UW Medicine Infection Control Training Module

Transcription

1 UW Medicine Infection Control Training Module TABLE OF CONTENTS UW MEDICINE INFECTION CONTROL TRAINING MODULE... 1 TABLE OF CONTENTS... 1 CHAPTER 1: INTRODUCTION... 3 About Quizzes... 3 About Evaluation... 3 Learning Objectives... 3 Infection Control Monitoring & Consequences... 4 CHAPTER 2: STANDARD PRECAUTIONS...6 Standard precautions apply to all patients all the time... 6 Clean Your Hands Frequently!... 6 Use Respiratory Hygiene/Cough Etiquette... 7 Wear Personal Protective Equipment to Protect Yourself and Patients... 7 Sequence Matters... 7 Caps Maximize Protection... 8 Gowns Guard Against Body Fluids... 8 Eye Protection Glasses Aren't Enough... 9 Gloving Protect Your Hands from Contamination... 9 CHAPTER 3: EXPANDED PRECAUTIONS Expanded, Transmission Based Precautions...13 Contact Precautions...13 Contact Precautions Prevention Procedures...14 Droplet Precautions...14 Droplet Precautions Prevention Procedures...15 Airborne Precautions...15 Airborne Precautions Prevention Procedures...16 Which Respirator?...17 CHAPTER 4: INFLUENZA Seasonal and 2009 H1N1 Influenza...21 Influenza Principles...21 CHAPTER 5: SYNDROMIC PRECAUTIONS Initiate Precautions Immediately...22 If in Doubt...22 Case Feedback...26 CHAPTER 6: ASEPTIC TECHNIQUES AND OTHER MEASURES TO PREVENT SURGICAL SITE AND OTHER PROCEDURE RELATED INFECTIONS What Are Aseptic Techniques?...27 Surgical Site Infection Prevention...27 The Gold Standard /48

2 Examples of Additional Aseptic Practices Required for Common Clinical Procedures...30 Chronic Wound Care/Dressing Changes...31 Case: Hepatitis C Outbreak...32 What Are Aseptic Techniques?...32 Other Practices/Procedures Outside the Operating Room...33 The Gold Standard...33 Examples of Additional Aseptic Practices Required for Common Clinical Procedures...33 Wound Care/Dressing Changes...35 CHAPTER 8: IMMUNIZATION & TESTING Patient Safety Precautions...37 Healthcare Worker Safety Precautions...39 Influenza Vaccination is Recommended for All Healthcare Workers!...40 Follow Post Exposure Rules...41 Get Screened for TB...41 POST TEST ASSESSMENT /48

3 Chapter 1: Introduction About Quizzes A quiz will be given at the end of each of the two infection control modules. If you score less than the 80% correct, you will need to go back and retake it. Questions and cases presented during the course are not scored. About Evaluation An evaluation form will appear after you've taken the quiz. We welcome your recommendations for improving the training. Timothy H. Dellit, MD Medical Director, Infection Control Associate Medical Director Harborview Medical Center Estella Whimbey, MD Medical Director, Healthcare Epidemiology and Infection Control, Employee Health Associate Medical Director University of Washington Medical Center Audio text Tim Dellit audio text Infection Control is a vital part of patient safety concerned with the prevention of healthcare associated infections and the transmission of infectious agents among patients and healthcare workers. Every year, there are 2 million healthcareassociated infections in this country responsible for 90,000 deaths. The emergence of multidrug resistant organisms such as MRSA, VRE, and Acinetobacter has been associated with increased patient morbidity and mortality, increased length of stay, and increased healthcare costs. Estella Whimbey audio text Fundamental infection control measures such as hand hygiene, respiratory hygiene, standard and transmission based precautions, aseptic techniques, and immunization against vaccine preventable diseases play a significant role in preventing the transmission of infectious agents within the healthcare setting. We hope that the infection control concepts in this module will help you to protect your patients, your co workers, and yourself. Learning Objectives At the end of this module you will be able to: 1. Implement standard precautions as well as the expanded transmission based precautions including: 2. Contact Precautions (and Contact Enteric Precautions) 3. Droplet Precautions 4. Airborne Precautions 5. As part of standard and transmission based precautions o o Explain how and when to perform hand hygiene, with either alcohol based products or soap and water List the principles of respiratory hygiene and cough etiquette which apply to patients as well as healthcare workers. 3/48

4 o Describe when and how to use personal protective equipment, including how to don and remove: Gloves Gowns Hats Eye protection Surgical masks N95 respirators PAPRs 6. Outline syndromic strategies for isolation and management of patients with various clinical syndromes, such as respiratory illnesses, diarrheal illnesses, and rash. 7. Outline necessary steps for aseptic techniques when performing wound dressing changes and doing sterile procedures such as insertion of central vascular catheters, lumbar puncture, paracentesis, thoracentesis, and chest tube insertion (CHANGED ORDER TO REFLECT CHANGING ORDER OF CHAPTER 5 AND CHAPTER 6). 8. Describe the risks involved in bloodborne pathogen exposures and how to prevent and manage exposure to bloodborne pathogens. 9. Recognize the need for all healthcare workers to be screened for tuberculosis at a minimum of once a year, and to provide documentation for immunity to vaccine preventable diseases such as measles, mumps, rubella, varicella, hepatitis B and pertussis. Physicians will also be able to explain the importance of influenza vaccination for themselves and their patients. Infection Control Monitoring & Consequences Infection Control is a vital part of patient safety and is involved in the surveillance and prevention of healthcareassociated infections (HAI) and transmission of infectious pathogens. Healthcare associated infections Catheter associated bloodstream infections (see Central Line Module for more detail) Surgical site infections (see Patient Safety Module for more detail) Ventilator associated pneumonia Catheter associated urinary tract infections Multidrug resistant/marker organisms MRSA VRE Carbapenem resistant Acinetobacter ESBL producing organisms C. difficile Aspergillus Tuberculosis Influenza Who monitors healthcare associated infections (HAI)? In addition to reporting rates of HAI internally through departmental and hospital quality improvement programs, process and outcome measures related to HAI are reported externally through quality organizations such as: University HealthSystem Consortium The Joint Commission Centers for Medicare & Medicaid Services Washington State Department of Health CDC National Healthcare Safety Network 4/48

