UW Medicine Infection Control Training Module

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... 13 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... 21 Seasonal and 2009 H1N1 Influenza...21 Influenza Principles...21 CHAPTER 5: SYNDROMIC PRECAUTIONS... 22 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... 27 What Are Aseptic Techniques?...27 Surgical Site Infection Prevention...27 The Gold Standard...30 1/48

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... 37 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... 44 2/48

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In addition to meticulous aseptic practices, there are many other practices that should be closely adhered to in order to minimize the risk for surgical site infection. Pre operatively Treat remote infections Encourage smoking cessation Ensure that the patient takes antiseptic showers or baths Avoid removal of hair or use clippers or a dipilatory method; no razors Perform surgical hand antisepsis prior to donning sterile gloves. Remove rings, watches, and bracelets. Remove debris from underneath fingernails. Perform surgical hand antisepsis using either an antimicrobial soap or an alcohol based hand rub with persistent activity. When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, usually 2 6 minutes. Longer scrub times (e.g. 10 minutes) are not necessary. When using an alcohol based surgical hand scrub product, follow the manufacturer's instructions. Before applying the alcohol solution, prewash and dry hands and forearms completely. After application of the alcohol based product, allow hands and forearms to dry thoroughly before donning sterile glove. Intraoperatively/Perioperatively Rigorously practice sterile technique Don surgical attire: sterile gloves and gowns; masks; eye protectors; hair covers Cleanse the surgical site with an antiseptic agent Antibiotic Prophylaxis. Administer intravenous antimicrobial prophylaxis within 1 hour before incision (or within 2 hours for vancomycin and fluorquinolones). Use an antimicrobial prophylactic agent consistent with published guidelines. Discontinue use of prophylactic antibiotics within 24 hours after surgery (or 48 hours for cardiothoracic procedures). Maintain normothermia perioperatively 28/48

Control blood glucose level perioperatively Restrict infected personnel Limit personnel traffic in the operating room Post operatively Protect the surgical site with a sterile dressing for 24 48 hours postoperatively. Use sterile technique (sterile gloves, dressings and equipment) when caring for and changing a dressing on surgical incisions which remain open or have a drain. Prevent other post op infections e.g. catheter related bloodstream infections, ventilator associated pneumonia, catheter associated urinary tract infections Other Practices/Procedures Outside the Operating Room There are many other practices/procedures that require aseptic technique. These include procedures involving breach of the skin and mucous membranes, or instrumentation of the vasculature or other normally sterile bodily sites such as: Intravascular procedures Insertion of and care of non-vascular catheters/drains (e.g. foley catheters and chest tubes) Lumbar puncture Thoracentesis, paracentesis, arthrocentesis Preparing and administrating parenteral medications and solutions 29/48

The Gold Standard The operating room is the gold standard for maximum aseptic practices during all surgical procedures. During procedures performed outside the operating room there is some variability in the stringency of the aseptic practices required during different procedures. However, all procedures require: Hand hygiene Gloves Cleansing of the insertion/procedural site with an antiseptic agent Sterile equipment Meticulous care to prevent contamination of o hands o surgical attire o equipment o procedural site after application of the antiseptic agent. Any PPE needed to prevent the contamination of the healthcare worker with the blood and bodily fluids of the patient. Examples of Additional Aseptic Practices Required for Common Clinical Procedures Vascular Catheter Insertion Central venous catheters (CVCs) carry a substantially greater risk for infection than peripheral intravenous catheters (PIV). Therefore, the level of barrier precautions needed to prevent infection during insertion of CVCs is more stringent. CVC PIV During insertion use: Maximal sterile barrier precautions (sterile gown, sterile gloves, mask, cap, and full body sterile drape) Non-sterile gloves No drapes Other Lumbar Punctures Foley Catheter Insertion Arthrocentesis, Thoracentesis, Paracentesis Sterile gloves and sterile drape Sterile gloves and sterile drape Sterile gloves and sterile drape Wear a face mask to prevent the droplet transmission of oral Single-use packet of sterile lubricant jelly 30/48

