Vancouver Island Health Authority

Transcription

1 Vancouver Island Health Authority INFECTION PREVENTION AND CONTROL Home and Community Care Manual July 28/09

2 TABLE OF CONTENTS 1.0 INTRODUCTION GENERAL INFORMATION ABOUT INFECTIONS The Chain of Infection ROUTINE PRACTICES ROUTINE PRACTICES AND ADDITIONAL PRECAUTIONS Hand Hygiene Admission and Risk Assessment of Client Immunizations Use of Personal Protective Equipment (PPE) Gloves Gowns and Protective Apparel (i.e. Aprons) Masks and/or Other Face Protection (goggles, face shield) Additional Precautions Contact Precautions (Gown and Gloves) Droplet precautions (Surgical Mask) Airborne precautions (N-95 Mask) Client Activities Visitors Pets MAINTAINING A CLEAN, SAFE ENVIRONMENT Nursing Supply Bag Contents and Equipment Storing Supplies in Clients homes Computer Paper/Medical Records Safe Handling of Needles, Syringes and Sharps Laboratory Specimens Client Care Equipment and Supplies Return of supplies and equipment Household Cleaning Personal Care Supplies Food Safety Laundry Handling, Sorting and Washing Laundry Protection of Workers Handling Laundry Collection and handling Washing and drying Storage Dry Cleaning Waste Disposal PESTS AND INFESTATIONS HEALTHY WORKPLACE STRATEGIES/OCCUPATIONAL HEALTH Immunization Illness Injury CLEANING OF REUSABLE MEDICAL EQUIPMENT Cleaning, Disinfecting and Sterilization Single Use Items Dedicated Staff Responsible for Cleaning and Disinfecting Equipment

3 8.4 HCC Multi-Use Equipment: General principles Client at High Risk- requires dedicated equipment Clients at Low Risk- use Multi-Client Use Medical Equipment Blood Pressure Cuffs Transfer Belts (T-belts) Medicines- Injectable Guidelines for Accepting Donations of Medical Supplies from Clients Considerations for Establishing/ Accepting an Existing Loan Facility ENVIRONMENTAL CLEANING IN VIHA COMMUNITY SITES Definition of Terms: Properties of cleaner/disinfectants to consider: Frequency of Cleaning Home and Community Care Nurses working in VIHA Ambulatory Clinics Cleaning Expectations Furniture and Building in Client Care Areas APPENDICES Appendix #1: Personal Protective Equipment- Donning and Doffing/Glove Use Appendix #2: Care of Computer Equipment in the Home and Community Setting Appendix #3: Directions for Preparing and Using a Chlorine-based Disinfectant Appendix #4: Bedbug Protocols for Care Providers Who Make Home Visits Appendix #5: Reprocessing Requirements for Specific Equipment Appendix #6: Cleaning Frequency Appendix #7: Education Sheets Methicillin Resistant Staphylococcus Aureus (MRSA) Community Information Pamphlet Client/Visitor/Family information Pamphlet Public Health Staff or Community Based Healthcare Workers (HCWs) Information Pamphlet Extended Spectrum Beta Lactamase Producing Bacteria (ESBLs) Fact Sheet for Patient, Resident, Family and Visitors Fact Sheet for Healthcare Workers Vancomycin Resistant Enterococci (VRE) Fact Sheet for Patient and Family Fact Sheet for Healthcare Workers REFERENCES

4 This document and its references have been adapted from PICNet s final draft of: PICNet Infection Control Guidelines: Providing Health Care to the Client Living in the Community 4

5 1.0 INTRODUCTION Trends in health care have seen many changes that have shifted pressure onto community caregivers. Early hospital discharge, increased age and acuity of discharged patients, increasing associated chronic illnesses and lifestyle factors are some of the challenges home health care providers face. New technologies and treatments have permitted patients with previously fatal diseases to survive and live longer in the community as long as health care is provided in their home. Community health centers and home health providers are now delivering increasingly more complex, invasive care such as intravenous therapy, hemodialysis, wound care or ventilator therapy. These changes bring about increasing opportunities for transmission of infection. Health care provided in the community or home setting is multidisciplinary. It includes, but is not limited to, care provided by home care nurses, home support staff, dieticians, social providers, speech therapists, occupational therapists and physiotherapists. There is little evidence to suggest that the provision of health care in the home setting results in substantial disease transmission. Most infections in this setting are related to procedures and devices such as urinary or intravascular catheters. Risks of transmission relate to aseptic practices of the caregiver, cleaning and disinfection of equipment and supplies used between clients and environmental cleanliness. Guiding Principles 1. Infection prevention and control strategies are designed to protect clients, health care providers and the community from the risk of transmissible disease. 2. Health care associated infections cause significant morbidity and mortality and at least 30% of health care-associated infections can be prevented by following infection prevention and control strategies. 3. A systematic approach to infection prevention and control requires each health care provider to play a vital role in protecting everyone who utilizes the health care system, in all of its many forms: pre-hospital settings, hospitals, clinics, offices, home care and community programs, etc. 4. Health care providers follow infection prevention and control practices at all times and use critical thinking and problem solving in managing clinical situations. 5

