(Adapted from BC Centre for Disease Control Document on Respiratory Outbreaks)
There are important concepts regarding infection prevention and control measures that have been clarified over the past decade. Working with occupational health and safety groups and building engineers has created a framework that includes three levels of control: engineering controls, administrative controls and personal protective measures.
(Source: Public Health Agency of Canada. Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care. 1999. http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/ 99vol25/25s4/index.html)
Transmission of infection during the provision of health care requires three elements: a source of infecting microorganisms, a susceptible host, and a means of transmission for the microorganism. In health care settings, because agent and host factors are more difficult to control, interruption of transfer of microorganisms is directed primarily at transmission.
Human sources of the infecting microorganisms in health care facilities may be clients, health care providers, visitors, care providers or family members and may include persons with acute disease, persons in the incubation period of a disease, persons who are colonized by an infectious agent but have no apparent disease, or persons who are chronic carriers of an infectious agent. Other sources of infecting microorganisms can be the client’s own endogenous flora, which may be difficult to control, food, water and inanimate environmental objects that have become contaminated, including equipment and medications. The microorganisms include bacteria, viruses, fungi and parasites transmitted through these means and also via vectors such as lice, mosquitoes, flies and vermin.
Resistance among persons to pathogenic microorganisms varies greatly. Some persons may be immune to infection or may be able to resist colonization by an infectious agent. Other individuals exposed to the same agent may establish a comfortable or residential relationship with the infecting microorganism and become asymptomatic carriers. Others may develop clinical disease. Host factors such as: extremes of age; underlying diseases; certain treatments with antimicrobials, corticosteroids, or other immunosuppressive agents; irradiation; and breaks in the first line of defense mechanisms (e.g. those caused by such factors as surgical operations, anesthesia, invasive procedures and indwelling devices) may make clients more susceptible to infection. Client self-care practices can improve host susceptibility (e.g. good oral hygiene, proper hydration, nutrition, skin, hand hygiene, respiratory etiquette and environmental factors) and reduce risk of infection.
Microorganisms are transmitted in health care settings by several routes, and the same microorganism may be transmitted by more than one route. There are five main routes of transmission: contact, droplet, airborne, common vehicle, and vectorborne. For the purpose of this manual, common vehicle and vectorborne will be discussed only briefly because neither play a significant role in typical health care associated infections.
Routine Practices are a way of thinking and acting that forms the foundation
for limiting the transmission of microorganisms in all health care settings.
It is the standard of care for all patients/clients/residents.
Reference: Rick Wray, Hospital for Sick Children
Routine Practices have been used by the Public Health Agency of Canada since 1999 for the process of risk assessment and risk reduction strategies. They are used with all clients/residents at all times and include education of health care providers, clients, families and visitors. Routine Practices supercede, and are more encompassing, than previous bloodborne pathogen precautions or Universal Precautions.
Based on the assumption that all blood and certain body fluids (urine, feces, wound drainage, sputum) contain infectious organisms (bacteria, virus or fungus), Routine Practices reduce exposure (both volume and frequency) of blood/body fluid to the health care provider. The key to implementing Routine Practices is to assess the risk of transmission of microorganisms before any interaction with patients/clients/residents. The consistent use of Routine Practices will assist in reducing exposure (both volume and frequency) of all blood/body fluid to the health care provider and transmission to others and the environment.
The Elements of Routine Practices Are:
Routine Practices prevent transmission of microorganisms in most settings and include the following requirements (see PIDAC Routine Practices Poster- Appendix IIB):
Hand hygiene is the single most important thing to do to prevent transmission of infection. Although health care providers know the importance of hand hygiene, studies continue to show health care providers perform hand hygiene less than half the time they should. Hand hygiene should be performed:
Hand hygiene also includes caring for hands to maintain intact skin. Regular use of hand lotion is recommended.
See attached Hand Hygiene Fact Sheet (Appendix IIA).
Screening for communicable diseases (coughs, colds and diarrhea). In the clinic setting, ask simple questions.
Risk Assessment: there are two levels of assessment required.
Respiratory etiquette includes covering a cough or sneeze and disposing of tissues in a waste receptacle (see attached Respiratory Etiquette poster in Appendix IIE).
Risk Reduction Strategies will assist the health care provider in minimizing his or her exposure to body fluids and mucous membranes. Once the risk assessment has been completed, strategies, including hand hygiene, use of personal protective equipment (PPE), client placement and cleaning and disinfection of equipment, should be used to reduce risk of transmission of microorganisms within the health care setting. Whenever you might come in contact with non intact skin, mucous membranes or body fluids, you need to put on a barrier or personal protective equipment (PPE).