pharyngeal flora when placing a catheter or injecting material into the spinal or epidural space as in milligrams, spinal and epidural anesthesia, intrathecal chemotherapy. Sterile, continuously closed drainage system. Aseptic Technique is Mandatory When Preparing and Administering Parenteral Medications Multidose vials of medication/solutions can become vehicles for transmitting infections between patients. Whenever possible, use single dose vials, especially when medications will be administered to multiple patients. Before filling a syringe from a multidose vial wipe the top with 60-70% alcohol. Do not reinsert used needles or syringes into a multiple-dose medication/solution vial. Use a sterile, single use, disposable needle and syringe for each injection. Chronic Wound Care/Dressing Changes Residents must consistently follow aseptic principles and maintain clean technique when performing chronic wound care/dressing changes: Explain procedure to the patient Remove the existing dressing: 1. Wash/gel hands 2. Don non sterile gloves 3. Loosen and remove dressing(s) one-by-one. If dressings are difficult to remove, use sterile saline to assist in loosening them. Be careful not to dislodge drains or tubes. Pull the tape toward the wound. 4. Discard soiled dressings appropriately 5. Remove and discard non-sterile gloves 6. Wash/gel hands Dress the wound: 1. Don a new pair of non sterile gloves 2. Observe the wound for signs of complications and/or wound infection 3. Perform any special procedures such as obtaining cultures, irrigating the wound, packing, or cleansing 4. Dress the wound (dress the wound site first, followed by the drain site) 5. Place drain sponges around any drain o Place two sponges over penrose drains 6. Place a cover dressing over the primary dressing 7. Secure dressing 8. Remove gloves & discard appropriately 31/48

9. Wash/gel hands Case: Hepatitis C Outbreak A large outbreak of hepatitis C virus infections is reported among patients in an outpatient clinic. Lapse of adherence to which basic principles of aseptic technique for the preparation and administration of parenteral medications could explain how this outbreak occurred? A. Reuse of contaminated syringes and/or needles to sequentially administer medications to multiple patients. B. Contamination of multi dose vials of saline or parenteral medication used on multiple patients. C. Contamination of instruments and medical equipment, as in hemodialysis units. D. A substance abusing healthcare worker infected with hepatitis C who self injects patient narcotics and then reuses the needle to inject patients. E. All of the above. Aseptic Technique Case Feedback A large outbreak of hepatitis C virus infections is reported among patients in an outpatient clinic. Correct/Incorrect Answers A. Reuse of contaminated syringes and/or needles to sequentially administer medications to multiple patients. B. Contamination of multi dose vials of saline or parenteral medication used on multiple patients. C. Contamination of instruments and medical equipment, as in hemodialysis units. D. A substance abusing healthcare worker infected with hepatitis C who self injects patient narcotics and then reuses the needle to inject patients. E. All of the above. FEEDBACK. All of these unsafe injection practices have been reported to cause large outbreaks of hepatitis C infections and other blood borne pathogen infections among patients. It is imperative to follow strict aseptic technique and safe injection practices when administering parenteral therapy. Chapter 7: Aseptic Techniques What Are Aseptic Techniques? 32/48

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 Other Practices/Procedures Outside the Operating Room There are many practices/procedures that require aseptic technique. These include procedures involving breach of the skin and mucous membranes, or instrumentation of the vasculature or other normally sterile bodily sites such as: Surgical site incisions Intravascular procedures Insertion of and care of non vascular catheters/drains (e.g. foley catheters and chest tubes) Lumbar puncture Thoracentesis, paracentesis, arthrocentesis Preparing and administrating parenteral medications and solutions The Gold Standard The operating room is the gold standard for maximum aseptic practices during all surgical procedures. During procedures performed outside the operating room there is some variability in the stringency of the aseptic practices required during different procedures. However, all procedures require: Hand hygiene Gloves Cleansing of the insertion/procedural site with an antiseptic agent Sterile equipment Meticulous care to prevent contamination of o hands o surgical attire o equipment o procedural site after application of the antiseptic agent. Any PPE needed to prevent the contamination of the healthcare worker with the blood and bodily fluids of the patient. Examples of Additional Aseptic Practices Required for Common Clinical Procedures 33/48