6 2.0 GENERAL INFORMATION ABOUT INFECTIONS Microorganisms are very much a part of our world. They perform a variety of essential functions and interact with every living creature. There are several categories of microorganisms that cause infection. These are bacteria, viruses, fungi and parasites. Some of these microorganisms are more pathogenic (likely to cause disease) than others. However, if conditions are favorable, any microorganism is capable of causing disease in humans. In health care settings, infections are generally categorized into whether the person likely acquired the infection from their interaction with health care or whether they acquired the infection from the community. Usually when an individual develops an infection they may show signs and symptoms such as fever, vomiting, diarrhea, cough etc, although the interaction may only be a detectable immune response such as a TB skin test conversion (sub-clinical infection). Common Clinical Signs of Infection Inflamed skin Fever or chills Pus Nausea or Vomiting Diarrhea Pain Cough Painful urination Skin that is red, hot, swollen or has a rash Temperature above 38 C Green or yellow drainage or discharge from a wound or body cavity Unexplained by change in diet, medications, etc. Persistent or copious diarrhea Sore throat or other pain, also pain that is disproportionate to severity of injury Productive cough And/or frequent urination 6

7 2.1 The Chain of Infection Because microorganisms can, in some circumstances, threaten our health, control measures have been developed to inhibit their spread. These control measures are based on knowledge of the six main factors that influence the spread of microorganisms. These factors are collectively known as The Chain of Infection. The individual links of the chain of infection are explained below: Bacteria, Viruses, Parasites Elderly, Young, Immuno-compromised Infectious Agent Contaminated objects Stagnant water People Pets Susceptible Host Reservoir of Infection Breaks in skin Breathing, swallowing Mucus membranes Invasive procedures Sexual activity Portal of Entry Mode of Transmission Portal of Exit Body Excretions Coughing/sneezing Equipment Direct or indirect contact (person-to-person or contaminated object to person) Common vehicle contaminated food, blood, medication, instruments Airborne Vector borne insects, bats, ticks. Infectious Agent: Each microorganism that causes human infections has characteristics that influence its ability to cause an infection. These include the number of organisms required to cause infection, ability of the microbe to cause disease, ability of the organism to breech natural barriers, ability to survive in the environment and ability to develop resistance to antimicrobials. Reservoir of Infection: Reservoirs (sources) of infection include: people (both healthy and ill), inanimate objects, medical instruments (surgical instruments), equipment (blood pressure cuffs, commodes), food, water and vectors such as mosquitoes or bats. Example: a reservoir for salmonella would be contaminated foods such as poultry, including eggs (especially cracked and raw ones). 7

8 Portal of Exit: The exit of the pathogen is dependent on the location of the microorganism in the body. Microorganisms can be expelled from the respiratory tract during breathing, coughing or sneezing and from the gastrointestinal tract (GI) via saliva, emesis, feces or drainage from sites within the GI tract. Urine, blood, genital secretions and drainage from wounds may also carry microorganisms out of the body. Example: Hepatitis A exits the body via the GI tract through vomiting, diarrhea, improperly washed hands after toileting. Mode of Transmission: Microorganisms can be transmitted from their reservoir or source to a susceptible host by several routes: Direct Hand to Person Contact This is the most common mode of transmission. Indirect Contact- hands pick up organisms from contaminated surfaces or equipment and then transmit them to other individuals. Droplet Contact this involves exposure of the mucus membranes of the conjunctiva, nose and mouth as a result of sneezing or coughing by an infected person. These droplets are heavy and usually travel no more than about one meter (three feet). Airborne transmission this occurs by dissemination of an infectious agent either by droplet nuclei or tiny particles in the air. The agent is widely dispersed by air currents and inhaled. Common vehicle a contaminated inanimate vehicle such as food, water or blood products may serve as a passive vector for transmission or even allow the microorganisms as part of their normal flora or an infection. Some microorganisms have single routes of transmission (i.e. TB) while others have two or more routes (i.e. measles or salmonella). Portal of Entry: These may be the same as the portals of exit. All of the portals have natural barriers that protect the body from microorganisms. Barriers are normally effective but may allow microorganisms to enter if the barriers are damaged or if they have been compromised by invasive medical devices (i.e. catheters). Examples of portals of entry include the gastrointestinal tract where the infection is by ingestion or the urinary system via urinary catheter. Susceptible Host: Humans have defense mechanisms to protect against infections. These include skin, mucous membranes, certain body secretions such as tears, inflammatory response, genetic, hormonal, nutritional and/or behavioral mechanisms and personal hygiene. The same organism may produce different severity of illness in individuals depending upon host mechanisms. Occasionally, circumstances arise where the normal balance between microorganisms and their host is disturbed. This may be due to a disease process, altered immune status, extremes of age, invasive procedures, drug therapy, poor nutrition, irradiation etc. Should the host develop an infection as a result of this disturbance, a new reservoir of microorganisms may be established, thus further increasing the risk of infection to other people. Interruption of the chain of Infection By understanding the basic roles and functions of microorganisms in our environment, principles can be applied to interrupt the chain of infection. Good personal hygiene and proper handling of body excretions and secretions cannot be over emphasized. Diligent hand hygiene remains the single most important element in controlling the spread of infection. Preventing infections is everybody s business. 8

