NO LONGER BAPTISM BY FIRE:

IMPLEMENTATION OF THE INFECTION PREVENTION AND CONTROL PLAN: PART 2

APRIL 18, 2018

Peg Gilbert, RN, MS, CIC, FAPIC

Quality IC, LLC 1

Objectives

Identify when transmission based precautions are used

Relate the type of Personal Protective Equipment (PPE) needed for transmission based precautions

Identify 3 essential elements for safe injections

Distinguish disinfectant use for equipment and surfaces

Review appropriate disposal of PPE, potentially infectious waste and sharp devices

2

OSHA Definition

Personal protective equipment is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses.

OSHA Requirements:

Safely designed and constructed

Maintained in a clean and reliable fashion.

Fit comfortably, encouraging worker use

Provided by employer3

OSHA Requirements

Employers are required to train each worker required to use personal protective equipment to know:

When it is necessary

What kind is necessary

How to properly put it on, adjust, wear and take it off

The limitations of the equipment

Proper care, maintenance, useful life, and disposal of the equipment 4

OSHA PPE Standard 1910.132, website download, Jan, 2017

When is it necessary?

Standard Precautions

Guidelines for preventing exposure to blood, body fluids, secretions, excretions , broken skin, or mucous membranes

Based on the concept that body fluids from ANY patient can be infectious

Use on every patient

Use necessary PPE for protection to prevent exposure

Include: Hand hygiene, respiratory etiquette, cleaning and disinfection of equipment, injection safety, handling of linens 5

When is it necessary?

Standard Precautions: Use gowns and gloves with uncontrolled secretions, pressure ulcers, draining wounds, stool incontinence, and ostomy tubes and bags

Expanded Precautions:

Uncontrolled secretions or drainage

Evidence of MDRO transmission from one patient to another in the HHC agency

Poor compliance with Standard Precautions 6

Expanded Precautions

Category Specific

Contact

Droplet

Airborne

Assess the patient

Does the patient maintain hygiene? (Cover their cough, compliant, continent)

Are they at increased risk to contaminate the environment?

Are they immunosuppressed? 7

Contact Isolation Goal: Prevent transmission of microorganisms spread by contact

with the source

Direct Contact Sources

Cuts

Abrasions

Wounds

Lesions

Indirect Sources

Contaminated equipment

Clothing, stethoscopes

Toys

Furniture

8

Contact Isolation Personal Protective Equipment

Gloves and Gowns

Hand Hygiene

Soap and water with visibly soiled Examples: MDRO + ESBL Infected draining pressure ulcer Can it be contained?

Contagious skin infections: Lice & Scabies Zip lock bags Hard plastic containers

9

PHIL 15345 Scabies

Multidrug Resistant Organisms

When gowns and/or gloves might be used include the following:

Bathing

Assisting with toileting

Changing briefs

Changing a wound dressing

Manipulating patient devices (e.g., urinary catheter)

10Facility Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update - CRE Toolkit

Expand for C. difficile

Personal Protective Equipment

Gloves and Gowns

Hand Hygiene: Soap and water

Keep AHR available

Cleaning Product with C. difficile kill claim

11

C. Diff, PHIL 16786

Droplet Isolation Prevent transmission of microorganisms spread by large, moist droplets

inhaled by or landing on the mucous membranes of the susceptible host

PPE

Surgical Mask within 3 feet

Examples:

Influenza

Meningitis (known or suspected)

Haemophilus influenza

Neisseria meningitides (meningococcal)

Some pneumonias, strep, meningococcal

Vaccine preventable diseases:

rubella, mumps, pertussis

12

Initial Encounter Involve patient

Cover mouth/nose when sneezing/coughing

Use tissues and dispose in no-touch receptacle

Observe hand hygiene after soiling of hands with respiratory secretions

Wear surgical mask out of room or maintain spatial separation, >3 feet if possible from HCW

Use at point of entry to home

Transport with surgical mask

Designate non-critical equipment (such as stethoscopes, thermometers) between patients or dont bring it in

All equipment must be properly cleaned and disinfected prior to use on another patient

13

Influenza is in the community

Contact patients and families before the home visit to determine whether anyone in the household has an influenza-like illness.

Postpone nonessential services

If unable assign personnel who are not at increased risk for complication of pandemic influenza

Wear appropriate respiratory protection: Droplet may need contact

Include environmental controls with a scheduled visit: Open windows to increase air exchanges and dilute the concentration of organisms

Place the patient in a separate room with door closed

Minimize contact with others in the home.