5 Washington State House Bill 1106 was passed in 2007 requiring the mandatory reporting of healthcareassociated infections by all hospitals in Washington State including: July 1, 2008: Central line associated bloodstream infections in the ICU January 1, 2009: Ventilator associated pneumonia January 1, 2010: Selected surgical site infections o Cardiac surgery o Total hip and knee arthroplasty o Hysterectomy What is the consequence of mandatory HAI reporting? HAI affects audit scores and payment for services. The Centers for Medicare & Medicaid Services will no longer pay for complications that occur in the hospital including: Oct 1, 2008 Oct 1, 2009 Future rule considerations Object left in during Surgical site infection: MRSA surgery Spinal surgery C. difficile Air embolism Elbow arthroplasty Ventilator associated Blood incompatibility Shoulder arthroplasty pneumonia Catheter associated UTI Bariatric surgery Pressure ulcers DVT/PE Vascular catheterassociated infection Surgical site infection: Mediastinitis after CABG Hospital acquired injury, i.e. falls 5/48

6 Chapter 2: Standard Precautions Standard precautions apply to all patients all the time Standard Precautions combine the major features of Universal Precautions and Body Substance Isolation based on the principle that all blood, body fluids, secretions, excretions except sweat, non intact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions apply to all patients regardless of suspected or confirmed infection. In addition to hand hygiene, the use of personal protective equipment (PPE) may be indicated depending on the nature of your interaction with the patient and extent of anticipated exposure. Equipment or items in the patient's environment (room) are likely to be contaminated and should be thought of as an extension of the patient. Clean Your Hands Frequently! Hand hygiene is the single most important step you can take to reduce transmission of infectious agents. Clean your hands before and after contact with a patient or the patient's environment. As you may not always be able to anticipate potential contact with the patient or their environment, you are expected to perform hand hygiene upon entering and exiting the patient s room, both in the hospital as well as in the clinics. Gloving does not replace the need to perform hand hygiene. Use either an alcohol based product or soap and water. When MUST you use soap and water? Do It Right When your hands are visibly soiled or you are caring for a patient with Clostridium difficile (alcohol will not kill the spores). Improved hand hygiene has been associated with decreased transmission of resistant organisms, such as methicillin resistant Staphylococcus aureus (MRSA), and decreased incidence of healthcare associated infections, such as MRSA bacteremia. Use alcohol based products effectively: 1. Apply product to palm of one hand. Follow manufacturer's recommendation for volume of product to use (usually an amount adequate to keep hands wet for at least 15 seconds). 2. Rub hands together, covering all surfaces of hands and fingers, until hands are dry. Use soap and water effectively: 1. Wet hands first with water not hot water because repeated exposure may increase the risk of dermatitis. 6/48

7 2. Apply product to hands. Follow manufacturer's recommendation for amount of product to use. 3. Rub hands together vigorously for at least 15 seconds, covering all surfaces of hands and fingers. 4. Then rinse hands with water. 5. Dry thoroughly with disposable towel. Use towel to turn off faucet and open door, where needed. Use Respiratory Hygiene/Cough Etiquette Everyone healthcare workers, patients and visitors with signs and symptoms of a respiratory illness should take precautions to prevent transmission. Do It Right Cover your mouth and nose when you cough or sneeze. Use a tissue, your upper sleeve, or your elbow not your hands. Dispose of used tissues in the wastebasket. Wear a surgical mask, if tolerated. Clean your hands frequently. Stay > 3 feet from others. Healthcare workers with influenza like illness including fever and cough or sore throat should stay home until fever and respiratory symptoms resolve for 24 hours. Similarly, in order to protect our patients, visitors with influenza like illness should be instructed that they are welcome to return to the hospital once their symptoms have resolved for 24 hours. Wear Personal Protective Equipment to Protect Yourself and Patients Personal Protective Equipment (PPE) Personal Protective Equipment (PPE) includes a variety of barriers used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents. Appropriate barriers depend on your interaction with the patient. Sequence Matters Donning and removing PPE carefully and in the correct order increases its effectiveness as a barrier. You may contaminate your body, your clothes, your patient, other people or the environment if you don't put on PPE properly or if you remove it sloppily or out of sequence. Perform hand hygiene immediately before donning any PPE. Put on PPE outside a patient room right before going in. 1. Cap 2. Gown 3. Surgical mask or respirator 4. Eye protection 5. Gloves 7/48