9 3.0 ROUTINE PRACTICES Routine practices is the term used by Health Canada/Public Health Agency of Canada to describe the system of infection prevention and control practices recommended in Canada. Close attention to routine practices if fundamental to preventing transmission of microorganisms from patient to patient, patient to staff and staff to patient in all health care settings. The four basic elements of Routine Practice include: 3.1 Hand hygiene Hand hygiene is everybody s responsibility: staff, clients, visitors and volunteers. Hand Hygiene is the most effective way to prevent the transmission of microorganisms. Compliance with hand hygiene recommendations requires continuous reinforcement. Either alcohol based hand rub (ABHR) or soap and warm water (especially when hands are visibly soiled) are accepted methods of hand hygiene Clients who are able to participate in self-care should be taught, encouraged and reminded of the importance of hand hygiene before leaving their homes for common/public areas, after using the toilet and before eating or preparing food Clients who are unable to assume responsibility for self care should be assisted in washing their hands whenever their hands may be contaminated and as recommended above Healthcare workers (HCW) should use disposable paper hand towels, not multi-use terry cloth hand towels Risk assessment Risk assessment (as it relates to client symptoms, care and service delivery) includes assessment for: Risk factors which contribute to infections Screening for infectious diseases Presence of fever, respiratory symptoms, rash, diarrhea, excretions and secretions The need for any additional precautions 3.3 Risk reduction strategies Risk reduction strategies include: Appropriate client placement and use of preventative workplace practices Respiratory (cough) etiquette Clean environment, equipment and laundry Use single use equipment or ensure proper disinfection and sterilization of reusable equipment Appropriate waste management and safe sharps handling Following Food Safe principles Use of personal protective equipment (PPE) 3.4. Education and health promotion of health care providers, clients and families/visitors/volunteers It is important to educate health care providers regarding infection prevention and control strategies. 9

10 For community agencies and health care offices within Vancouver Island Health Authority, there is an online Infection Prevention and Control manual available on the VIHA intranet. Once this has been referred to, take your question/concern to your HCC Leader. If they are unable to assist you, they will direct you to call or the Community Resource Team (CRT) Nurse or the VIHA Community Infection Prevention and Control Practitioner. Provide leadership and act as a role model to other health care providers, clients/residents and families/visitors with regard to infection prevention and control strategies Demonstrate work practices that reduce the risk of infection- e.g. use hand hygiene, proper PPE, be immunized etc. Do not come to work with a communicable disease. Communicate between all sectors of health care to ensure that new/current material is available (i.e. Wellness and Safety) Contact Wellness and Safety if you have, or have been exposed to, an infectious disease (i.e. nausea, vomiting, diarrhea, chicken pox). Education for clients should include specific information about their general condition (usually this is provided by the attending physician) and specific information concerning any infection. If the client has an infection, this information should include the organism and practices necessary to reduce the risk of spread. The health care provider should provide VIHA approved education and materials for the client and family as appropriate for the presenting condition. Education should include: Importance of how and when to perform good hand hygiene: before leaving their residences for public areas and upon returning home from outings, after using the toilet and before eating or preparing food. How to practice good respiratory etiquette which includes covering the nose and mouth with a single use, disposable tissue or coughing/sneezing into the upper arm (even when this is due to allergies or dust) or using a disposable tissue to blow/wipe nose and performing hand hygiene after coughing or sneezing or blowing/wiping nose. The importance of keeping hands away from the mucous membranes of the eyes and nose (avoid rubbing the eyes and nose). BCCDC Heath Files is helpful as a client/family reference. 10

11 4.0 ROUTINE PRACTICES AND ADDITIONAL PRECAUTIONS 4.1 Hand Hygiene Hand hygiene is the single most important procedure for preventing the transmission of any kind of infection in any setting. When performing hand hygiene in a client s home, it is preferred that the provider use his/her own hand hygiene supplies provided by the agency. The client s bar soap should not be used because it may be contaminated. A neutral hand soap from a disposable dispenser should be used for and washing. Remove jewelry prior. Fingernails should be kept short. Artificial nails and nail extenders are not acceptable, as they are known to harbour infectious organisms. Using the client s hand hygiene supplies When performing hand hygiene in a client s home, it is preferred that home care staff use their own hand hygiene supplies. When this is not possible, the client s liquid soap may be used if the dispenser appears to be clean and the home environment is clean. The client s bar soap should NOT be used if it has been resting in pool of accumulated water because it may be contaminated with bacteria. When drying hands, staff members may use either their own paper towels or the client s paper towels. The client s cloth towels may be used if they are clean and have not been used previously by anyone in the home. Hand drying is an integral part of cleaning the hands. The friction created by hand drying can remove many bacteria by rubbing away transient microorganisms and dead skin cells, and it can remove bacteria from deeper skin layers. Bar Soap Bar soap should not be carried by the staff members making home visits because it may not have sufficient time to dry. Pooled moisture in a staff member s home care supply bag may support the growth of Gram-negative bacteria. It is recommended to clients and their family members that shared bar soap should be allowed to dry between uses. Liquid soap dispensers Plain soap is acceptable but it should be used in liquid form. Liquid soap pump dispensers may become contaminated and serve as a reservoir for microorganisms. Therefore, a small soap container is recommended. A small container can be cleaned when empty and brought back to the office to be refilled. A container that is almost empty should be completely emptied, cleaned and dried before it is refilled. Liquid soap should not be added to a partially full soap dispenser. Refilling a dispenser is more cost effective and can serve as an indicator of the frequency with which the home care staff are washing their hands in the home. Alcohol Based hand Rub (ABHR) Failure to use a sufficient volume of ABHR may result in an ineffective effort to cleanse the skin. The volume of ABHR used is a factor affecting the efficacy of hand hygiene. Follow the manufacturer s recommendations regarding the volume of product to use. In general, the VIHA IPC team recommends an amount of 3-5 ml but ENOUGH should be applied to cover all surfaces of the hands. Some staff have expressed concern regarding a build-up on their hands after using ABHR repeatedly. For this reason, some manufacturers have recommended that users of their products wash their hands with soap and water after a certain number of product 11