Vascular Catheter Insertion Central venous catheters (CVCs) carry a substantially greater risk for infection than peripheral intravenous catheters (PIV). Therefore, the level of barrier precautions needed to prevent infection during insertion of CVCs is more stringent. CVC PIV During insertion use: Maximal sterile barrier precautions (sterile gown, sterile gloves, mask, cap, and full body sterile drape) Non sterile gloves No drapes Surgical Site Incision Care Protect with a sterile dressing for 24 48 hours postoperatively. Use sterile technique (sterile gloves, sterile dressings and equipment) when caring for and changing a dressing on surgical incisions which remain open or have a drain. Other Lumbar Punctures Foley Catheter Insertion Arthrocentesis, Thoracentesis, Paracentesis Sterile gloves and sterile drape Sterile gloves and sterile drape Sterile gloves and sterile drape Wear a face mask to prevent the droplet transmission of oral pharyngeal flora when placing a catheter or injecting material into the spinal or epidural space as in milligrams, spinal and epidural anesthesia, intrathecal chemotherapy. Single use packet of sterile lubricant jelly Sterile, continuously closed drainage system. Aseptic Technique is Mandatory When Preparing and Administering Parenteral Medications Multidose vials of medication/solutions can become vehicles for transmitting infections between patients. Whenever possible, use single dose vials, especially when medications will be administered to multiple patients. Before filling a syringe from a multidose vial wipe the top with 60 70% alcohol. Do not reinsert used needles or syringes into a multiple dose medication/solution vial. 34/48

Use a sterile, single use, disposable needle and syringe for each injection. Wound Care/Dressing Changes Residents must consistently follow aseptic principles and maintain clean technique when performing wound care/dressing changes: Explain procedure to the patient Remove the existing dressing: 7. Wash/gel hands 8. Don non sterile gloves 9. Loosen and remove dressing(s) one by one. If dressings are difficult to remove, use sterile saline to assist in loosening them. Be careful not to dislodge drains or tubes. Pull the tape toward the wound. 10. Discard soiled dressings appropriately 11. Remove and discard non sterile gloves 12. Wash/gel hands Dress the wound: 10. Don a new pair of non sterile gloves 11. Observe the wound for signs of complications and/or wound infection 12. Perform any special procedures such as obtaining cultures, irrigating the wound, packing, or cleansing 13. Dress the wound (dress the wound site first, followed by the drain site) 14. Place drain sponges around any drain o Place two sponges over penrose drains 15. Place a cover dressing over the primary dressing 16. Secure dressing 17. Remove gloves & discard appropriately 18. Wash/gel hands Case: Hepatitis C Outbreak A large outbreak of hepatitis C virus infections is reported among patients in an outpatient clinic. Lapse of adherence to which basic principles of aseptic technique for the preparation and administration of parenteral medications could explain how this outbreak occurred? A. Reuse of contaminated syringes and/or needles to sequentially administer medications to multiple patients. B. Contamination of multi dose vials of saline or parenteral medication used on multiple patients. C. Contamination of instruments and medical equipment, as in hemodialysis units. D. A substance abusing healthcare worker infected with hepatitis C who self injects patient narcotics and then reuses the needle to inject patients. 35/48

E. All of the above. Aseptic Technique Case Feedback A large outbreak of hepatitis C virus infections is reported among patients in an outpatient clinic. Correct/Incorrect Answers A. Reuse of contaminated syringes and/or needles to sequentially administer medications to multiple patients. B. Contamination of multi dose vials of saline or parenteral medication used on multiple patients. C. Contamination of instruments and medical equipment, as in hemodialysis units. D. A substance abusing healthcare worker infected with hepatitis C who self injects patient narcotics and then reuses the needle to inject patients. E. All of the above. FEEDBACK. All of these unsafe injection practices have been reported to cause large outbreaks of hepatitis C infections and other blood borne pathogen infections among patients. It is imperative to follow strict aseptic technique and safe injection practices when administering parenteral therapy. 36/48

