient. Change
gloves between tasks and procedures on the same patient after
contact with materials that may contain a high concentration of
microorganisms. After removing gloves, perform hand hygiene. If
hands are visibly dirty, contaminated with proteinaceous material,
or visibly soiled with blood or body fluids, wash hands with soap
and water. When hands are not visibly dirty, alcohol-based hand
rubs can be used for hand decontamination.
f.
Surgical masks and protective eye wear (e.g. goggles or face
shields) should be worn by a HCW during procedures that are likely
to generate splashes or sprays of blood or other body fluids, in
order to prevent exposure of mucous membranes in the mouth, nose,
and eyes.
g.
Gowns or aprons should be worn during procedures that are likely
to generate splashes of blood or other body fluids.
h.
If hands or other skin are visibly dirty, contaminated with
proteinaceous material, or visibly soiled with blood or body
fluids, wash with soap and water. Wash with nonantimicrobial or
antimicrobial soap (preferably liquid, not bar) and warm water
(not hot). Rub the hands or other skin area using friction
creating lather for 10 – 15 seconds. Rinse and pat dry with a
disposable towel. When hands are not visibly soiled, or after
removing visible material with nonantimicrobial soap and water,
alcohol-based hand rubs can be used for hand decontamination.
i.
Health care workers with exudative skin lesions or weeping
dermatitis should refrain from direct patient contact, or handling
patient care equipment, until the skin condition resolves.
2.
Transmission-Based Precautions
Transmission-Based precautions are broken up into three categories:
Contact Precautions, Droplet Precautions, and Airborne Precautions.
They are always used in addition to Standard Precautions when the
route of transmission is not interrupted by the use of Standard
Precautions alone. At times, based on the routes of transmission,
combinations of Transmission-Based precautions may be used.
Transmission-Based Precautions must remain in place while test results
are pending based on the clinical presentation and likely pathogens.
a.
Contact Precautions
Contact Precautions are intended to prevent the spread of
microorganisms by direct or indirect contact with persons or
contaminated areas. They are implemented when there is the presence of
a specific organism or an increased risk of transmission.
Contact Precautions consist of:
*
Donning Personal Protective Equipment (PPE) as needed (See
Standard Precautions above)
*
Gown and gloves will be worn for all interactions that may involve
contact with any patient or contaminated areas for which Contact
Precautions apply.
*
All protective equipment shall be applied prior to entry and
discarded before exiting the environment containing a potentially
infectious agent.
b.
Droplet Precautions
Droplet Precautions are intended to prevent the transmission of
organisms spread through close respiratory or mucous membrane contact
with respiratory secretions.
Droplet Precautions consist of:
*
Donning Personal Protective Equipment (PPE) as needed (See
Standard Precautions above)
*
A mask is donned prior to close contact with a patient where
Droplet Precautions apply.
*
Mask shall be applied prior to entry and discarded after exiting
the environment containing a potentially infectious agent
*
When transporting a patient on Droplet Precautions, the patient
shall wear a mask and practice Respiratory Hygiene/Cough
Etiquette.
c.
Airborne Precautions
Airborne Precautions are intended to prevent the transmission of
organisms that remain infectious over long distances when suspended in
the air. Healthcare workers should be particularly alert to the need
for preventing Mycobacterium tuberculosis (TB) transmission in
settings in which persons with HIV infection receive care. The
TB-related precautions are described in detail in CDC’s Guideline for
Preventing Transmission of Mycobacterium tuberculosis in Health-care
Settings, 2005 (CDC.MMWR 2005; 54: RR-17 12).
Respiratory protection is broadly regulated by OSHA under the
Occupational Safety and Health Standards.
Airborne Precautions consist of:
*
Donning Personal Protective Equipment (PPE) as needed (See
Standard Precautions above)
*
Prior to entering room, mask or respirator shall be worn based on
disease specific recommendations.
*
Local Health Department Directors and Supervisors should verify
staff providing care for patients with vaccine-preventable
airborne diseases (e.g., measles, chickenpox, and mumps) are
immune to those diseases.