12 applications (i.e. between 5 and 10). This recommendation is aimed more at maximizing staff members acceptance and use of the product than it is at further reducing the bacterial count on the hands. Because of the alcohol content, prior to using any spark producing equipment or using matches hands must be rubbed together until they are dry and ALL alcohol has evaporated. Aerosol hand rub containers should be stored at ambient, indoor conditions, NOT AT HIGH TEMPERATURES. These containers should be kept sealed and away from heat sources or open flames. Aerosol containers or foam dispensers should not be stored in the trunk of a vehicle or any other closed space that can develop high temperatures when exposed to the sun or external heat source. Hand hygiene facilities Home care staff members do not have the same access to needed equipment and supplies as in a health care facility. Staff members may find themselves caring for a client without access to clean or running water. When running water is not available, staff members should use an ABHR for routine hand hygiene. ABHR should be used when it would be appropriate to decontaminate the hands, such as after performing client care. If the HCC staff has used the ABHR for hand hygiene, there is no need for them to wash their hands with soap and unless: 1. their hands are visibly dirty or contaminated or 2. their hands are soiled with blood or other body fluids or 3. they are caring for a client with known or suspected C.difficileassociated diarrhea or bacillus anthrasis (anthrax) If hands are visibly soiled with dirt, blood or other body fluids and there is no running water available in the home, clean the hands first with an individual-use towelette, followed by the ABHR. Wash hands with soap and water as soon as feasible. Irritant contact Dermatitis associated with hand hygiene Home care staff should be provided with hand creams or lotions to minimize the occurrence of dry, irritated or cracked skin or dermatitic skin. When selecting a hand cream or lotion, information should be obtained from the manufacturer regarding any interactions that these products may have with the use of approved VIHA gloves used as personal, protective barriers. These products can also become contaminated. If lotions are used, liquids or tubes that can be squirted are recommended so that the hands do not come into direct contact with the container spout. Direct contact with the spout could contaminate the lotion inside the container. Staff members should never use lotion from multiple use jars or containers into which the hands must be dipped. The use of small, individual-use containers or pump dispensers that can be discarded when empty should be considered. While working in the community, there may be other times when a health care worker should wash his/her hands: Before: entering the client s home handling any clean supplies that will be used by the client (i.e. an unopened package of adult briefs or other supplies) 12

13 handling any medical equipment used by the client entering the agency clinician bag. After: handling Pets (petting, grooming or disposing of pet s excrement) handling any medical equipment that has been used by the client touching any household plants handling the client s soiled clothes or dirty laundry after exiting the client s home. 4.2 Admission and Risk Assessment of Client All client admissions to Home and Community Care programs carry potential risk of introducing and transmitting infections within the services (from client to client). It is important for the health care provider to keep in mind that the information on the referral form may not present the complete picture. Early identification, in conjunction with education for the client and family, is an essential component of infection prevention and control in the community. Depending on the intake process for new clients, there may be two opportunities to perform a risk assessment: 1. Point of Entry. At the point of entry, or while booking appointments for initial interaction, questions regarding potential infectiousness should be asked such as whether the individual has a fever, cough, rash or vomiting/diarrhea. This risk assessment should be ongoing for all interactions. 2. Admissions. During the admission process, a more complete health history is completed by using information from the person s intake form or other documentation as well as interviewing the client. The initial assessment should include questions related to the presence of infection. They include asking the client if they have the following signs, symptoms or conditions: Fever New or worsening Cough New rash Inability to contain bodily fluids, urine or feces, through the use of diapers, briefs, panty liners or stoma care Wound drainage that cannot be contained by a dressing The client has been tested for Antibiotic Resistant Organisms (i.e. MRSA, VRE or ESBL). Ongoing assessment of the client should include observations for: Skin and soft tissue infections (boils, cellutitis); determine if secretions are contained Infestations (i.e. scabies, head/body lice) Gastroenteritis (vomiting, diarrhea) Any acute infection (fever, cough) Client s ability to comply and cooperate Continence issues. Factors demonstrated to increase one s risk of developing infections include: Extremes of age Recent or extended stay in an acute care facility or recurrent hospitalizations Invasive procedures and presence of invasive devices (i.e. IV, urinary catheter, tracheostomy, gastrostomy feeding tube) Recurrent antibiotic use 13