Have patient follow respiratory hygiene and cough etiquette

Mask patient or at a minimum, cover cough with tissue or arm

Request patient perform frequent hand hygiene, make sure in easy reach 14

Airborne Isolation Prevent transmission of microorganisms spread on very small particles that

drift on air currents (droplet nuclei, dust)

Negative Pressure Room: 12 air exchanges/hour, test daily

Room door stays closed

N95 or PAPR - Must have Medical Evaluation prior to fit test or wear

Examples:

Measles

Chicken Pox - Varicella

Herpes Zoster

Tuberculosis15

Non Drug Resistant TB

Patient can be discharged without 3 negative sputum smears if

Follow-up plan has been made with local TB program

Patient is on standard treatment and directly observed therapy (DOT) is arranged

No person in home

AII Precautions for Nontraditional Settings: Home Health Care

17

Administrative Controls

Environmental Controls

Respiratory Protection Controls

Train patients, family re: meds, cough etiquette, medical evaluation.

Postpone travel until not infectious.

No cough-inducing procedures unless infection controls in place

Consider N95 RP for staff transporting persons with infectious TB.

Resource: Appendix A

18Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf

What kind is necessary?

The types of PPE that are used in the home care environment are:

Gloves: Protect hands

Gowns/aprons: Protect skin and/or clothing

Masks: Protect mouth/nose

Respirators: Protect respiratory tract from airborne infectious agents

Goggles: Protect eyes

Face shields: Protect face, mouth, nose and eyes 19

GlovesChange: Between patientsBetween procedures

Hand Hygiene:Before and after

Disposal:Regular trash unless caked or dripping blood or other potentially infectious material (OPIM)

20

WHO, Glove information leaflet, Download, Jan, 2017

Gloves

Use with Standard, Contact Precautions but may need with all

Always combine with hand hygiene

Work from clean to dirty

Do not touch other surfaces

Change, heavily soiled or punctured

Never wash or reuse

Select correct type and size

Vinyl higher failure rate than latex or nitrile, no powder

Put on last when combined with other PPE 21

https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/ppe.html

Gowns

Always used in combination with gloves

Extend glove over wrist of gown

Cover torso and snug at the wrist

Types

Cotton (non disposable)

Disposable

Moisture resistant or Impervious

Lab coats are not PPE

Reminder may be applicable with Standard Precautions! 22

Face Protection Provides protection for sprays and secretions

in mucous membranes

Mask

Fit snugly over nose and mouth

May be placed on coughing patients

Goggles

Fit snugly over eyes even with glasses

Single use/reuse if policy for cleaning

Face Shield

Cover forehead, chin and wrap around neck

Use in place of mask and goggles

23

Respiratory Protection

Used with Airborne Precautions

Protect from inhalation of small particles

of infectious agents, less than 5 microns

Must be approved by National Institute

for Occupational Safety and Health (NIOSH)

Types

N95 Masks

Must be fit tested and user fit test when donned

Powered air-purifying respirator (PAPR)

24

Medical Evaluation Appendix C to Sec. 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory)

To the employer: Answers to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a medical examination.

To the employee:

Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.

Part A. Section 1. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator (please print).

1. Today's date:_______________________________________________________

2. Your name:__________________________________________________________

3. Your age (to nearest year):_________________________________________

4. Sex (circle one): Male/Female

5. Your height: __________ ft. __________ in.

6. Your weight: ____________ lbs.

7. Your job title:_____________________________________________________

8. A phone number where you can be reached by the health care professional who reviews this questionnaire (include the Area Code): ____________________

9. The best time to phone you at this number: ________________

10. Has your employer told you how to contact the health care professional who will review this questionnaire (circle one): Yes/No

11. Check the type of respirator you will use (you can check more than one category):a. ______ N, R, or P disposable respirator (filter-mask, non-cartridge type only).b. ______ Other type (for example, half- or full-face piece type, powered-air purifying, supplied-air, self-contained breathing apparatus).

https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9783

25

https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9783

Donning PPE

Gown first

Mask or respirator

Goggles or face shield

Gloves

26

Removing PPE

Gloves

Face shield or goggles

Gown

Mask or respirator

27

Where to Remove PPE

Depends on type of PPE

Gloves after reason for use, can be in room

Gowns at doorway, before leaving room

Remove respirator outside room, after door has been closed

Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub

28*

Limitations of PPE Contaminated outside front

Areas of PPE that have or are likely to have been in contact with body sites, materials, or environmental surfaces where the infectious organism may reside

Front of mask is contaminated: No Mask necklaces!