8 Remove all PPE at the doorway of a patient room before you leave (or in the anteroom if there is one), unless you are wearing a respirator. Dispose of PPE properly, and then perform hand hygiene immediately. 1. Gloves 2. Eye Protection 3. Gown 4. Surgical mask or respirator 5. Cap If wearing a respirator: Remove gloves, eye protection, and gown before leaving the room. Perform hand hygiene. Leave the room, and close the door. Don clean gloves. Remove respirator (and cap, if you are wearing both), and discard or disinfect, as appropriate. Remove gloves. Perform hand hygiene. More details about respirator use appears later in this course. Remember to perform hand hygiene after removing and disposing of PPE! Caps Maximize Protection Don a cap any time it may be necessary to prevent contact with potentially infectious agents, such as to protect yourself from a patient's body fluids. Caps or hair coverings are standard PPE when performing invasive procedures, such as placement of a central line. They are part of maximal barrier precautions, which are covered later in this course and include: hand hygiene, sterile gown, cap, mask, sterile gloves and full body drape. Gowns Guard Against Body Fluids Protect your skin and clothing from coming into direct contact with blood, other body fluids, or other possible contaminants by wearing a gown. Every time you wear a moisture or fluid repellent gown, also wear gloves. Do It Right Putting on gown: 1. Put on gown with opening at the back. 2. Secure at neck and waist. o If gown is too small to close completely behind you, use two gowns: Gown #1 ties in front, gown #2 ties in back. 3. Extend gloves over gown cuffs. Removing gown: 8/48

9 1. Unfasten ties. 2. Peel gown away from neck and shoulders. 3. Turn contaminated outside toward the inside. 4. Fold or roll into a bundle. 5. Discard in waste/laundry container. 6. Perform hand hygiene. White coats and scrubs are NOT PPE and are not substitutes for a moisture or fluid repellent gown. If your personal attire is soiled, the hospital will launder your clothing. Please read the policy on inadvertent soiling of personal attire. Eye Protection Glasses Aren't Enough Use either a face shield, a mask with an attached eye shield, or a respirator with goggles to help prevent splash and large droplet exposure to your eyes and face. Clean and disinfect any reusable eye protection (such as wrap around Gargoyles) after you remove them. Do It Right Putting on face shield: 1. Position face shield over face. 2. Secure on brow with headband. 3. Adjust to fit comfortably Putting on goggles: 1. Position goggles over eyes. 2. Secure to head using earpieces or headband. 3. Adjust to fit comfortably. Removing goggles or a face shield: 1. Grasp earpieces or headband. 2. Lift away from face. 3. Discard in designated receptacle for reprocessing or disposal. Eyeglasses and contact lenses are NOT considered adequate eye protection. Gloving Protect Your Hands from Contamination Gloving protects you from direct contact with potentially infectious material from these sources: 9/48

10 On or inside a patient, such as in blood, other body fluids, or mucous membranes In a patient's environment, such as on equipment, bedding, or other surfaces As part of standard precautions, wear gloves when you anticipate direct contact with blood or body fluids, mucous membranes, non intact skin, and other potentially infectious material. Don gloves last after any other PPE you need. Remove gloves first before any other PPE you're wearing. Follow "Dirty" to "Clean" Guidelines: Change to new gloves and perform hand hygiene when going from "dirty" to "clean" areas. Also change to new gloves when your gloves are damaged or heavily soiled. 10/48

11 Do It Right Putting on gloves: 1. Insert hands into gloves. 2. Extend gloves over cuffs of gown, if wearing gown. Removing gloves: 1. Grasp outside of first glove near wrist with other gloved hand. 2. Peel away from hand, turning glove inside out. 3. Hold first glove in remaining gloved hand. 4. Slide ungloved fingers under wrist of second glove. 5. Peel second glove off, over first glove, creating a bag with the contaminated surface on the inside. 6. Discard in waste container. Gloving does not replace the need to clean your hands. Perform hand hygiene before putting on gloves and after removing them. Case: 34 Year Old man On morning rounds you assist in performing a dressing change on a 34 year old man with a 10 x 20 cm open wound with considerable serosanguinous drainage that soaks the dressing and his sheets. Which of the following statements is correct? A. Since this patient is not known to be colonized with a resistant organism, "Standard Precautions" should be used without the need for gloves or gown. B. Hand hygiene is not required if gloves are worn to change the dressing. C. "Standard Precautions" for this patient would include hand hygiene before and after contact with the patient or his environment and the use of gown and gloves when performing the dressing change. D. "Standard Precautions" only apply to bloodborne pathogens. Case Feedback On morning rounds you assist in performing a dressing change on a 34 year old man with a 10 x 20 cm open wound with considerable serosanguinous drainage that soaks the dressing and his sheets. Correct/Incorrect Answers A. This answer is incorrect. "Standard Precautions" apply to all patients regardless of their diagnosis or presumed infection status. As part of "Standard Precautions" gloves and gown should be used for patient care activities involving contact with bodily substances. 11/48