Chapter 8: Immunization & Testing Patient Safety Precautions Vaccines are one of the greatest achievements of biomedical science and public health. 80% declines in cases and deaths for vaccine preventable diseases. 25% decline in deaths due to Streptococcus pneumoniae 48% reduction in risk of death in influenza patients over 65 years of age Click for more information Vaccines have led to declines greater than 80% in cases and deaths for vaccine preventable diseases such as diphtheria, mumps, pertussis, tetanus, hepatitis A, hepatitis B, Haemophilus influenzae type b and varicella (JAMA 2007;298:2155 62). Cases and deaths due to invasive Streptococcus pneumoniae have decreased by 34% and 25%, respectively, with prior vaccination associated with improved survival, decreased respiratory failure, and length of stay among hospitalized patients with pneumococcal pneumonia (Clin Infect Dis 2006;42:1093 101). Seasonal influenza accounts for 225,000 hospitalizations and 36,000 deaths each year in the United States with greatest impact on the very young and elderly. Influenza vaccination has been associated with 27% reduction in risk of hospitalization and 48% reduction in risk of death in patients over 65 years of age (N Engl J Med 2007;357:1373 81) as well as in patients with co morbid conditions. 37/48

Hospitals are now graded on their ability to vaccinate high risk patients for S. pneumoniae and Influenza. Persons for whom annual influenza vaccination is recommended All children aged 6 months 18 years All persons aged > 50 years Pregnant women Adults and children with chronic pulmonary, cardiovascular, renal hepatic, hematological, or metabolic disorders Adults and children with immunosuppressive conditions Adults and children with neurological disorders at increased risk of aspiration Residents of chronic care facilities Healthcare personnel Anyone who lives with or cares for people at high risk for infl uenza related complications including: o o Household contacts and caregivers of children from birth up to 5 years of age. Household contacts and caregivers of people > 50 years old, or anyone with medical conditions that put them at higher ask for severe complications of influenza Persons for whom pneumococcal polysaccharide vaccination (PPSV) is recommended Previously unvaccinated adults age > 65 yrs old. Age 2 to 64 yrs with any of the following conditions: a. cigarette smokers age > 19 yrs old. b. functional or anatomic asplenia c. immunocompromising conditions or on immunosuppressive therapy d. organ or bone marrow transplantation e. chronic renal failure or nephrotic syndrome f. chronic cardiovascular disease or pulmonary disease (including asthma) g. cerebrospinal fluid leak h. diabetes mellitus i. alcoholism or chronic liver disease j. candidate for or recipient of cochlear implant A second dose of PPSV is indicated for persons who are: Age > 65 yrs old and previously vaccinated with PPSV before age 65 yrs if at least 5 yrs have elapsed since first dose At highest risk of serious pneumococcal disease or likely to have a rapid decline in pneumococcal antibody levels (categories b e above) Intervals Between Doses Children > 2 yrs old who previously received pneumococcal conjugate vaccine and who need a first dose of PPSV, should wait at least 8 wks following the last PCV dose before receiving PPSV. Persons age > 2 yrs old in need of a second PPSV should wait at least 5 yrs following their first PPSV dose. 38/48

Healthcare Worker Safety Precautions You Must Meet These Requirements To protect our healthcare workers as well as our patients, all faculty, residents, fellows, staff, students, and volunteers are required to do the following: Provide documentation of immunity to the following vaccine preventable diseases: o Measles o Mumps o Rubella o Varicella o Hepatitis B o Pertussis Undergo annual TB screening Document Your Immunity For each of the following disease categories you must meet at least one of the criteria listed the vaccination criteria, history criteria, or serology criteria. 39/48