Clean inside, outside back, ties on head and back

Areas of PPE that are not likely to have been in contact with the infectious organism

29

Limitations of PPE Contamination occurred in 79.2% of PPE simulations

Monitor

Risk assessment

Practice!

30

Equipment in the home

Limit amount, dedicate until discharge

Non critical equipment: (doesnt touch open skin)

Store to prevent contamination

Plastic bins

Inspect before use

Water stains

Integrity of package

Clean and disinfect after use if non-disposable

Clean using Manufacturers guidelines

Place contaminated reusable items in a plastic bag for transport and subsequent cleaning and disinfection at discharge

Away from pets. 31

Equipment in the car

Transport to protect cleanliness and integrity of packaging Separation of clean and dirty Alcohol hand rub: Bottle expands in heat Gloves degrade Any rubber, gets hard and sticky, i.e. Foleys Need to check expiration dates and rotate stock monthly Regular cleaning of bag inside and out If brought in home Never place on floor Avoid placement on fabric covered surfaces Surface that can be cleaned Electronics cleaning 32

Outbreaks due to Injection Practice

49 since 2001 because of extrinsic contamination of injectable medical products at the point of administration

Twenty-one of these outbreaks involved transmission of HBV or HCV; the other 28 represented outbreaks of bacterial infections, primarily invasive bloodstream infections.

~ 90% of these known outbreaks occurred in outpatient settings.

Hundreds of patients became infected, plus an estimated 150,000 patients required notification to undergo bloodborne pathogen testing after their potential exposure to unsafe injections

Unsafe injection practices fall into two overlapping categories Reuse of syringes

Mishandling of medications.

MMWR May 31, 2013 / 62(21);423-425

33

Relative transmission efficiency of bloodborne viral infections

HBV HCV HIV

Injection drug use +++ ++++ ++

Sexual +++ + ++

Perinatal ++++ + ++

Occupational +++ +/- +/-

34

Risk of infection after needle stick

35

Source Risk Odds! Survival

HBV 6.0 30.0% 1/3 >7 days in environment

HBeAg+ 22.0-30.0%

HBeAg- 1.0 6.0%

HCV 1.8% 1/30 9 weeks in syringe

HIV 0.3% 1/300 Syringe several days

A Growing Problem?

growing reservoir of infected individuals who can serve as a source of transmission to others if safe injection practices and other basic infection control precautions are not followed

Aging population more frequent interactions with the healthcare system

Prevalence of Hepatitis C is highest among

persons born 1945-196436

Perz et al, Hepatology 2012.Accepted Article, doi: 10.1002/hep.25688

Safe Injection Practice Research

Report found 5,446 provider respondents:

6% sometimes or always use single-dose/ single-use vials for more than one patient

1% sometimes or always reuse a syringe but change the needle for a second patient

15.1% reuse a syringe to enter a multi-dose vial

6.5% save multi-dose vial for use on another patient

(Pugliese G., et al AJIC Dec. 2010)

37

Safe Injection Practice Research (New)

A panel of physicians and nurses - 690 survey respondents:

12% of physicians and 3% of nurses indicated reuse of syringes for >1 patient

5% of physicians indicated this practice usually or always occurs

A higher proportion of oncologists reported unsafe practices in the workplace

38

(Kossover-Smith, et.al, AJIC 45 (2017) 1018-23

http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html

Guidelines

39

Equipment Reuse

PHIL, ID# 9303 content: CDC/ Judy Schmidt

40

Reuse of syringes

No reuse of syringes on multiple patients, even if the needle or cannula on the syringe is changed.

41

Saline or Heparin Syringes Do NOT dilute or reconstitute IV push medications by drawing up the contents into a

commercially available, prefilled flush syringe of 0.9% sodium chloride.

Prefilled syringes of saline and heparin are regulated by the US Food and Drug Administration as devices, not as medications. Approved for flushing of vascular access devices

Are NOT approved for the reconstitution, dilution, and/or subsequent administration of IV push medications.

Such use would be considered off label and not how manufacturers intended these products to be used

Prefilled flush syringes have not been tested for product safety when used in this manner.

Warnings intended to limit the use of prefilled syringes for medication preparation and administration appear on some syringe barrels, clearly stating IV flush only.

42

ISMP SAFE PRACTICE GUIDELINES FOR ADULT IV PUSH MEDICATIONS

OSHA Standard

OSHA BBP standard: The revision now specifies that "safer medical devices, such as sharps with engineered sharps injury protections and needleless systems" constitute an effective engineering control, and must be used where feasible.