12 B. This answer is incorrect. Although gloves should be worn in this situation, the wearing of gloves does not replace the need for hand hygiene. Gloves may have small unapparent defects or may be torn during use, and hands can become contaminated during the removal of gloves. C. This answer is correct. Hand hygiene provides the foundation of "Standard Precautions" with the use of gloves when touching blood, body fluids, secretions, excretions, mucous membranes, and non intact skin. Gowns should be used to prevent soiling of clothing during patient care activities that are likely to pose a risk of contact with blood, body fluids, secretions, or excretions. D. This answer is incorrect. "Standard Precautions" apply to not only blood, but all body fluids, secretions, and excretions (except sweat), non intact skin, and mucous membranes in order to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. 12/48

13 Chapter 3: Expanded Precautions Expanded, Transmission Based Precautions These precautions could prevent serious in some cases life threatening infections among patients, and help protect you, your family, colleagues, and other community members. Use expanded transmission based precautions in addition to standard precautions with patients suspected or known to be infected with epidemiologically important pathogens transmitted by: Contact. Contact precautions guard against pathogens that spread through contact with the patient or the patient's environment. Droplet. Droplet precautions guard against spread through large droplets, which may spread over short distances (up to three feet). Airborne. Airborne precautions guard against spread through small droplet nuclei, which remain suspended and may spread over long distances. Some conditions require multiple types of transmission based precautions, such as contact precautions and droplet precautions, or contact precautions and airborne precautions. Use of additional barriers at your discretion is always appropriate. In an effort to standardize infection control practices across hospitals, the Washington State Hospital Association has also incorporated the following additional transmission based categories and signage. Contact Enteric. Similar to contact precautions with the additional requirement that soap and water must be used upon exiting the room due to a diarrheal illness such as Clostridium difficile or norovirus. Airborne Respirator. This is to distinguish an illness such as tuberculosis which requires use of a PAPR or N95 respirator from an illness which requires previous immunity such as varicella zoster. Contact Precautions Use To Prevent transmission of epidemiologically important microorganisms that may spread by direct contact with the patient or the patient's environment, which can be a major source of transmission. In particular, Contact Precautions are used to prevent the transmission of multidrug resistant organisms such as MRSA or VRE. Consider this chart showing the percent of surfaces positive for MRSA in the environment of an infected patient. Use With Patients suspected or known to be infected with microorganisms that can be transmitted by direct contact. Examples: MRSA Vanocomycin resistant enterococci 13/48

14 Highly resistant Gram negative bacteria such as carbapenem resistant Acinetobacter or extended spectrum beta lactamase producing organisms Clostridium difficile Contact Precautions Prevention Procedures Follow These Steps Place patient in a private room, if feasible, or cohort with patients with the same organism. Limit patient movement from room to essential purposes. If movement is necessary, contain and cover the infected or colonized areas of the patient's body. Before entering patient room, in which order should you do the following? Flash text Before entering the patient room, in which order should you do the following? o Perform hand hygiene. o Put on PPE in this order: 1. Gown 2. Gloves Before leaving the patient room, in which order should you do the following? o o Remove PPE in this order: 1. Gloves 2. Gown Perform hand hygiene. Contact Enteric Precautions For patients with suspected or confirmed Clostridium difficile disease or other diarrheal illness such as norovirus. Gown and gloves are required for entering the room. For hand hygiene, wash hands with soup and water. Alcohol based gel or foam is not sufficient for sporeforming organisms or to remove potential fecal soilage. Droplet Precautions Use To Prevent transmission of microorganisms in large respiratory droplets (> 5 microns) generated by coughing, sneezing, or talking, or by cough inducing procedures. 14/48

15 Use With Patients suspected or known to be infected with microorganisms that can be transmitted by large respiratory droplets. Examples: Influenza Meningococcal meningitis Pertussis Respiratory syncytial virus (RSV) Some conditions require multiple types of transmission based precautions, such as contact and droplet precautions. Examples: Influenza, RSV, and adenovirus. Droplet Precautions Prevention Procedures Follow These Steps Place patient in a private room, if feasible, or cohort with patients with the same infection. Maintain spatial separation > 3 feet. Limit patient movement from room. If movement is necessary, place surgical mask on patient, if tolerated. Airborne Precautions Use To Prevent transmission of microorganisms in droplet nuclei (small respiratory droplets, < 5 microns) or dust particles. Airborne precautions include special air handling because droplet nuclei/small droplets remain suspended in the air for long periods of time and can be dispersed a great distance from the source by air currents. Use With Patients suspected or known to be infected with microorganisms that can be transmitted by droplet nuclei/small droplets. Examples Tuberculosis (TB). (PAPR or N95 required with Airborne Respirator signage.) Measles (rubeola). (Surgical mask is sufficient. PAPR or N95 not required.) Varicella zoster (chicken pox or disseminated herpes zoster, or in immunocompromised patients localized herpes zoster). (Surgical mask is sufficient. PAPR or N95 not required.) Some conditions require multiple types of transmission based precautions, such as contact and airborne precautions. Examples: PAPR or N95 AND gown and gloves: severe acute respiratory syndrome (SARS), small pox, monkeypox, avian 15/48