Protect yourself and others from body substances and mucous membranes. You will need to put on a barrier or personal protective equipment (PPE) whenever there is a risk of coming in contact with non-intact skin, mucous membranes or body fluids.
Gloves: The most commonly worn personal protective equipment is quality vinyl gloves. Choose glove material based on the risks for which you are wearing them (e.g. vinyl for personal care and wound care, latex for sterile invasive procedures, nitrile for exposure to chemicals). Wear them for likely hand exposure to blood and body fluids.
Put on clean gloves just before touching mucous membranes and non-intact skin.
Change gloves and perform hand hygiene when:
Remove gloves promptly after use and perform hand hygiene before touching clean items and environmental surfaces; before touching your eyes, nose and mouth; and before going on to another client. Remove gloves as the first step in the removal of PPE.
When to Wear Gloves
When there is a risk of exposure/splash/contact with blood, body fluids and nonintact skin.
When Not to Use Gloves
Masks (Surgical) Face Protection/Face Shields: Wear masks to provide protection of the health care provider’s nose and mouth from likely splashes and sprays of blood or body fluids. Face shields and eye protection guard the eyes of health care providers against likely splashes and sprays of blood or body fluids. Choose eye gear that protects the eye from all directions. Splashes and sprays can be generated from a client’s behaviour (e.g. coughing or sneezing) or during procedures (e.g. suctioning, wound irrigation, cleaning soiled equipment, using a spray hose). Surgical masks with ear loops are the easiest to put on and remove. Apply masks after donning the gown and eye protection next. Apply before performing a procedure and wear within three to five feet of the coughing, sneezing client. This prevents the transmission of microorganisms to the health care provider’s mucous membranes in their eyes, nose and mouth to reduce infection.
N95 Respirators: For additional information, please visit: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/99vol25/25s4/index.html.
A fit tested N95 respirator is required to protect the airways of the health care provider. It is intended to seal tightly to the face and filters airborne organisms. Wear a fit tested N95 respirator if:
Gowns: Put on the gown as the first procedure when donning PPE; mask and eye protection is the second procedure. Wear long sleeved gowns to protect uncovered skin and clothing from likely splashes, sprays or soiling during procedures and client care activities. Remove the soiled gown promptly after use and perform hand hygiene to avoid transfer of organisms to clients and the environment. Remove gown after glove removal in the PPE removal sequence. See attached Fact Sheet on Gowns, Aprons and Lab Coats (Appendix IIJ)
Safe handling of sharps reduces exposure to bloodborne pathogens. Use appropriate barriers and safe work practices when using sharp instruments and devices (e.g. needles , scalpels, etc.), after procedures and when cleaning used instruments. Use point of use disposal receptacles for sharps and use puncture resistant containers with clear labels, a handle and tight fitting lid to reduce risk in the work area.
Dispose of sharps immediately in a clearly labelled, puncture resistant container. Do not recap, bend or manipulate needles in any way for disposal. The container should have a tightly fitting lid that seals and prevents leakage. This reduces risk to you, other health care providers, clients and others in the environment (e.g. waste disposal handlers). Fill containers only to ¾ full, close the lid securely and tape closed. Replace the used container. Safety of placement of the sharps container in the client’s home/mobile clinics should be a top priority in consideration of children, confused adults, drug abusers, etc.
Used sharps are considered biomedical waste in health care offices, labs and long term care facilities. Dispose of used sharps containers in accordance with regulations from municipal, provincial/territorial authorities. For home care, follow municipal regulations for disposal as some municipalities allow used needles from domestic waste to be disposed of as general waste.
(For more information on sharps safety, please visit the Ontario Safety Association for Community and Health Care website:http://www.osach.ca/new/SaftInfo/SEMS.html.)
Ensure multi-use equipment is not used in the care of another client until it has been properly cleaned and re-processed. Do not re-use single use items. Use clean hands to handle clean equipment. Any equipment or device that comes in contact with mucous membranes, open areas or beneath the skin in sterile sites must be re-processed correctly. Single use items, such as a tourniquet or needle, are one-client use only and are disposed of properly.
There are three categories of client equipment (each category defines how it must be cleaned to prevent infection transmission).
When does re-useable medical equipment require cleaning?
If re-useable medical equipment doesn’t touch the client’s skin, does it require cleaning, disinfection or sterilization?
There is no requirement for routine disinfection or sterilization as those pieces of equipment carry little risk of spreading infection. However, there is a requirement to disinfect or sterilize those pieces of equipment if they become contaminated with blood or body fluids or if they have been exposed to a client with an infectious organism.
What other strategies should be used to reduce risk when using medical equipment with a client who has an infectious organism?
