Interim Guidance: Infection Prevention and Control Measures

28 July 2009

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• Table 1:  Identification of the Physical Setting and Level of Patient Interaction
• Table 2: Identification of the Patient Clinical Status and Source Control Capability
• Table 3:  Level of Precautions Matrix
• Table 4 Personal Protective Equipment Suggested for the Level of Precautions for Human Cases of H1N1 2009
• Appendix A : Point of Care Risk Assessment Tool for H1N1 2009
• Appendix B:  Visitors / Accommodation

The PCRA tool consists of tables 1 to 4. 

A step-by-step description on how to use them follows :

Table 1:  Identification of the Physical Setting and Level of Patient Interaction

Physical Setting and Level of Patient Interaction	Description	Example
No Patient Interaction, Non-Clinical	Area with no patient access (restricted areas)	Non-clinical setting (medical record department, administrative office, central pharmacy, information technology office, central storage area, mail room, central maintenance areas, business office, etc.).
No Direct Patient Interaction and No Indirect Contact	No face-to-face interaction and no indirect contact with patients.	Hallways, cafeteria, public areas, clinical areas with no patient access (charting room, office, storage room, staff lounge, medication room, etc.), totally enclosed reception/triage areas with physical barrier between HCW and patient.
Indirect Contact	No direct patient interactions; Indirect contact only with patient environment or contaminated inanimate objects	Discharge patient room cleaning, equipment cleaning.
Direct Patient Interaction	Direct, face-to-face interaction with patient (within  2m of the patient)	Providing patient care, home care visit, assisting with Activity of Daily Living (ADL), diagnostic imaging, phlebotomy services, physiotherapy, occupational therapy, recreational therapy, intra-hospital transport/portering, non-enclosed triage/registration area, cleaning patient bedspace while occupied, routine ambulance or inter-facility transport.
Direct Patient Interaction with Potential for Aerosol Generation	Performing and/or assisting with Aerosol Generating Medical Procedures (AGMP)	Open endotracheal suctioning, bronchoscopy, endotracheal intubation, tracheostomy procedures, nebulized therapy, cardiopulmonary resuscitation.

Table 2: Identification of the Patient Clinical Status and Source Control Capability

Patient Clinical Status and Source Control Capability	Description	Patient Presentation
Recovered from Influenza	Patient recovered from influenza	Influenza-infected patient, beyond the known period of communicability
Influenza and Compliant or Weak Cough and Not Compliant	1) Patient with symptoms compatible with influenza with cough	Cough of any intensity and Adherence with respiratory hygiene Adherence to hand hygiene
	2) Patient with symptoms compatible with influenza with weak or no cough	Weak or no cough and Not adherent with respiratory hygiene Not adherent to hand hygiene
Influenza and Forceful Cough and Not Compliant	Patient with symptoms compatible with influenza	Forceful cough and Not adherent with respiratory hygiene Not adherent to hand hygiene
Influenza and AGMP	Patient with symptoms compatible with influenza	And an Aerosol Generation Medical Procedure (AGMP) is being performed

Note: If more than one risk level identified (e.g., multiple concurrent patient interactions), select the higher risk level.

Table 3:  Level of Precautions Matrix

	Physical Setting and Level of Patient Interaction
Patient Clinical Status and Source Control Capability	No Patient Interaction Non clinical	No Direct or Indirect Patient Interaction	Indirect Contact	Direct Patient Interaction	Direct Patient Interaction with AGMP
Recovered from Influenza	I	I	II	II	II
Influenza and Compliant or Weak Cough and Not Compliant	I	I	II	III	IV
Influenza and Forceful Cough and Not Compliant	I	I	II	III	IV
Influenza and AGMP	I	I	II	IV	IV

Note:  It is anticipated that the majority of patients with H1N1 2009 will be cared for using level II and III and a minority would be cared for using level IV precautions.

Table 4 Personal Protective Equipment Suggested for the Level of Precautions for Human Cases of H1N1 2009

	Hand hygiene	Respiratory hygiene	N95 Respirator	Mask*	Eye Protection	Gown	Gloves
Level I	Yes	Yes	No Patient Contact – Not Required
Level II	Yes	Yes	No, Except as per Additional Precautions*	As Per Routine Practices
Level III	Yes	Yes	No, Except as per Additional Precautions*	Yes	Yes	As Per Routine Practices
Level IV	Yes	Yes	Yes	No	Yes	As Per Routine Practices

*Additional Precautions recommend an N95 respirator for known or suspected active tuberculosis or measles.

Appendix A

Point of Care Risk Assessment Tool for Pandemic (H1N1) 2009 Flu Virus

Prior to any patient interaction, all health care workers (HCWs) have a responsibility to always assess the infectious risk posed to themselves and to other patients, visitors, and HCWs.  This risk assessment is based on professional judgement about the clinical situation and up-to-date information on how the specific healthcare organization has designed and implemented engineering and administrative controls, along with the availability and use of Personal Protective Equipment (PPE).