16 influenza and viral hemorrhagic fevers. Surgical mask AND gown and gloves: varicella (chicken pox) Airborne Precautions Prevention Procedures Follow These Steps For all infections with microorganisms that can be transmitted by droplet nuclei/small droplets: Place patient in a private, negative pressure room, and keep the door closed except for entry and exit. Monitor to ensure negative pressure with 6 to 12 air changes per hour. Limit patient movement from room. If movement is necessary, place surgical mask on patient, if tolerated. Follow either Scenario #1 or Scenario #2, below. Scenario #1 (for TB) Before entering the patient room: 1. Perform hand hygiene. 2. Put on respirator. After leaving the patient room: 1. Remove respirator. 2. Perform hand hygiene. Scenario #2 (for other infections requiring airborne and contact precautions) Before entering the patient room, in which order should you do the following? Perform hand hygiene. Put on PPE in this order: 1. Gown 2. Respirator 3. Eye protection if not using a PAPR, but using a fitted N95 mask 4. Gloves Before leaving the patient room, in which order should you do the following? Remove PPE in this order: 1. Gloves 2. Eye protection 3. Gown Perform hand hygiene. After leaving the patient room: 16/48

17 Close the door. Put on clean gloves. Remove respirator. Discard or disinfect as appropriate. Remove gloves. Perform hand hygiene. Which Respirator? Your respirator must be a NIOSH approved, fitted N95 respirator (disposable particulate respirator) or a higher filtrating device, such as a PAPR, depending on the requirements at your facility. PAPRs Preferred for aerosol generating procedures Require training for proper use Currently the preferred respirators for tuberculosis at UWMC and HMC N95 Masks Must be fit tested annually Require training for proper use Must check seal each time worn Cannot be worn by those with beards PAPR How To Key Points Test battery before each use. If patient has TB, you can reuse the head cover if it's not soiled or torn. Disinfect the head cover after each use. For all other airborne diseases, discard head cover in a biohazardous waste container after single use. Disinfect battery pack and hose after use. Putting on the PAPR 1. Unplug the PAPR battery unit and hose from the charger. 2. Turn the PAPR on by pressing the gray button. 3. Perform an airflow check prior to each use: o Hold the distal end of the air hose (without head cover attached) vertically. o Drop the bullet shaped airflow indicator, cone pointed down, into the open end of the air hose. o Cover the slots at the end of the air hose. o The indicator cone should float high enough for the lower band on the cone to rise above the rim of the airflow hose. o If the airflow is inadequate, place a defective equipment sticker on the PAPR and test a different unit. o After testing for airflow, return the bullet shaped airflow indicator cone to the cart. 4. Attach the airflow unit around your waist. 5. Insert the slotted end of the hose tube into the head cover. 6. If the head cover is new, remove the protective paper from the face shield. 17/48

18 7. Put on and fasten the head cover. 18/48

19 Removing the PAPR 1. Unfasten and remove the head cover. o If being used for a TB patient, disinfect head cover and store for reuse. o If being used for a patient with another airborne disease, discard head cover into a biohazardous waste container. 2. Unfasten airflow unit from your waist. 3. Disinfect the hose and waist pack with a SaniCloth or CaviCide. 4. Deglove, and perform hand hygiene. 5. Replace and connect the disinfected PAPR hose and battery unit on the cart. 6. Verify unit is plugged into an electrical outlet. N95 Respirator How To Key Points Do not enter a contaminated area if you can't get a proper fit. Follow the seal check instructions for your particular fitted N95 each time you use it. Putting on the N95 Check face shield fit before entering any patient room. Adjust nosepiece if there is leakage around the nose. Adjust headbands if need to create a secure facial seal around the edges of the respirator. You are required to go through a yearly training and evaluation, which includes a health questionnaire, in order to use an N95 respirator. Case: 35 Y.O. Man A 35 year old man suffers multiple injuries in a motor vehicle accident and requires intubation in the intensive care unit. On hospital day 5 he develops increasing fever, pulmonary infiltrates, and purulent endotracheal secretions. Due to concern for ventilator associated pneumonia, a quantitative bronchoalveolar lavage is performed demonstrating 50,000 colonies of methicillin resistant Staphylococcus aureus (MRSA). Which of the following infection control statements is correct? A. The patient should be placed in contact precautions with the use of gown and gloves only for those individuals with direct patient contact. Members of the team checking labs on the computer or adjusting equipment in the patient's room do not need to gown and glove. B. The patient should be placed in contact precautions with the use of gown and gloves for any contact with the patient or their environment and the use of masks and faceshields per standard precautions. C. The patient should remain in contact precautions until treatment of his infection is complete at which point he can come out of isolation. D. Hand hygiene is not necessary if gloves are worn when caring for the patient. 19/48

20 Case Feedback A 35 year old man suffers multiple injuries in a motor vehicle accident and requires intubation in the intensive care unit. On hospital day 5 he develops increasing fever, pulmonary infiltrates, and purulent endotracheal secretions. Due to concern for ventilator associated pneumonia, a quantitative bronchoalveolar lavage is performed demonstrating 50,000 colonies of methicillin resistant Staphylococcus aureus (MRSA). Correct/Incorrect Answers A. The patient should be placed in contact precautions with the use of gown and gloves only for those individuals with direct patient contact. Members of the team checking labs on the computer or adjusting equipment in the patient's room do not need to gown and glove. INCORRECT. Gloves and gown should be used for any contact with the patient or their environment as the environment is frequently contaminated and should be viewed as an extension of the patient. Studies have found that 42% of gloves become contaminated with MRSA after touching items in the room without directly touching the patient. B. The patient should be placed in contact precautions with the use of gown and gloves for any contact with the patient or their environment and the use of masks and faceshields per standard precautions. CORRECT. When caring for patients on contact precautions, donning of gown and gloves should occur upon room entry with removal prior to exiting due to concern for environmental contamination. Masks and faceshields should be worn when performing aerosol generating procedures such as suctioning, endotracheal care, or intubation as part of standard precautions. C. The patient should remain in contact precautions until treatment of his infection is complete at which point he can come out of isolation. INCORRECT. Patients may remain colonized with multidrug resistant pathogens despite appropriate antimicrobial therapy. Check with infection control at your facility to determine protocols for clearance. Harborview no longer routinely clears patients with MRSA from contact precautions as in previous years < 7% of patients colonized with MRSA actually cleared during their hospitalization. D. Hand hygiene is not necessary if gloves are worn when caring for the patient. INCORRECT. The use of gloves does not replace the need for hand hygiene. Gloves may have small unapparent defects or may be torn during use, and hands can become contaminated during the removal of gloves. 20/48