43

The CDC estimates that healthcare workers sustain nearly 600,000 percutaneous injuries

annually involving contaminated sharps.Revision to OSHA's Bloodborne Pathogens Standard Technical Background and Summary, April, 2001

Single-use/Single-dose

Vial of liquid medication intended for parenteral administration meant for use in a single patient for a single case/procedure/injection.

Single-dose or single-use vials are labeled as such by the manufacturer and typically lack an antimicrobial preservative.

Size does not matter

Cannot be saved for next visit44

PHIL #14217 CDC/ Doug Jordan, M.A

http://www.cdc.gov/injectionsafety/providers/provider_faqs_singlevials.html

http://www.cdc.gov/injectionsafety/providers/provider_faqs_singlevials.html

Multi-dose Vials (MDV)

A bottle of liquid medication (injectable) that contains more than one dose of medication

Is approved by the Food and Drug Administration (FDA) for use on multiple persons

Contains a preservative

Preservatives do not protect from contamination. 45

Handling of Multi-dose MedicationsMulti-dose medication should be:

Dedicated to single patient

Entered only with sterile needle and sterile syringe

Rubber septum should be disinfected with alcohol prior to each entry

Dated upon initial entry and discarded within 28 days of opening or according to manufacturers instructions

Discarded if sterility is compromised

46

Expiration Date VersusBeyond-use Date (BUD)

Manufacturers expiration date: the date after which an unopenedmulti-dose vial should not be used

Beyond-use date: The date after which an opened multi-dose vial should not be used

Beyond-use date should never exceed the manufacturers original expiration date

Relabeling required by Joint Commission Standard MM.03.01.01, The Joint Commission requires organizations to re-label multi-dose vials with a revised expiration date once the multi-dose vial is opened or punctured

The Joint Commission. Standards FAQ Details. Punctured or Opened New Expiration Date. ttps://www.jointcommission.org/standards_information/jcfaqdetails. aspx?StandardsFaqId=1080&ProgramId=46 (accessed 2017 January 2).

47

Aseptic Technique

Prepare Medication in clean area

Well lit

No food

Handwashing/AHR

Nothing stored on floor

Sharps container

48

AICC 30 Dolan SA, et al. Am J Infect Control 2010; 38:167-72

Glove Use with Injections

Key Elements Indications Precautions

When Wear non-sterile single use gloves: When performing venipuncture or venous access injections

Do not use gloves for routine intradermal, subcutaneous or intramuscular injections

Change If soiled, torn or punctured Do not wash or decontaminate gloves

After treatment Remove before leaving the area Do not wear outside of treatment area, charting, hallways

Wash Hands

49

WHO best practices for injections and related procedures toolkit March 2010, pg 59

Lab draws

PHIL #13492, Content: CDC/ Amanda Mills

72 home health care nurses completed a 152-item self-administered mailed risk assessment questionnaireRNs employed in home health care agencies in New York State.Nine (13%) of the home health care nurses experienced 10 needlesticks in the 12-month period before the study.Only 4 of the needlesticks were formally reported to the nurse's employer. The devices most frequently associated with needlesticks were hollow-bore and phlebotomy needles, and included 3 needles with safety features. Exposure was most commonly attributed to patient actions, followed by disposal-related activities.

Gershon RR1, Pogorzelska M, Qureshi KA, Sherman M, Am J Infect Control. 2008 Apr;36(3):165-72. doi: 10.1016/j.ajic.2007.04.278. Home health care registered nurses and the risk of percutaneous injuries: a pilot study. 50

https://www.ncbi.nlm.nih.gov/pubmed/?term=Gershon RR[Author]&cauthor=true&cauthor_uid=18371511https://www.ncbi.nlm.nih.gov/pubmed/?term=Pogorzelska M[Author]&cauthor=true&cauthor_uid=18371511https://www.ncbi.nlm.nih.gov/pubmed/?term=Qureshi KA[Author]&cauthor=true&cauthor_uid=18371511https://www.ncbi.nlm.nih.gov/pubmed/?term=Sherman M[Author]&cauthor=true&cauthor_uid=18371511https://www.ncbi.nlm.nih.gov/pubmed/18371511?dopt=AbstractPlus

Using Sharps

Before Beginning a Procedure

Organize equipment at the point of use

Make sure work space has adequate lighting

Keep sharps pointed away from the user

Locate a sharps disposal container, or have one nearby

Assess the patients ability to cooperate

Get help if necessary

Ask the patient to avoid sudden movement

Be Prepared

Preventing Needlesticks and Other Sharps InjuriesEverything You Need to Know, Part III: Safe Work Practices, CDC