Immunization Requirements Vaccination Criteria History Criteria Serology Criteria DISEASE CATEGORY Measles and Mumps If born before 1/1/1957: Documentation of 1 dose of live vaccine given after 12 months of age If born after 1/1/1957: Documentation of 2 doses of live vaccine given after 12 months of age and at least one month apart Physiciandocumented disease hx Positive IgG serology Rubella Varicella Hepatitis B Tetanus Diphtheria Pertussis If born before 1/1/1957: Considered immune, except women who can become pregnant If born after 1/1/1957: Documentation of 1 dose of live vaccine given after 12 months of age Physiciandocumented disease hx Positive IgG serology Documentation of 2 doses of live vaccine given after 12 months of age and at least one month apart Hx of varicella disease or Herpes zoster based on healthcare provider diagnosis, or verification by provider of selfreported varicella disease Positive IgG serology Documentation of 3 dose vaccine series and positive anti HBs serology or Signed waiver for those who decline vaccine series Positive anti HBs serology If age 19 to 64 years old: Documentation of a single dose of Tdap vaccine* Influenza Documentation of vaccination annually *Tdap may be given as little as two years after administration of Td vaccine. Influenza Vaccination is Recommended for All Healthcare Workers! Influenza vaccination of healthcare workers reduces: transmission of influenza in healthcare settings staff illness and absenteeism 40/48

It is an important part of patient safety with reductions in patient morbidity and mortality. Two randomized studies in long term care facilities found that influenza vaccination of healthcare workers was associated with a 50% reduction in patient mortality (Lancet 2000;355:93 7 and J Infect Dis 1997;175:1 6). All healthcare workers at UW Medicine are expected to either receive annual influenza vaccination or complete an online educational module and sign a declination form. Annual influenza vaccination can protect yourself, your family, and your patients from influenza. Follow Post Exposure Rules If exposed to a potential infectious agent, follow up with Employee Health for evaluation and management. Evaluation and management may entail: review of immunization and TB testing record potential consideration of pos exposure prophylaxis on an individual basis for exposures such as influenza or pertussis. Exposures to bloodborne pathogens are discussed in more detail in the bloodborne pathogen section, but in those cases, healthcare workers should immediately seek evaluation with Employee Health or the emergency department after hours. Get Screened for TB New Employees: Two Step Initial Screening All newly employed HCWs undergo two step testing using the Mantoux tuberculin skin test (TST). The second test occurs one to three weeks after the first test. Reaction to tuberculin wanes in some infected people, so they may have a falsenegative result from their first test. However, the TST may stimulate their immune system, causing a positive result from subsequent tests. If results of both tests are negative: The HCW is classified as uninfected. If either result is positive: The HCW is classified as previously infected and must complete a chest x ray and TB symptom survey. All HCWs must be screened for TB at least once a year. If hx of negative TST: The annual screening consists of a TST. If hx of positive TST: The screening consists of a TB symptom survey. A history of BCG vaccination without documentation of a positive TST is not an exemption. TB Post Exposure Screenings HCWs who are exposed to TB are screened for TB by having a TST (unless known positive) and two TB symptom surveys, one shortly after the exposure to establish a baseline and another at 8 to 10 weeks after the exposure. 41/48