21 Chapter 4: Influenza Seasonal and 2009 H1N1 Influenza The emergence of the 2009 H1N1 (swine) influenza in April 2009 has led to the development of a standardized approach to patients with suspected or confirmed influenza, regardless of subtype. These recommendations have evolved as more information is learned about the transmission and virulence of the 2009 H1N1 influenza subtype and may continue to evolve in the future. Please contact your facilities infection control program for current recommendations. Influenza Principles To reduce the risk of influenza transmission to our patients and staff, UW Medicine supports the need to have all employees vaccinated unless there is a medical contra indication. All UW Medicine employees will receive the influenza vaccine OR complete an online educational module prior to signing a declination. Staff who are experiencing flu like symptoms should not come to work until 24 hours following resolution of fever and respiratory symptoms. Visitors should be encouraged to not visit if experiencing symptoms or if they have been recently exposed to someone with the flu. All staff caring for INPATIENTS with suspected or confirmed influenza should adhere to a combination of standard, droplet and contact precautions with use of surgical mask, eye protection, gown and gloves upon entering the room. When OUTPATIENT/ED patients present to our system with flu like symptoms or cough, they should immediately be given a surgical mask to wear to cover their cough and be segregated from the general population if possible. When caring for a patient with flu like symptoms in the OUTPATIENT/ED setting, standard and droplet protection should be followed, which includes surgical mask with eye protection and gloves. Routine use of gowns is not required unless there is concern for contact with respiratory secretions. N95 respirators (or PAPRs) should be reserved for higher risk aerosol generating procedures in patients with suspected or confirmed influenza such as intubation/extubation, bronchoscopy, open suctioning of airway, or cardiopulmonary resuscitation. 21/48

22 Chapter 5: Syndromic Precautions Certain clinical syndromes warrant expanded precautions in addition to standard precautions to prevent transmission of infections, including these: Diarrheal illnesses Fever and rash Respiratory illnesses, such as influenza and tuberculosis Initiate Precautions Immediately Begin appropriate syndromic precautions from the time that you suspect such a syndrome based on the patient's presentation. Do not wait for confirmation of the diagnosis. By then, the illness may have been transmitted to you, your colleagues, other patients, and so on. You can help prevent this. If in Doubt Any time you are uncertain about whether to implement expanded precautions: Implement the precautions. and/or Contact Infection Control at your facility, and ask. Details of how to implement expanded precautions may vary by facility. Know your facility's policies. Case: 70 Year Old Woman 70 year old woman admitted from nursing home in January with sudden onset of nausea, vomiting, and uncontrollable diarrhea with reports of similar illness in other residents of the facility. She also has a history of recurrent urinary tract infections for which she has received multiple courses of antibiotics. Which of the following statements is correct? A. Since other residents have a similar illness, her presentation is most consistent with a viral illness and no special precautions need to be taken. B. Strict hand hygiene with an alcohol containing product should be done before and after contact with the patient to prevent transmission to other patients. C. Only patients who have diarrhea due to Clostridium difficile need to be placed in a private room. D. The patient should be placed in a private room with the use of gown and gloves to prevent contamination from fecal soilage. E. Healthcare workers who develop similar diarrheal symptoms can continue to engage in patient care as long as they wash their hands. 22/48

23 Case Feedback 70 year old woman admitted from nursing home in January with sudden onset of nausea, vomiting, and uncontrollable diarrhea with reports of similar illness in other residents of the facility. She also has a history of recurrent urinary tract infections for which she has received multiple courses of antibiotics. Correct/Incorrect Answers A. Since other residents have a similar illness, her presentation is most consistent with a viral illness and no special precautions need to be taken. INCORRECT. Patients with uncontrollable diarrhea should be placed in a private room with use of gown and gloves for patient care activities that involve risk of fecal contamination. In particular, this patient's presentation is consistent with norovirus like illness, which can be easily transmitted to healthcare workers and other patients without appropriate precautions. B. Strict hand hygiene with an alcohol containing product should be done before and after contact with the patient to prevent transmission to other patients. INCORRECT. Alcohol containing hand hygiene products will not remove possible soilage and are not as effective as soap and water against enteric viruses such as Norovirus or the spores of C. difficile. Due to the risk of fecal contamination, soap and water should be used after contact with a patient having diarrhea or their environment. C. Only patients who have diarrhea due to Clostridium difficile need to be placed in a private room. INCORRECT. Patients with the syndromic presentation of diarrhea should be placed in a private room while undergoing evaluation for possible infectious etiologies in order to prevent transmission to other patients. Viral causes of diarrhea such as Norovirus and Rotavirus are readily transmissible and require similar contact precautions to C. difficile. D. The patient should be placed in a private room with the use of gown and gloves to prevent contamination from fecal soilage. CORRECT. This patient should be placed in a private room due to her presentation of uncontrollable diarrhea regardless of etiology. E. Healthcare workers who develop similar diarrheal symptoms can continue to engage in patient care as long as they wash their hands. INCORRECT. Healthcare workers with diarrhea should stay home until well and avoid patient contact due to the highly transmissible nature of viruses such as Norovirus. Case: 37 Year Old Man A 37 year old man returns from Thailand with 3 day history of fever 39 C, rash starting on face extending down trunk, malaise, coryza, and non productive cough. He was sexually active with commercial sex workers during his trip and does not know his immune status. Which of the following statements is correct? A. His presentation is most likely acute HIV infection so standard precautions are adequate for his care. B. He should be placed in a negative pressure Airborne Isolation Infection Room while being evaluated for the cause of his symptoms. C. The immune status of the healthcare workers caring for him is not important as long as they wear a mask upon entering the room. D. Public health should be notified once his diagnosis is confirmed. 23/48