During a ProcedureAware Maintain visual contact with sharps during use Be aware of family nearby Control the location of sharps to avoid injury to yourself and

others Activate safety feature of devices with engineered sharps injury

prevention features as soon as procedure is completed Observe audible or visual cues that confirm the feature is locked

in place

PHIL Image 6233

Sharps Waste Management No federal regulations governing the safe

disposal of needles and syringes in the home

Many may end up in the household trash with risk sanitation and sewage treatment workers, janitors and housekeepers, and children.

Ensure that home care clients are instructed in the proper disposal of sharps according to applicable laws and regulations.

Encourage disposal of their used needles through other means such as community drop-off programs, household hazardous waste facilities, sharps mail-back programs, or at-home needle destruction device

53

https://www.epa.gov/sites/production/files/2016-02/documents/med-govt_0.pdf

Safe Disposal

Functional: Durable, closeable and resistant to opening

after final closure, puncture resistant, leak resistant, sufficient

number and size accommodate the largest sharp used in the area,

stable on horizontal surface, biohazard label

Accessible: Conveniently located, must be at location of use, crash carts, laundry

Visible: Readily visible, vertical height where can see opening

Accommodating: Routinely replaced and not allowed to be overfilled.

Inappropriate places: Corners, backs of doors, inside cabinet doors, areas over where people may sit, near light switches, etc. where container subject to impact or dislodgement by pedestrian traffic

54Selecting, Using and Evaluating Sharps Containers, DHHS NIOSH publication 97-111OSHA Standard 1910.1030

During Cleanupn Up and Dispose with Care

Be accountable for sharps you use Check procedure trays, waste materials, and

bedding for exposed sharps before handling Look for sharps/equipment left behind

inadvertently Secure the container to prevent spillage prior to

returning to car

While Disposing of Sharpslean Up and Dispose With Care Inspect container Keep hands behind sharps Never put hands or fingers into sharps container If you are disposing sharps with attached tubing

Be aware that tubing attached to sharps can recoil and lead to injury

Maintain control of both tubing and the device during disposal Visually inspect sharps container for overfilling Replace containers before they become overfilled

If You Find Improperly Disposed Sharps in Environmentan Up and Dispose With Care Handle carefully

Keep hands behind sharps at all times

Use mechanical device if you cannot safely pick up sharps by hand

Sharps injury or BBP Exposure

The National Institute for Occupational Safety and Health (NIOSH) recommends that if an employee experiences a needlestick/sharps injury or is exposed to blood or other body fluid during the course of work that the following steps be taken immediately: Wash needlestick and cuts with soap and water.

Flush splashes to the nose, mouth, or skin with water.

Irrigate eyes with clean water, saline, or sterile irrigates.

Report the incident to your supervisor.

Seek medical treatment immediately.

Questions about appropriate medical treatment for occupational exposures to blood is available from the Clinician Consultation Center (1-888-448-4911). 58

OSHA, Healthcare Wide Hazards, Bloodborne Pathogens, Post-Exposure Follow-up

https://www.cdc.gov/niosh/topics/bbp/http://nccc.ucsf.edu/

Specimen Transport General Guidelines

Use Standard Precautions

Utilize appropriate collection device

Use sterile equipment and aseptic technique to collect specimens

Collect prior to administration of antibiotics when possible

Avoid contamination with indigenous flora from surrounding tissues

Collect a sufficient volume to ensure all tests requested may be performed

Label specimen properly with patient name, Id number, source, specific site, date, time of collection and initials of collector

Promptly transport usually must be within

Point of Care Testing

60PHIL #13708, CDC/Amanda Mills

Practices Associated with HBV Transmission During Assisted Monitoring of Blood Glucose

61

Use of fingerstick devices or insulin pens

on multiple persons

Failure to clean and disinfect blood

glucose testing meters between each use

Failure to change or use gloves, or perform

hand hygiene between procedures

Patel et al. ICHE 2009; 30:209-14, Thompson et al. JAGS 2010, MMWR 2005; 54:220-3

www.cdc.gov/injectionsafety

Fingerstick Devices

Recommendations

Fingerstick devices should never be used for more than one person

Autodisabling single-use fingerstick devices should be used for assisted monitoring of blood glucose