14 Presence of a surgical wound, decubitus ulcer or other chronic wound Exposure to a person who is infected with an organism and had draining skin lesions or wounds or copious respiratory secretions Age or medication related malnutrition and/or immunosuppression Conditions requiring extensive hands-on care Poor personal and/or household hygiene Cognitive challenges (i.e. brain injury, dementia, mental health conditions). NOTE: the presence of an organism such as MRSA or VRE should not exclude the client from home care as long as they meet the criteria for home nursing services Immunizations All clients should be encouraged to discuss their immunization needs with their family physician or local health unit and keep their immunization status current. The following are recommended: Combined diphtheria-tetanus vaccine: should be updated if a booster has not been given in the previous 10 years. Annual influenza vaccine Pneumococcal vaccine: to eligible individuals who have not received one previous dose in their lifetime. These immunizations are provided by Public Health and may be obtained through the client s general practitioner or local Public Health Unit. 4.3 Use of Personal Protective Equipment (PPE) It is important to protect yourself and others from bodily substances and mucous membranes. You will need to put on a barrier or personal protective equipment whenever there is a risk of coming in contact with non-intact skin, mucous membranes or bodily fluids. Infection control supplies should be available for HHC staff who provide direct client care and for staff who admit clients to the program. For instance, the admitting staff member may need to wear a mask if a client is coughing. The risk assessment may change between encounters. During the risk assessment, if routine practices and personal protective equipment are to be used, this additional equipment should be provided. The presence of infection in the client will dictate the type of PPE taken into the home. Infection control supplies that are taken into the home may be kept in a supply bag that the caregiver carries between clients homes or the supplies can be left in the client s home for staff use. Staff members who visit clients but do not provide direct, hands-on care (such as social workers or dieticians) do not need to have a full complement of infection control supplies. 14

15 Mandatory PPE supplies The following is a list of supplies that must be available to staff: 1. Hand Hygiene: Neutral liquid hand soap ABHR of at least 70% volume per volume Hand drying supplies (i.e. paper towels) Lotion or cream 2. Cleaning: Rubber household gloves Single use disposable cloths Liquid neutral detergent Disposable paper towels Approved disinfectant for equipment requiring removal of heavy soiling 3. Personal Protective Equipment (PPE) Non sterile, latex or latex-alternative gloves Impermeable gown and/or apron Surgical mask (this could include an attached visor) Eyewear protection if a visor is not attached to surgical mask (i.e. goggles or face shield) Sharps container Biohazard bag to carry laboratory supplies, if needed Bag labeled as bio hazardous Sterile gloves for procedures requiring sterile technique 70 % ethyl alcohol wipes (antisepsis for small skin areas) 4. Miscellaneous: One way valve resuscitation mask Blood spill kit N-95 Respirator mask (only if the HCC staff member has been fit-tested by Employee Wellness & Safety Department and the client has been placed on Airborne Precautions. For instance, an HCC Nurse needing to make a home visit to provide wound care on a known TB client who is still infectious) Gloves Touch is a fundamental part of human interaction and can be an important aspect of quality client care. Gloves are not needed for routine client care when the contact is limited to a client s intact skin, (i.e. assisting in bathing). Glove use is not a substitute for hand washing. Wear the appropriate type of glove for the task (see below) Remove hand jewelry (jewelry reduces the effectiveness of thorough hand hygiene and can tear gloves) Perform hand hygiene before putting on and after removing gloves Disposable gloves must not be reused and may be disposed of as regular garbage. Three types of gloves are available: sterile disposable, clean non-sterile disposable and non-disposable rubber gloves. 15

16 Sterile (Surgical) Gloves are worn to protect clients from contamination during an aseptic procedure. They also provide protection for the wearer. Use when performing a sterile procedure (i.e. inserting or changing a urinary catheter). Clean (Non-Sterile) Disposable Gloves (single use medical examination gloves latex or copolymer nitryl or nitrile) are worn to protect the wearer from sources of contamination. Use when touching blood or other body secretions and excretions, mucous membranes, undiagnosed rashes or protecting the care givers skin if they are at risk due to non-intact skin such as a dermatitis. Choose the appropriate glove to fit the specific task (i.e. Latex or Nitrile gloves for exposure to chemicals). Non-Disposable Rubber Gloves (i.e. Rubber Household Gloves) are for tasks other than client care. Use when protecting hands from chemicals and detergent solutions while performing routine housekeeping. Rubber gloves should be cleaned after use and only be used in one home. Examination Glove Latex / latex alternative (e.g. nitrile) Vinyl (PVC) Polyethylene/ Polythene Sterile Non-Sterile Non-Sterile Only used in catering All aseptic procedures with potential exposure to blood or body fluids. Sterile pharmaceutical preparations. Non-aseptic procedures with a high risk of exposure to blood or body fluids. Procedures involving sharps Handling cytotoxic material Handling chemicals and disinfectants Tasks which are short and nonmanipulative Tasks which will not pull or twist the glove Tasks where contact with blood or body fluids is unlikely For cleaning tasks Gowns and Protective Apparel (i.e. Aprons) The routine use of gowns and aprons for basic client care is not necessary. Impermeable gowns and/or plastic aprons should be worn when a staff member's clothing is likely to become soiled with blood, feces, urine, wound/skin drainage or any other secretions or excretions. Gowns/aprons must always be changed between clients and should be disposed into regular garbage after use. 16