24 Case Feedback A 37 year old man returns from Thailand with 3 day history of fever 39 C, rash starting on face extending down trunk, malaise, coryza, and non productive cough. He was sexually active with commercial sex workers during his trip and does not know his immune status. Correct/Incorrect Answers A. His presentation is most likely acute HIV infection so standard precautions are adequate for his care. INCORRECT. While he should have an HIV RNA sent for possible acute HIV syndrome, the differential diagnosis is broad and includes viral etiologies such as measles, or varicella if vesicular. Therefore, Airborne Precautions should be used with placement in a negative pressure room. B. He should be placed in a negative pressure Airborne Isolation Infection Room while being evaluated for the cause of his symptoms. CORRECT. The patient should be placed in a negative pressure Airborne Infection Isolation room with the use of a mask and eye protection. This patient was subsequently diagnosed with measles and should remain in isolation for 4 days after the onset of rash. C. The immune status of the healthcare workers caring for him is not important as long as they wear a mask upon entering the room. INCORRECT. Only non susceptible healthcare workers should enter the room with mask and eye protection. Healthcare workers should review their vaccination and immune status for measles, mumps, and rubella with employee health. D. Public health should be notified once his diagnosis is confirmed. INCORRECT. Public health should be notified for any SUSPECTED or confirmed cases of measles to assist in diagnostic testing through the state lab and for contact investigation. In addition, infection control should be notified immediately about patients presenting with fever and a rash in order to ensure appropriate precautions are taken during their hospital stay Case: 22 Year Old Woman A 22 year old woman with history of asthma presents to emergency department in January with four day history of fever 39 C, cough, sore throat, shortness of breath, and severe myalgias. Upon further questioning, you discover that she returned from Indonesia four weeks ago after a two month visit with her family. She did not visit any open air markets or handle live poultry. Her CXR demonstrates diffuse bilateral infiltrates and due to progressive hypoxia she is intubated and placed on mechanical ventilation. Which of the following statements is correct? A. No special precautions are necessary for patients with influenza since it is not very transmissible. B. She should be placed in a private room in droplet and contact precautions with the use of a surgical mask, eye protection, gown and gloves for routine care. C. A surgical mask alone is recommended for intubation of patients with suspected or confirmed influenza. D. Although her influenza A nasopharyngeal PCR was positive, she should not be treated with antivirals since she presented more than 48 hours after symptom onset. 24/48

25 E. She should be placed into a negative pressure airborne infection isolation room with use of PAPRs due to concern for avian influenza. Case Feedback A 22 year old woman with a history of asthma presents to emergency department in January with four day history of fever 39 C, cough, sore throat, shortness of breath, and severe myalgias. Upon further questioning, you discover that she returned from Indonesia four weeks ago after a two month visit with her family. She did not visit any open air markets or handle live poultry. Her CXR demonstrates diffuse bilateral infiltrates and due to progressive hypoxia she is intubated and placed on mechanical ventilation. Correct/Incorrect Answers A. No special precautions are necessary for patients with influenza since it is not very transmissible. INCORRECT. Influenza is readily transmitted to healthcare workers and other patients within the hospital with an attack rate of 20 to 30%. All patients with suspected or confirmed influenza should be placed in droplet and contact precautions for routine care. B. She should be placed in a private room in droplet and contact precautions with the use of a surgical mask, eye protection, gown and gloves for routine care., CORRECT. Patients with suspected or confirmed influenza should be placed in a private room with the use of a surgical mask, eye protection (such as a face shield or goggles), gown and gloves upon entering the room. C. A surgical mask alone is recommended for intubation of patients with suspected or confirmed influenza. INCORRECT. When performing high risk aerosol generating procedures in patients with suspected or confirmed influenza such as intubation/extubation, bronchoscopy, or open suctioning of the airway, an N95 respirator is recommended in addition to eye protection, gown, and gloves. A PAPR may be used in place of the N95 respirator, but the hood must be appropriately cleaned to avoid self contamination as opposed to the single use N95 for patients with influenza. D. Although her influenza A nasopharyngeal PCR was positive, she should not be treated with antivirals since she presented more than 48 hours after symptom onset. INCORRECT. Recent literature suggests that treatment of hospitalized influenza patients with antivirals such as oseltamavir is associated with improved survival even if they presented more than 48 hours after symptom onset. In addition, treatment of hospitalized patients with influenza may decrease viral shedding and risk of nosocomial transmission. E. She should be placed into a negative pressure airborne infection isolation room with use of PAPRs due to concern for avian influenza. INCORRECT. It is important to screen patients who present with influenza like illness for possible avian influenza and place those patients with possible avian influenza into a negative pressure room with the use of airborne respirator and contact precautions. Risk factors for avian influenza include travel to an affected area with 10 days of symptom onset AND direct contact with poultry. While Indonesia has had avian influenza activity, this patient did not have direct poultry contact and her symptoms started more than 10 days after returning from Indonesia. Case: Multiple Patients Case 1. A 30 year old Vietnamese man presents to emergency department with one week history of worsening nonproductive cough, fever, night sweats, and right sided chest pain. CXR demonstrates a large right pleural effusion. 25/48