Home care supply

62

PHIL #13707 CDC/Amanda Mills

Blood Glucose Meters

Blood glucose meters should be assigned to an individual and not shared

If shared, clean and disinfect after every use with an EPA-registered disinfectant (per manufacturers instructions)

If the manufacturer does not specify how it should be cleaned and disinfected, it should not be shared

63

PHIL #13565 CDC/Amanda Mills

Insulin Pens and Vials

Insulin pens are intended for use by a single person

Insulin pens should be labeled with the individual persons name on the barrel

The needle is changed after each administration

Ensure patient/family using correctly

64

One and Only Campaign print materials: http://www.oneandonlycampaign.org/sites/default/files/upload/image/SIPC_Brochure_InsulinPen_updated2.pdf

Personal Protective Equipment

Handwashing before and after glove use

Wear gloves during blood glucose monitoring and during any other procedure that involves potential exposure to blood or body fluids

Avoid handling test strip containers with soiled gloves to avoid contamination. If a new test strip is needed, discard soiled gloves and perform hand hygiene before obtaining a new test strip.

Dispose of sharps in approved containers.

65

Environmental Cleaning Cleaning

Removal of all soil from objects/surfaces

Decontamination

Removal of pathogenic microorganisms from objects to ensure they are safe to handle

Disinfection

Elimination of many or all pathogenic organisms with the exception of spores

Sterilization

Complete elimination of all microbial life, including spores. In practice, usually described as a probability function (e.g., as the probability of a microorganism surviving sterilization being one in one million).

66

Spaulding Classification

EH Spaulding believed the way an object is disinfected depends on the objects intended use. CRITICAL - objects which enter normally sterile tissue or the vascular system

or through which blood flows should be sterile.

SEMICRITICAL - objects that touch mucous membranes or skin that is not intact require a disinfection process (high-level disinfection [HLD]) that kills all microorganisms but high numbers of bacterial spores. Cleaner must achieves 6 log kill

NONCRITICAL -objects that touch only intact skin require low-leveldisinfection

67

Must follow directions to work

68

Decreasing Order of Resistance of Microorganisms to Disinfectants/Sterilants

Prions

Bacterial spores (C. difficile)

Mycobacteria

Small, non-enveloped viruses (noro, polio)

Fungal and Mold spores

Gram-negative bacilli (Acinetobacter, ESBL)

Large, non-enveloped viruses (Rotovirus)

Gram-positive bacteria (MRSA, VRE)

Enveloped viruses (HBV, HCV, HIV )

Most Resistant

Most Susceptible

Understanding the Physiology of Healthcare Pathogens for Environmental Disinfection, ICT, February 23, 2012

69

Decreasing order of Resistance of Microorganisms

70

Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, Last update: February 15, 2017

Considerations for Clean Environment Food Preparation area

Disinfectant rinsed if not food safe

Toys

Appropriate cleaning based on criteria, critical, semi-critical, non-critical

Ensure product is effective

CDI or spore forming organism present

EPA registered

Wipes are wet, dwell time, changed

Clean, safe storage of supplies

Look for a non-porous surfaces, fabrics71

Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) Last update: February 15, 2017

Environmentally Safe as alternative?

These alternatives (e.g., ammonia, baking soda, vinegar, Borax, liquid detergent) are not registered with EPA and should not be used for disinfecting because they are ineffective against S. aureus.

Borax, baking soda, and detergents also are ineffective against Salmonella Typhi and E.coli

Undiluted vinegar and ammonia are effective against S. Typhi and E.coli

Many sites in the home kitchen and bathroom are microbially contaminated, use of hypochlorites markedly reduces bacteria

Consider targeted hygiene conceptwhich means identifying situations and areas (e.g., food preparation surfaces and bathroom) where risk exists for transmission of pathogensmay be a reasonable way to identify when disinfection might be appropriate 72

Clostridium difficile spores at 20 min

73

C. Difficile spores, Rutala, 2006

Waste Management

Non sharp waste should be placed into designated containers (e.g., plastic bag) and followed by hand hygiene procedures.

Surfaces that may become contaminated should be cleaned and disinfected with an HHC agency-approved disinfectant. The U.S. Occupational Safety and Health Administration (OSHA), in its enforcement procedures for bloodborne pathogens, has stated that HHC agencies will not be held responsible for the disposal of regulated waste in the home.