17 4.3.3 Masks and/or Other Face Protection (goggles, face shield) Masks are not often required in Home Care settings. Health care providers should wear a mask (that covers the mouth and nose) and goggles or a face shield during client-care activities that are likely to cause splashes or sprays of blood, body fluids, secretions or excretions onto the face such as: irrigation using fluid under pressure, suctioning or tracheotomy care. Prescription eyewear does not provide adequate protection; therefore goggles or face shields that fit over eyewear must be worn whenever splashes or sprays are anticipated. Surgical masks provide a physical barrier against respiratory droplet secretions that are spread during close contact, sneezing, coughing, singing and certain procedures. A surgical mask should be worn, when within one meter of a coughing client, for activities that are likely to cause splashes or sprays onto the face or for aseptic procedures. They are single use only and usually worn in conjunction with eye protection. An exception to this may be the use of a surgical mask when performing some aseptic procedures. N95 Masks are used for some viral illnesses such as measles or chickenpox and also for TB. When a person with active pulmonary tuberculosis coughs, sneezes or sings heartily, they expel the tubercle bacilli in droplet nuclei. Once the nuclei enter the atmosphere they evaporate to a 1-3 micron size and thus require a tight-fitting filter mask for protection. If an N95 mask is deemed necessary, fit testing is required. Health care workers should only use the type of mask for which they were successfully fit tested. Principles for using any type of masks: Perform hand hygiene before putting on. The mask should fit snugly over the face and should fully cover the nose, mouth and chin. The metallic wire part of the facemask should fit securely over the bridge of the nose to prevent leakage. Tie all strings that keep the mask in place or fix the rubber bands of the mask around the ears properly. Do not dangle the mask around your neck. Change mask if it becomes wet. Perform hand hygiene after removing and discarding the mask. It is important to remove (doff) PPE in a way that does not contaminate oneself. Please see appendix #1 for a protocol for donning and doffing PPE. 4.4 Additional Precautions Occasionally, routine practices are not sufficient to interrupt the transmission of certain organisms, and additional precautions are required. These precautions fall into three categories based upon the actual mode of transmission of the organism: 1. contact 2. droplet 3. airborne These precautions are used in addition to the routine practices described earlier Contact Precautions (Gown and Gloves) Contact precautions are used for clients known or suspected to have microorganisms that can be spread by direct contact with the client or by indirect contact with environmental surfaces or client care equipment. Examples of conditions that require contact precautions are enteric infections and skin infections that are highly contagious (impetigo, scabies, non-contained abscesses). 17

18 In these situations, gloves should be worn for all direct contact with the client as well as direct contact with the client s immediate environment, personal items and equipment. A clean, impervious gown should also be worn to protect the health care provider s clothing from contamination when there is substantial contact with the client or environmental surfaces as well as when the client is incontinent or has diarrhea, an ileostomy, a colostomy or uncontained wound drainage. After the gown and gloves are removed, hand hygiene is required. No special treatment is required for linen or dishes and eating utensils. Attention should be focused on preventing the transmission of the organisms to the next client or environment visited Droplet precautions (Surgical Mask) Droplet precautions are used for clients known or suspected to have microorganisms transmitted by large, particle droplets. These droplets may be produced during coughing, sneezing or certain procedures such as suctioning. These particles are propelled a short distance, approximately 1 meter (3 feet), and do not remain suspended in the air. Common conditions that may be encountered in the Home and Community Care setting include: acute respiratory infection, streptococcal pharyngitis, mumps and influenza. In addition to routine practices, health care providers should wear a surgical mask when providing direct care to the patient when they are in close proximity (1 meter/3 feet). No special treatment is required for linen or dishes and eating utensils Airborne precautions (N-95 Mask) Airborne precautions are rarely used in HCC but would be used for clients known or suspected to have microorganisms spread via airborne particles. These may consist of small particle residue that results from the evaporation of large droplets or dust particles containing skin squamous and other debris. These can remain suspended in the air for long periods of time and are spread by air currents within a room or over a long distance. Conditions that require this level of precaution include: pulmonary or laryngeal TB, disseminated herpes zoster and chickenpox or measles. For these situations, in addition to routine practices, health care providers should wear an N-95 mask for which they have been fit tested. N-95 masks should be worn for the entire duration of the home visit. No special treatment is required for linen, dishes or eating utensils. Should a client that requires additional precautions need to seek medical care, the office or site should be notified in advance of the additional precaution requirement. In cases of droplet or airborne precautions the client should be asked to wear a surgical mask and perform hand hygiene prior to leaving their home. Clients with an infection requiring contact, droplet or airborne precautions should not use public or volunteer transport. In all cases when additional precautions are necessary, clients and family members should receive basic education about how to prevent transmission of the illness and proper use of any personal protective equipment needed. 18