26 Thoracentesis is performed with 1,200 WBC (88% lymphocytes) and elevated total protein 5.4 and LDH 358 in pleural fluid meeting Light criteria for exudative pleural effusion. Case 2. A 50 year old woman from Marshall Islands with one month history of cough, pleuritic chest pain, and 10 lb. weight loss. CXR with 1.8 cm x 3.3 cm right upper lobe cavitary lesion as well as smaller cavitary lesion in left upper lobe. Case 3. A 54 year old Native American with history of HIV (CD4 276 and undetectable viral load on HIV medications) and heavy alcohol use with chronic cough "as long as he can remember" and subjective fevers. CXR with minimal inflammatory residua in superior portion of right hilum. Which of these patients should be placed in a negative pressure room for airborne infection isolation (AII) with sputum collection for AFB smear and culture? A. Patient 1 B. Patient 2 C. Patient 3 D. Patient 1 and 2 E. Patient 2 and 3 F. All three patients Case Feedback Case 1. A 30 year old Vietnamese man presents to emergency department with one week history of worsening nonproductive cough, fever, night sweats, and right sided chest pain. CXR demonstrates a large right pleural effusion. Thoracentesis is performed with 1,200 WBC (88% lymphocytes) and elevated total protein 5.4 and LDH 358 in pleural fluid meeting Light criteria for exudative pleural effusion. Case 2. A 50 year old woman from Marshall Islands with one month history of cough, pleuritic chest pain, and 10 lb. weight loss. CXR with 1.8 cm x 3.3 cm right upper lobe cavitary lesion as well as smaller cavitary lesion in left upper lobe. Case 3. A 54 year old Native American with history of HIV (CD4 276 and undetectable viral load on HIV medications) and heavy alcohol use with chronic cough "as long as he can remember" and subjective fevers. CXR with minimal inflammatory residua in superior portion of right hilum. Correct/Incorrect Answers A. Patient 1 FEEDBACK. A lymphocytic exudative pleural effusion should raise suspicion for tuberculosis (TB), and foreign born individuals currently account for 80% of the TB cases in King County. Because up to 50% of individuals with pleural TB may have a positive sputum culture, these patients should be considered potentially infectious, placed into AII, and evaluated for active pulmonary TB. However, patient 1 is not the only patient for whom this is true. 26/48

27 B. Patient 2 FEEDBACK. Tuberculosis (TB) should be considered in all patients presenting with cough and constitutional symptoms for greater than two weeks, and the finding of upper lobe infiltrates or cavitary disease necessitates evaluation for active pulmonary TB. In addition, there has been a recent outbreak of TB in individuals from the Marshall Islands. This patient should be considered potentially infectious, placed into AII, and evaluated for active pulmonary TB. However, patient 2 is not the only patient for whom this is true. C. Patient 3 FEEDBACK. HIV patients with tuberculosis (TB) may not present with classic upper lobe infiltrates. In fact, 7 to 14% of patients with HIV and culture positive pulmonary TB may have a normal CXR. Therefore, this patient with HIV infection and a chronic cough with subjective fevers should be placed into AII and evaluated for pulmonary TB despite the minimal CXR findings. However, patient 3 is not the only patient for whom this is true. D. Patient 1 and 2 FEEDBACK. All three patients should be placed into AII and evaluated for active pulmonary tuberculosis (TB). See feedback for A., B. and C. for specifics. E. Patient 2 and 3 FEEDBACK. All three patients should be placed into AII and evaluated for active pulmonary tuberculosis (TB). See feedback for A., B. and C. for specifics. F. All three patients FEEDBACK. All three patients should be placed into AII and evaluated for active pulmonary tuberculosis (TB). See feedback for A., B. and C. for specifics. Chapter 6: Aseptic Techniques and Other Measures to Prevent Surgical Site and Other Procedure Related Infections What Are Aseptic Techniques? Aseptic technique: a set of practices performed before, during, and after a clinical procedure to minimize contamination by microorganisms and the risk of post surgical/procedural infection. These practices include: Vigorous hand hygiene Cleansing of the surgical/procedural site with an antiseptic agent Sterile drapes Surgical/procedural attire: sterile gloves and gowns; masks; eye protectors; and caps Sterile equipment Maintenance of a sterile surgical/procedural site and field "No touch" techniques Surgical Site Infection Prevention 27/48