Household trash is regulated at the state and local government level. In certain circumstances, additional guidance for waste handling and disposal may be provided based upon emerging pathogens

74

Cleaning Solutions

Disposal

Dispose of used solutions immediately to avoid them becoming reservoirs

Many are nonrefillable container

Discard in accordance with policy and label directions

75

Patient and Family Teaching

The healthcare provider is responsible for providing the responsible family member information about infection-control procedures to follow in the home, including hand hygiene, proper cleaning and disinfection of equipment, and safe storage of cleaned and disinfected devices.

Standard Precautions Transmission Based Precautions Procedure processes Equipment cleaning and storage Waste Management

76

Involve Patient/Families

Consider literacy, language, elderly

Return demonstration of critical skills

Written guidance

77

Hand Hygiene Resource for Patients

Available on Home Health Quality Improvement Web site

http://www.homehealthquality.org/CMSPages/GetFile.aspx?guid=a06c365e-

5f56-42ab-adda-1715dcf94171

78

http://www.homehealthquality.org/CMSPages/GetFile.aspx?guid=a06c365e-5f56-42ab-adda-1715dcf94171

CAN THE PATIENT USE THEM ALONE?

New Hand Sanitizer Wipes for patient use

Provide 1 pack of wipes on admission

Instruction for use

Use before and after bathroom, eating/drinking, contact with others, coughing and sneezing

Use first wipe to clean hands, then discard wipe. Sanitize with a second wipe

Do not discard in toilet

Discard after single use

Do not distribute to Staff or

Patient family79

Influenza Signs and symptoms Protection Length of time contagious Prevention and treatment Patient Family Resources

Flu and You Brochure https://www.cdc.gov/immigrantrefugeehea

lth/pdf/seasonal-flu/flu_and_you_english_508.pdf

A Flu Guide for Parents of Children or Adolescents with Chronic Health Conditions

https://www.cdc.gov/flu/pdf/freeresources/updated/chronichealth_fluguide_brochure.pdf

80

https://www.cdc.gov/immigrantrefugeehealth/pdf/seasonal-flu/flu_and_you_english_508.pdfhttps://www.cdc.gov/flu/pdf/freeresources/updated/chronichealth_fluguide_brochure.pdf

Lillian Wald and Henry Street Settlement

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Contact

Peg Gilbert, MS, RN, CIC, FAPIC

E-Mail

peggilbert@qualityic-llc.com

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mailto:peggilbert@qualityic-llc.com

Structure BookmarksNO LONGER BAPTISM BY FIRE:NO LONGER BAPTISM BY FIRE:NO LONGER BAPTISM BY FIRE:NO LONGER BAPTISM BY FIRE:IMPLEMENTATION OF THE INFECTION PREVENTION AND CONTROL PLAN: PART 2APRIL 18, 2018

Peg Gilbert, RN, MS, CIC, FAPICPeg Gilbert, RN, MS, CIC, FAPICPeg Gilbert, RN, MS, CIC, FAPIC

Quality IC, LLCQuality IC, LLC

FigureFigure

ObjectivesObjectivesObjectivesObjectives

Identify when transmission based precautions are used

Relate the type of Personal Protective Equipment (PPE) needed for transmission based precautions

Identify 3 essential elements for safe injections

Distinguish disinfectant use for equipment and surfaces

Review appropriate disposal of PPE, potentially infectious waste and sharp devices

OSHA DefinitionOSHA DefinitionOSHA DefinitionOSHA Definition

Personal protective equipment is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses.

OSHA Requirements:

Safely designed and constructed

Maintained in a clean and reliable fashion.

Fit comfortably, encouraging worker use

Provided by employer

OSHA RequirementsOSHA RequirementsOSHA RequirementsOSHA Requirements

Employers are required to train each worker required to use personal protective equipment to know:

When it is necessary

What kind is necessary

How to properly put it on, adjust, wear and take it off

The limitations of the equipment

Proper care, maintenance, useful life, and disposal of the equipment

OSHA PPE Standard 1910.132, website download, Jan, 2017OSHA PPE Standard 1910.132, website download, Jan, 2017OSHA PPE Standard 1910.132, website download, Jan, 2017

When is it necessary?When is it necessary?When is it necessary?When is it necessary?

Standard Precautions

Guidelines for preventing exposure to blood, body fluids, secretions, excretions , broken skin, or mucous membranes

Based on the concept that body fluids from ANY patient can be infectious

Use on every patient

Use necessary PPE for protection to prevent exposure

Include: Hand hygiene, respiratory etiquette, cleaning and disinfection of equipment, injection safety, handling of linens

When is it necessary?When is it necessary?When is it necessary?When is it necessary?