*
Any person with suspected or confirmed TB disease of the lungs,
airway, or larynx shall be isolated from other patients. If
available, this person shall be placed in a room that meets the
requirements for an Airborne Infection Isolation Room (AIIR). If
an AIIR in unavailable, a separate room apart from other patients
with the door closed shall be used. Persons with suspected or
confirmed TB should wear a surgical or procedure mask, if possible
and should observe strict Respiratory Hygiene/Cough Etiquette. In
addition, they should be instructed to keep the mask on when not
in an AIIR.
For indications for discontinuing Airborne Precautions, see Guidelines
for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings 200, [Appendix A] and Guidelines for
Preventing the Transmission of Mycobacterium tuberculosis in
Health-Care Settings, 2005
3.
Additional Guidance
a.
KY DPH Communicable Disease Branch should be contacted, if
possible, before a patient suspected of having measles or
varicella is brought into a health center.
b.
KY DPH Communicable Disease Branch should be consulted to help
determine how to minimize airborne exposure and as to which
potentially exposed persons should receive Post-exposure
prophylaxis, Vaccine or Immune Globulin.
c.
A surveillance system must be established for injuries such as
needle-sticks, percutaneous injuries, and mucous membrane
contamination.
d.
All workers to whom Standard Precautions apply should be offered
Hepatitis B vaccine with appropriate training regarding hepatitis
B, hepatitis B vaccination, the efficacy, safety, method of
administration, and benefits of vaccination, and that the vaccine
and vaccination are provided free of charge to the employee. A
written statement of Declination of Hepatitis B vaccination must
be signed by an employee who chooses not to accept the vaccine and
kept in Local Health Department files,
http://www.osha.gov/SLTC/etools/hospital/hazards/bbp/declination.html
e.
To minimize risk of exposure during emergency mouth-to-mouth
resuscitation, mouthpieces, resuscitation bags, or other
ventilation devices should be available for use in areas where the
need for resuscitation might arise. This includes health
department settings where anaphylaxis may develop as a result of
drug therapy.
f.
Disinfection means the use of a chemical procedure that eliminates
virtually all recognized pathogenic microorganisms but not
necessarily all microbial forms (e.g., bacterial endospores) on
inanimate objects. There are three levels of disinfection: high,
intermediate, and low:
*
High-level disinfection kills all organisms, except high levels of
bacterial spores, and is effected with a chemical germicide
cleared for marketing as a sterilant by the Food and Drug
Administration.
*
Intermediate-level disinfection kills mycobacteria, most viruses,
and bacteria with a chemical germicide registered as a
"tuberculocide" by the Environmental Protection Agency (EPA).
*
Low-level disinfection kills some viruses and bacteria with a
chemical germicide registered as a hospital disinfectant by the
EPA.
g.
Contaminated surfaces must be disinfected:
*
Use protective gloves, eye shields, and other PPE appropriate for
this task.
*
Use of an EPA-registered sodium hypochlorite product while
following manufacturers guidelines is preferred, but if such
products are not available, generic sodium hypochlorite solutions
(e.g., household chlorine bleach) may be used:
*
Use a 1:100 dilution (500--615 ppm available chlorine) to
decontaminate nonporous surfaces after cleaning a spill of
either blood or body fluids in patient-care settings.
*
If a spill involves large amounts of blood or body fluids,
or if a blood or culture spill occurs in the laboratory, use
a 1:10 dilution (5,000--6,150 ppm available chlorine) for
the first application of germicide before cleaning.
h.
In general, heat stable reusable medical devices (such as Suture
kits, IUD insertion and removal devices, uterine sounds, etc) that
enter the blood stream or enter normally sterile tissue must
always be reprocessed using heat-based methods of sterilization
(e.g., steam autoclave or dry heat oven).
i.
If sterilization is unavailable, reusable devices or items that
touch mucous membranes should, at a minimum, receive high-level
disinfection between patients. These devices include reusable
diaphragm-fitting rings and vaginal retractors.
*
Medical devices that require sterilization or disinfection must be
thoroughly cleaned to reduce material/bioburden before being
exposed to the germicide and the germicide and device
manufacturers' instructions should be closely followed.