Single use items (e.g. tourniquet) are used for one client only and are properly discarded after use. Reuseable medical equipment used to assess clients and provide care must be appropriately cleaned, disinfected or sterilized based on how it is used and whether it has come into contact with known or suspected infectious organisms. Re-useable medical equipment is not used in the care of another client until it has been properly cleaned. Use clean hands or clean gloves to handle clean equipment.
In a health care office or long term care facility, most critical items will be disposable, one time use. See attached sheet on Sterilization and Disinfection (Appendix III).
Multidose vials must be labelled with the date, time and initials of when the vial was opened to ensure potency. Use sterile needles and clean the stopper when withdrawing medications to ensure the vial maintains sterility. There have been cases of contamination of multidose vials if syringes or needles are re-used. Avoid multidose vials if possible due to the risk of contamination.
Medications, including vaccines that require refrigeration, must be stored in a manner that ensures they remain safe (e.g. cold chain for vaccines). This requires daily monitoring and documenting of fridge storage temperature. Separate fridge storage just for medications is required.
Clean Environment (Housekeeping Routines): In long term care facilities, community agencies and health care offices, horizontal/high touch surfaces need to be cleaned daily and when visibly soiled. Housekeeping Routines should involve cleaning and disinfecting surfaces, toys and objects with a low level disinfectant (See Table 1 for types of disinfectants). Encourage clients and their caregivers to perform regular cleaning of frequently touched surfaces (e.g. taps, sinks, toilets, bedside tables) as one way to prevent the spread of infection to others in the home.
|Quaternary ammonium compounds||LLD||Daily cleaning and sanitizing of surfaces and equipment||Use as directed on the label||Fairly inexpensive, releases volatile organic compounds|
|Accelerated hydrogen peroxide products||LLD||Daily cleaning and sanitizing of surfaces and equipment||As directed on the label||Safe and effective|
|Sodium hypochlorite (1:100 dilution of household bleach)||LLD||Daily cleaning and sanitizing of surfaces and equipment||Until dry||Disinfectant but no cleaning properties|
|Surface / Object||Procedure||Special Considerations|
|Horizontal surfaces such as overbed tables, work counters, baby weigh scales, beds, cribs, mattresses, bedrails, call bells||
||Special procedures called carbolizing are not necessary. Some environmental surfaces may require low level disinfection depending on the type of invasive procedure being done (nurseries, pediatric offices, procedure rooms)|
|Walls, blinds, curtains||Should be cleaned regularly with a detergent and as splashes/visible soil occur|
||Detergent is adequate in most
Blood/body spill should be cleaned with disposable cloths followed by disinfection with low level disinfectant
|Carpets/ upholstery||Should be vacuumed regularly and shampooed as necessary|
|Toys||Should be regularly cleaned, disinfected with a low level disinfectant, thoroughly rinsed and dried||For pediatric settings, toys should be constructed of smooth nonporous materials to facilitate cleaning. Do not use phenolics.|
|Toilets and commodes||
||Dedicated equipment is best|
Source: PHAC Handwashing, Cleaning Disinfection and Sterilization Guideline — 1998, Page 30.
Cleaning of surfaces requires the removal of body substances by staff wearing the appropriate PPE and then disinfecting the area. Appropriate routine cleaning and removal of soil are essential. Body fluid spills or equipment used by a client requires use of PPE (usually gloves when cleaning, removing the soil) and then disinfecting the area or equipment. WHMIS sheets (MSDS) must be available for the disinfectant being used. Commercial spill kits are useful for clinics and offices.
Cleaning is accomplished with water, detergents and mechanical action. Skin antiseptics should not be used for disenfecting inanimate objects. Detergents are adequate for most surface cleaning.
Regular schedules for daily cleaning are required. Client contact areas must be cleaned between each client. Responsibility for cleaning must be clearly assigned.
How to clean up (and disinfect) after a blood or body fluid spill:
Microbial counts on soiled linens are significantly reduced during mechanical action and dilution of washing and rinsing. With the high cost of energy and use of cold water detergents (which do not require heat to be effective), hot water washes (> 71 degrees C for 25 minutes) may not be necessary. Several studies show low temperature laundering will effectively eliminate residual bacteria to a level comparable to high temperature laundering. (Reference: PHAC Handwashing, Cleaning, Sterilization and Disinfection in Health Care, 1998, page 34.)
Linens used in the health care setting can be laundered together using detergent and dried in a hot air dryer to ensure killing of microorganisms. Linens with organic material left on them will require pre-treating to remove the material. It is impossible to clean laundry when organic material is present.
In health care settings, linen may be cleaned within the setting or sent to a commercial laundry facility. See the attached Laundry Fact Sheet in Appendix IIG for details on proper handling of laundry. Although soiled linen has been identified as a source of microorganisms, the risk of actual disease transmission appears negligible providing hygienic handling, storage and processing of clean and soiled linen are carried out. Clean laundry must be stored apart from soiled linens.