Standard Precautions: Use gowns and gloves with uncontrolled secretions, pressure ulcers, draining wounds, stool incontinence, and ostomy tubes and bags

Expanded Precautions:

Uncontrolled secretions or drainage

Evidence of MDRO transmission from one patient to another in the HHC agency

Poor compliance with Standard Precautions

Expanded PrecautionsExpanded PrecautionsExpanded PrecautionsExpanded Precautions

Category Specific

Contact

Droplet

Airborne

Assess the patient

Does the patient maintain hygiene? (Cover their cough, compliant, continent)

Are they at increased risk to contaminate the environment?

Are they immunosuppressed?

Contact IsolationContact IsolationContact IsolationContact Isolation

Goal: Prevent transmission of microorganisms spread by contact with the source

Direct Contact Sources

Cuts

Abrasions

Wounds

Lesions

Indirect Sources

Contaminated equipment

Clothing, stethoscopes

Toys

Furniture

Figure

Contact IsolationContact IsolationContact IsolationContact Isolation

Personal Protective Equipment

Gloves and Gowns

Hand Hygiene

Soap and water with visibly soiled

Examples:

MDRO + ESBL

Infected draining pressure ulcer

Can it be contained?

Contagious skin infections: Lice & Scabies

Zip lock bags

Hard plastic containers

FigurePHIL 15345 Scabies PHIL 15345 Scabies PHIL 15345 Scabies

Multidrug Resistant OrganismsMultidrug Resistant OrganismsMultidrug Resistant OrganismsMultidrug Resistant Organisms

When gowns and/or gloves might be used include the following:

Bathing

Assisting with toileting

Changing briefs

Changing a wound dressing

Manipulating patient devices (e.g., urinary catheter)

Facility Guidance for Control of CarbapenemFacility Guidance for Control of CarbapenemFacility Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update -CRE Toolkit

Expand for C. Expand for C. Expand for C. Expand for C. difficile

Personal Protective Equipment

Gloves and Gowns

Hand Hygiene: Soap and water

Keep AHR available

Cleaning Product with C. difficilekill claim

FigureFigureFigureC. Diff, PHIL 16786C. Diff, PHIL 16786C. Diff, PHIL 16786

Droplet IsolationDroplet IsolationDroplet IsolationDroplet Isolation

Prevent transmission of microorganisms spread by large, moist droplets inhaled by or landing on the mucous membranes of the susceptible host

PPE

Surgical Mask within 3 feet

Examples:

Influenza

Meningitis (known or suspected)

Haemophilus influenza

Neisseria meningitides (meningococcal)

Some pneumonias, strep, meningococcal

Vaccine preventable diseases:

rubella, mumps, pertussis

Figure

Initial EncounterInitial EncounterInitial EncounterInitial Encounter

Involve patient

Cover mouth/nose when sneezing/coughing

Use tissues and dispose in no-touch receptacle

Observe hand hygiene after soiling of hands with respiratory secretions

Wear surgical mask out of room or maintain spatial separation, >3 feet if possible from HCW

Use at point of entry to home

Transport with surgical mask

Designate non-critical equipment (such as stethoscopes, thermometers) between patients or dont bring it in

All equipment must be properly cleaned and disinfected prior to use on another patient

Influenza is in the communityInfluenza is in the communityInfluenza is in the communityInfluenza is in the community

Contact patients and families before the home visit to determine whether anyone in the household has an influenza-like illness.

Postpone nonessential services

If unable assign personnel who are not at increased risk for complication of pandemic influenza

Wear appropriate respiratory protection: Droplet may need contact

Include environmental controls with a scheduled visit:

Open windows to increase air exchanges and dilute the concentration of organisms

Place the patient in a separate room with door closed

Minimize contact with others in the home.

Have patient follow respiratory hygiene and cough etiquette

Mask patient or at a minimum, cover cough with tissue or arm

Request patient perform frequent hand hygiene, make sure in easy reach

Airborne IsolationAirborne IsolationAirborne IsolationAirborne Isolation

Prevent transmission of microorganisms spread on very small particles that drift on air currents (droplet nuclei, dust)

Negative Pressure Room: 12 air exchanges/hour, test daily

Room door stays closed

N95 or PAPR -Must have Medical Evaluation prior to fit test or wear

Examples:

Measles

Chicken Pox -Varicella

Herpes Zoster

Tuberculosis

Non Non Non Non Drug Resistant TB

Patient can be discharged without 3 negative sputum smears if

Follow-up plan has been made with local TB program

Patient is on standard treatment and directly observed therapy (DOT) is arranged

No person in home