*
An inexpensive environmental surface germicide effective against
HIV is a solution of sodium hypochlorite diluted to a 10% chlorine
bleach solution (1 part household bleach to 9 parts water)
prepared daily. (Bleach, however, is corrosive to metals
(especially aluminum) and should not be used to decontaminate
medical instruments with metallic parts.)
*
Non-heat stable reusable medical devices (such as
Diaphragm-fitting rings, IUD devices, uterine sounds, Biopsy
forceps, and Dental instruments) must receive high-level
disinfection after each use. Follow the device manufacturer’s
recommendations for appropriate disinfectants and technique. If
manufacturer recommendations are not available, the following
guideline is suggested for cleaning and disinfection (e.g.,
disinfectants to use, dilutions, and techniques; Reproline -2003):
*
Use protective gloves, eye shields, and other PPE appropriate for
this task
*
Thoroughly clean the reusable medical device by scrubbing with a
liquid detergent and water solution to remove all organic material
and then rinse well with water. It is essential to remove organic
matter before beginning disinfection.
*
Next, device must be completely immersed in a 10% Chlorine
solution (one part bleach to nine parts sterile water) or 6%
Hydrogen Peroxide solution (one part [30% solution] to 4 parts
sterile water ) for 20 minutes at room temperature, then remove
with sterile or high-level disinfected grasping device (forceps,
pickup, tongs, est.) or gloves.
*
Rinse device well using a sterile or high-level disinfected
grasping instrument (forceps, pickup, tongs, est.) or sterile
gloves to hold the device, rinse three times with sterile water.
*
Allow it to air dry suspended or on a clean, dry, disinfected
surface.
*
Once disinfected, devices should be used promptly or stored in a
dry, high-level disinfected, covered container. Stored containers
should be located in an area that is well ventilated and provides
protection against dust, moisture, as well as temperature and
humidity extremes.
*
Dispose of disinfection solutions down a utility sink drain or
into a flushable toilet and rinse or flush with water. Avoid
splashing.
j.
Needles must not be recapped or removed from disposable syringes.
k.
Disposable needles, syringes and other sharp items must be placed
in puncture-resistant containers for disposal. The containers are
to be located as close as practical to the area in which the items
were used.
l.
Infectious waste should be incinerated or managed according to
OSHA standards and guidelines.
4.
References
a.
CDC - Guidelines for Isolation Precautions: Preventing
Transmission of Infectious Agents in Healthcare Settings 2007,
June 2007
http://www.cdc.gov/ncidod/dhqp/gl_isolation.html
b.
CDC - Healthcare Infection Control Practices Advisory Committee
(HICPAC) http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm
c.
Guidelines for Preventing the Transmission of Mycobacterium
tuberculosis in Health-Care Settings, 2005
http://www.cdc.gov/mmwr/PDF/rr/rr5417.pdf
d.
CDC - Sterilization or Disinfection of Medical Devices
http://www.cdc.gov/ncidod/dhqp/bp_sterilization_medDevices.html
e.
Reproline - Infection Prevention Guidelines for Healthcare
Facilities with Limited Resources: 12 - High-Level Disinfection,
2003
http://www.reproline.jhu.edu/english/4morerh/4ip/IP_manual/ipmanual.htm
f.
HICPAC - Guidelines for Environmental Infection Control in
Health-Care Facilities
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm
g.
For additional guidance refer to OSHA compliance in the Policy and
Procedure Section of the Administrative Reference.
h.
Guidance and appropriate procedures for precautions may be found
in the federally required OSHA manual, onsite in every facility.
Or refer to the Occupational Safety and Health Standards.
http://www.osha.gov/pls/oshaweb/owastand.display_standard_group?p_toc_level=1&p_part_number=1910
i.
Guidance and appropriate procedures for precautions may also be
found in the LHDs Bloodborne Pathogens Exposure Control Compliance
Plan.
Page 6 of 6
Kentucky Public Health Practice Reference
Section: Infection Control
July 31, 2008

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