19 4.5 Client Activities Decisions regarding group activities should be based upon the clinical presentation of the client that day. Individuals with symptoms such as fever, cough, diarrhea, vomiting or with wounds in which the drainage cannot be covered and contained, should not participate in group events until symptoms have resolved. 4.6 Visitors Visitors who may have a communicable disease (i.e. Chicken pox, measles, diarrhea) should not visit clients during the period when they are ill. Education regarding disease communicability should be provided according to need. Visitors with respiratory tract infection or gastrointestinal symptoms should be asked to postpone their visits until they have recovered. Visitors should be encouraged to perform hand hygiene. 4.7 Pets In individual homes it is recommended that the family pet is not in the room when active care is given, especially clean or aseptic procedures such as initiating IV s, dressing changes or inserting Foley catheters. Pets can enhance a client s quality of life. Assisted living settings should have their own policy regarding pets. Appropriate infection control precautions will protect clients from pet-borne disease. The needs of clients with severe allergies should be considered as well as the safety of all. General guidelines in Assisted living settings are: Pets should be in good general health, house trained, good tempered, clean and examined regularly by a veterinarian. Vaccinations should be up to date. Pets should not be allowed in common food preparation areas Pets should have their own area for sleeping and eating. There should be an individual designated to be responsible for all care of the pet i.e.: feeding, exercise and hygiene (which includes clean up of any excrement). 19

20 5.0 MAINTAINING A CLEAN, SAFE ENVIRONMENT 5.1 Clinician Supply Bag The supply container/bag is not commonly associated with spreading infections as it does not come in contact with the client. Although it may contain critical items, the bag itself is not in contact with the client and thus there is no scientific evidence for placement of a barrier between the bag and the client s environment. If the bag must be taken into the home, place it on a clean, dry surface away from children and pets. Do not hang it from doorknobs that are often touched or on the floor, which is considered dirty. The health care provider s equipment /supply bag should be made of material that is easily cleaned or washable. The bag should be cleaned whenever it is visibly soiled and at scheduled intervals. On a regular basis (once a month) and when soiled, contents of the bag should be removed and the inside of the bag cleaned with a low level disinfectant ensuring the recommended contact time is met. If cloth, the bag should be washed in hot soapy water and dried in a dryer or hung to air dry. Care providers should perform hand hygiene prior to reaching into the bag to obtain supplies Contents and Equipment Prior to going into a client s home the caregiver should determine what supplies are necessary to provide care. In all settings, the amount of equipment and supplies going into the home should be limited, with a maximum of 7 days for dressing supplies. Supplies should include personal protective equipment needed for routine practices and additional precautions necessary. In specific situations, the caregiver may decide to take necessary supplies into the client s home in a disposable plastic or paper bag. The clinician supply bag can then be left in the trunk of the car. 5.2 Storing Supplies in Clients homes Any supplies, equipment or healthcare related items that need to be left in the client home should be placed in re-sealable storage bags or other type of closed container for storage on a shelf or in a drawer. Do not store supplies in cupboards under sinks. Do not leave supplies in reach of children or pets. 5.3 Safe Handling of Needles, Syringes and Sharps The person using a disposable item (i.e. needles, scalpel blades, blood glucose lancets, etc) is responsible for its safe disposal in an appropriate container. Examples of clinical sharps are: needles, stitch cutters and any other sharp object which may have been in contact with blood, body fluids or exudates. Needles must not be recapped, purposely bent, broken, removed from disposable syringe or manipulated by hand. Sharps must be disposed of at point of care. A small sharps container should be carried in each home care vehicle. Sharps containers must be clearly labeled, puncture resistant and have a tight fitting lid that seals. 20

21 Regardless of the purpose for which a syringe is used, if they have been labeled single use they are to be disposed of after using. Ensure that containers are safely placed in the client s home, mobile clinic or other setting in consideration of children, confused adults, drug abusers, etc. Sharps containers must not be over filled. Most containers indicate a line at about the ¾ mark, beyond which the container should not be filled. Immediately remove and replace containers when they are ¾ full. Broken glass contaminated with body fluids may be disposed of in sharps containers. Ensure the container is securely closed. Teach clients, their family members, friends or other caregivers in the home, the correct procedures for safe handling and disposal of sharps and sharps containers. Some municipalities in British Columbia may allow needles used in the home to be disposed of as general waste. They may require decontamination by adding bleach before sealing the lid. Check with local authorities or diabetic association in your region for the appropriate disposal method. Local pharmacies often have exchange programs for sharps containers. 5.4 Laboratory Specimens Collect specimens in an appropriate, sterile container. Avoid contaminating the outside of the specimen container with potentially infectious blood or body fluids. Close container securely. Wipe the outside surfaces of any soiled specimen container with disinfectant such as 70% alcohol. Label all specimens, place in laboratory biohazard bag, and attach the requisition to the outside of the bag and transport specimen according to laboratory requirements. Pertinent clinical information should be documented on the requisitions. Do not send leaking or soiled specimen containers to the laboratory. Specimens should be transported to the laboratory in the shortest time possible, and not stored for extended periods in a car. 5.5 Client Care Equipment and Supplies Clients should be evaluated on a case-by-case basis to determine what equipment is needed and whether dedicated equipment is indicated. Limit the amount of reusable equipment that is taken into the home of patients infected or colonized with organisms, including ARO s If dedicated patient care equipment is required, it should be left in the home until the patient is discharged from home care services. The equipment should be cleaned and properly disinfected before use by another client. Clean and disinfect any patient care equipment (i.e. stethoscopes) that cannot remain in the home before removing them from the home. If reusable items need to be taken to another site for cleaning, transport them in a disposable, plastic bag. If items are reusable and classified as semi-critical or critical instruments, take to a designated sterile processing department for reprocessing. 5.6 Return of supplies and equipment Any disposable supplies or paper/cardboard wrapped package that cannot be cleaned must be left with the client. 21