Point of Care Risk Assessment (PCRA) is an activity performed by the HCW before every patient interaction, to:

1. Evaluate the likelihood of exposure to H1N1 2009,
   • from a specific interaction (e.g., performing/ assisting with aerosol-generating medical procedures, other clinical procedures/ interaction, non-clinical interaction (i.e., admitting, teaching patient/ family), transporting patients, direct face-to-face interaction with patients, etc.),
   • with a specific patient (e.g., infants/ young children, patients not capable of self care/ hand hygiene, have poor-compliance with respiratory hygiene, copious respiratory secretions, frequent cough/ sneeze, early stage of influenza illness, etc.),
   • in a specific environment (e.g., single rooms, shared rooms/ washrooms, hallway,  influenza assessment areas, emergency departments, public areas, therapeutic departments, diagnostic imaging departments, housekeeping, etc.),
   • under available conditions (e.g., air exchanges in a large waiting area or in an airborne infection isolation room, patient waiting areas);
   AND
2. Choose the appropriate actions/ PPE needed to minimize the risk of patient, HCW/ other staff, visitor, contractor, etc. exposure to H1N1 2009 /suspect ILI case

PCRA is not a new concept, but one that is already performed regularly by professional HCWs many times a day for their safety and the safety of patients and others in the healthcare environment.  For example, when a HCW evaluates a patient and situation to determine the possibility of blood or body fluid exposure or chooses appropriate PPE to care for a patient with an infectious disease, these actions are both activities of a PCRA.

Appendix B:  Visitors / Accommodation

Human Cases of Pandemic (H1N1) 2009 Flu Virus

Since posting of the Pandemic (H1N1) 2009 Flu Virus guidance for infection prevention and control measures for health care workers (HCW) in health care settings, requests for additional guidance in specific areas and situations have been received.  The following guidance has been developed to address and/or clarify questions and concerns related to visitors and patient accommodation.

Visitors
Background
There is evidence from the literature that visitors may be a source of influenza that is transmitted in the health care setting (i.e. nosocomial influenza). During a community outbreak of H1N1, it can be expected that influenza could be introduced into the health care setting by visitors, which puts patients, HCW, and other staff at risk for infection. Visitors of patients with H1N1 could themselves become infected and, therefore, current interim guidance recommends that visitors of patients with H1N1 use the same personal protective measures as HCW. One consequence of providing personal protective equipment (PPE) to visitors is that shortages of PPE that would otherwise be available for HCW could occur. To minimize opportunities for introduction of H1N1 into the health care facility and to maximize availability of PPE and other resources (non-PPE supplies, personnel), it would be prudent for health care facilities to limit the number of visitors during an H1N1 pandemic wave. For compassionate reasons, exceptions to the guidance below may be allowed on a case by case basis.

Recommendations
When H1N1 is circulating in your community and you are seeing H1N1 admissions to your facility it is recommended that the following measures be instituted:

1. Points of Entrance
   Limiting points of entry to the facility.
   
   

   Posting signage (passive screening) at entry points instructing patients and visitors: 1) on how to self-screen for symptoms of influenza like illness (ILI), 2) to not visit if they have ILI symptoms, 3) if they have been allowed to visit for compassionate reasons, to notify staff immediately if they have signs and symptoms of ILI, and 3) to follow the facility’s infection prevention and control policies. 

   Actively screening visitors for ILI upon entry to high risk patient units, such as intensive/critical care and transplant units.

2. Visitor Restrictions
   
   Restricting access by children under the age of 12 years. If facilities allow children under the age of 12 years to visit, it is recommended that they be kept under the close supervision of an adult during the entire visit.
   
   
   • 2.1  Visitors with Influenza-like Illness (ILI)
     Restricting access by visitors with ILI.
     
     Scheduling and controlling visits to allow for appropriate screening and instruction on use of personal protective equipment and other precautions (e.g., hand hygiene, limiting surfaces touched) while in the patient's room. 
     
     2.2  Visits for Compassionate Reasons
     If facilities allow visitors with ILI to visit for compassionate reasons, it is recommended that the visitors be instructed in respiratory hygiene, wearing a mask1, hand hygiene and to go directly to visit that patient and exit directly after the visit.
     
     Limiting visitors for patients to persons who have been identified by the patient or next-of-kin as necessary for the patient's emotional well-being and care.
     
     Limiting the number of visitors to a patient at any one time to a maximum of two.
     
     Instructing visitors to limit their movement within the facility.
     

Accommodation
Background
In the situation where an influenza ward has not been established and/or there are insufficient numbers of private rooms to accommodate all patients with H1N1, the following guidance may be used for making decisions regarding accommodation.

Recommendations:
Shared rooms may be considered, in decreasing order of preference, for:
One or more patients with confirmed H1N1
One or more patients with probable H1N1
One or more patients with suspect H1N1 who are able to comply with respiratory hygiene and other infection prevention and control practices and for whom a 2 metre spatial separation can be maintained at all times

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