In homes, health care providers should handle any laundry soiled with blood or body fluids with gloves and avoid touching it to their clothes or skin; position the laundry basket nearby to reduce handling (keep off the floor and upholstered furniture); handle with minimal agitation and do not shake; remove fecal material into the toilet. Teach family or caregivers how to handle contaminated laundry safely. Wash heavily soiled laundry separately and add bleach to wash water according to manufacturers’ instructions if material is bleach tolerant.
Waste is divided into three categories; general, biomedical and pathological. Legislation requires that biomedical waste be handled and disposed of in such a way as to avoid transmission of potential infections.
The most obvious biomedical waste generated in a long term care facility, health office or community health agency are sharps. Use puncture resistant sharps containers to remove, store and dispose of used sharps such as needles, blades, razors and other items capable of causing punctures.
Some municipalities may allow needles used in the home to be disposed of as general waste. Sometimes they may require decontamination by adding bleach first and then sealing the lid. Check with local authorities for the appropriate disposal method. Teach clients and their caregiviers in homes how to handle and dispose of sharps and sharps containers safely. If legally discarding a sealed container of sharps in the garbage, place it in the middle of the garbage bag to reduce risk of injury to the waste handlers.
Non-anatomical waste, such as liquid blood or body fluid drainage (e.g. chest tube drainage containers, IV blood filled tubing), must also be packaged as biomedical waste.
See Local, Regional, Provincial and Federal regulations on waste. Licensed medical waste handlers must be used to remove biomedical and pathological waste.
Anatomical waste such as body parts is classified as pathological waste and must be disposed of according to the regulations for handling pathological waste.
All other waste, such as general office waste, used gloves or non-sharp medical equipment, may be disposed of in regular waste and requires no special handling other than containment during disposal and removal.
This does not include waste that is "domestic waste". The Canadian definition of biomedical waste does not include domestic waste.
Recommendations for waste handling:
Source: PHAC: Handwashing, Cleaning, Disinfection and Sterilization Guideline. 1998.
Liquid waste such as urine, feces, provodine iodine, irrigating solutions, suctioned fluids, excretions and secretions may be poured carefully down the client’s toilet, which is connected to a sanitary sewer or septic tank. Body fluids in small amounts such as blood in a syringe withdrawn from a CVAD before a blood sample is obtained may be discarded in a puncture proof sharps container. Provincial and territorial regulations may dictate the maximum volume of blood or body fluids that is permitted to be poured in the sanitary sewer (e.g. 300mls). If there is likely to be splashes or sprays from disposing of blood or body fluids, apply PPE.
All staff working in health care should have a two-step tubercline skin test at the beginning of employment unless they have documentation of a negative skin test in the past 12 months. The local Medical Officer of Health can advise on the need for routine testing depending on the prevalence of Tuberculosis in your community. Health care providers need to know their history of childhood communicable diseases.
Organizations should commit to promoting vaccine preventable diseases. Documentation of immune status will be considered when assigning a health care provider to a particular case.
For additional information, please review Health Canada’s Canadian Immunization Guideline at: http://www.phac-aspc.gc.ca/publicat/cig-gci/index-eng.php.
Recommended immunization of staff includes:
Staff should receive education on when to stay home from work in a health care setting. This includes:
Most employers of health care providers will have policies in this regard.
If sharps are used in the practice setting, you will need to know where, when and how to obtain follow up after a potential bloodborne pathogen exposure.
Health care providers and volunteers practice healthy behaviours by self screening for fever, new cough, diarrhea and new rashes, and staying home when sick.
Follow-up for punctures or mucous membrane exposures to bloodborne pathogens
If testing is required – serial testing should be conducted at time of exposure, then at three and six months.
Educate health care providers regarding infection prevention and control strategies.
Educate clients/residents/families about hygiene and infection prevention strategies such as hand hygiene.
Infection prevention and control health promotion
For Long Term Care, Home and Community Care Including Health Care Offices and Ambulatory Clinics
(See complete text for rationale)
1. Basic infection prevention measures are based on a knowledge of the chain of transmission and the application of Routine Practices in all settings at all times
2. The elements of Routine Practices include:
2.1 Hand Hygiene includes handwashing and use of alcohol-based hand rub (greater than 60% alcohol) before client care, between dirty and clean and when leaving the client
2.2 Screening and assessing clients must be done to identify any communicable disease risks with the client contact
2.3 Risk Reduction Strategies that provide reduced exposure in the presence of communicable diseases must be used. Those strategies include the following:
2.4 Providing health care provider and client education on infection prevention and control strategies is required