22 Any supplies in unopened, washable packaging (i.e. unopened plastic wrapped, incontinent pads) must be cleaned with a cleaning solution or solution soaked wipe prior to returning to the health unit. Maintain cleanliness/sterility of items while transporting to and from the client s home. Clean equipment should be kept separate from dirty equipment to avoid soiling or contamination of clean items. Store clean equipment and supplies in different colored plastic bags or in a box with a secure lid in the trunk of the vehicle (clear bags/boxes generally indicate equipment is clean) Remove visible soil from equipment prior to transporting back to the Health Unit for processing: o Wearing household rubber gloves, wipe down dirty equipment with a disposable cloth soaked in disinfectant approved by equipment manufacturer. DO NOT RINSE EQUIPMENT. o Wrap equipment in a plastic bag and seal with a twist tie. o Discard the cloth in the client s garbage. o Leaving gloves on, wash gloves (in a hand washing fashion) with a liquid, neutral soap and pat gloves dry with a disposable paper towel. o Dispose of paper towel in client s garbage. o Remove gloves, return to re-sealable bag and return to clinician s bag. Storing Clean and Dirty Supplies/Equipment in Vehicles Designate a clean and dirty area in the trunk of your vehicle. o A box can be placed in the trunk to hold clean supplies in plastic bags for transport to clients homes. o Place dirty/contaminated supplies in plastic bags in a separate box for transport back to the unit. o All containers must be clearly labeled o Review your agency policy and any Provincial laws related to transportation of waste materials. It is also recommended that VIHA staff who use a personal vehicle for work perform regular housekeeping on their vehicles. 5.7 Household Cleaning Client Environment: Consistent, regular cleaning assists in reducing the potential for environmental transmission of microorganisms. Encourage clients and their caregivers to perform regular cleaning of frequently touched surfaces (i.e. taps, sinks, toilets, bedside tables) to prevent the spread of infection to others in the home. Housekeeping routines should involve cleaning and disinfecting surfaces, toys and other surfaces with a low level disinfectant using the correct concentration and contact time. Please ensure that any toys cleaned with a disinfectant are also rinsed well, especially if they may be chewed, sucked or otherwise put in the mouths of children 1. Bathtubs: Good hygiene should be encouraged for all clients. Clients at home or in a group living arrangement may not have access to private bathroom facilities; bathtubs should therefore be cleaned after each use. Clients infected or colonized with an ARO or who have diarrhea or fecal incontinence, with resulting extensive fecal contamination of the skin, can be bathed in the bathtub as necessary for healthy skin care. After each use, the bathtub should be cleaned and disinfected. If it is a special purpose tub, it must be cleaned according to the manufacturer s instructions. 1 phenolics must not be used on toys or food contact surfaces 22

23 5.8 Personal Care Supplies Sharing personal care supplies can result in transmission of microorganisms. It is very important to ensure that clients personal care supplies are not shared and are kept clean. Personal care supplies include items used for bathing, skin care, nail care, oral hygiene and denture care, such as lotions, creams, soaps, razors, toothbrush, toothpaste, denture box, comb and hairbrush, nail file and nail clippers and any other articles needed for personal hygiene. PERSONAL CARE ITEMS SHOULD BE CLEANED REGULARLY Lotions Preferably, use lotions in a bottle with a pump. Do not share with other clients. Soaps Bar soap must be kept in a clean, dry soap dish that allows the bar to drain and air dry between uses. Personal liquid body wash is preferred because it is more easily stored between uses. Each resident using an incontinence brief should have a personal incontinence care cleanser. Creams Use a tongue depressor to dispense cream from jar to avoid contaminating the cream. Toothbrushes Change every three months and after an illness; keep in a plastic toothbrush container. Ensure it is stored protected from toilet aerosols. Wash the toothbrush container regularly; e.g. once a week or biweekly Denture Boxes Label, rinse and dry daily. Combs/hairbrushes Label. Clean at the same time as hair is washed. Clean in hot soapy water, rinse and allow to air dry. Nail files/clippers Label, clean and dry after each use. Razors Clean electric razors after each use with a personal razor brush. Do not share. Personal disposable razors can be used and must be disposed of in biomedical waste receptacles. Sharing an electric razor between residents is not considered an acceptable practice in a health care facility because it does not respect basic personal hygiene care measures and can expose residents to the transmission of microorganisms and infection. Bedpans Label with client s name and clean and disinfect after each use. Never place on the floor. Disposable bedpans are acceptable. Bowl for washing Label with client s name, clean with soap and water and dry after each use. 23