Case: 50 Year Old Man 50 year old man presents with 3 day history of fever 39.4 C, chills, cough, shortness of breath, myalgias, and decreased oral intake. CXR demonstrates diffuse patchy infiltrates and patient is admitted for community acquired pneumonia. A savvy intern is also concerned about possible influenza and sends a nasal swab for influenza A PCR, but the patient is not placed in droplet precautions and no mask was worn during the history and exam despite persistent coughing by the patient. The next day the influenza PCR comes back positive for influenza A. Review of the immunization status of the team finds that neither the intern or resident had received this year's influenza vaccination. Which of the following is correct? A. The exposed housestaff should be monitored for symptoms of influenza, but can continue patient care activities without post exposure prophylaxis. B. Influenza vaccination of healthcare workers is discouraged due to the high risk of Guillain Barre syndrome. C. Vaccination of healthcare workers is an important patient safety issue as it has been demonstrated to decrease patient morbidity and mortality. D. Droplet and contact precautions are only indicated once influenza infection is confirmed. Case Feedback 50 year old man presents with 3 day history of fever 39.4 C, chills, cough, shortness of breath, myalgias, and decreased oral intake. CXR demonstrates diffuse patchy infiltrates and patient is admitted for community acquired pneumonia. A savvy intern is also concerned about possible influenza and sends a nasal swab for influenza A PCR, but the patient is not placed in droplet precautions and no mask was worn during the history and exam despite persistent coughing by the patient. The next day the influenza PCR comes back positive for influenza A. Review of the immunization status of the team finds that neither the intern or resident had received this year's influenza vaccination. Correct/Incorrect Answers A. The exposed housestaff should be monitored for symptoms of influenza, but can continue patient care activities without oseltamivir prophylaxis. INCORRECT. Unvaccinated healthcare workers who are exposed to a patient with influenza should be encouraged to receive the influenza vaccine and must either take post exposure prophylaxis for 5 days or be removed for patient care activities to prevent nosocomial transmission. B. Influenza vaccination of healthcare workers is discouraged due to the high risk of Guillain Barre syndrome. INCORRECT. Influenza vaccination of healthcare workers is strongly encouraged. Aside from the 1976 swine influenza vaccine, studies do not demonstrate an increase in Guillain Barre Syndrome associated with influenza vaccination. If there is any additional risk, the estimated risk is approximately one additional case per million persons vaccinated which is substantially less than the risk for severe influenza. In fact, a recent study found that the risk of Guillain Barre Syndrome is four to seven fold higher following influenza infection than after influenza vaccination. C. Vaccination of healthcare workers is an important patient safety issue as it has been demonstrated to decrease patient morbidity and mortality. 42/48

FEEDBACK. Influenza vaccination of healthcare workers reduces transmission of influenza in healthcare settings, staff, illness and absenteeism, and is an important part of patient safety with reductions in patient morbidity and mortality. Two randomized studies in long term care facilities found that influenza vaccination of healthcare workers was associated with a 50% reduction in patient mortality. D. Droplet and contact precautions are only indicated once influenza infection is confirmed. FEEDBACK. Droplet and contact precautions should be initiated based on the patient's syndromic presentation and concern for possible influenza in order to prevent potential exposure to other patients and staff (see syndromic precautions section). 43/48

Post Test Assessment Please make sure you read the content before taking this quiz. An 80% score is required in order to pass. You can review the content of this module at any time. 1. Which of the following statements is correct? A. Standard Precautions are specifically used for patients with known infections due to resistant organisms. B. Gown and gloves are not used as part of Standard Precautions. C. Healthcare workers do not need to wash their hands before examining the next patient if they washed their hands after examining the previous patient. D. Masks should be worn as part of Standard Precautions during aerosolizing procedures such as suctioning a patient on mechanical ventilation or intubation. 2. Which of the following statements is correct? A. Hand hygiene is not necessary if gloves are used. B. After taking down a wound dressing, gloves should be changed prior to re dressing the wound. C. Alcohol based hand hygiene products are effective against spore forming organisms such as C. difficile. D. When used with a mask, glasses provide adequate eye protection. 3. Which of the following infection precaution pairing is incorrect? A. Pertussis and airborne precautions B. Influenza and both droplet and contact precautions C. MRSA and contact precautions D. Tuberculosis and airborne precautions E. C. difficile and contact enteric precautions 4. Which of the following statements is correct? A. Patients in droplet precautions must be in a negative pressure room. B. Touching objects in the room of a patient in contact precautions does not require the use of gown and gloves as long as you do not touch the patient. C. If no private rooms are available, patients in contact precautions for the same resistant organism may be cohorted together. D. As part of airborne respirator precautions, an N95 respirator may be used without documented fit testing. 5. Which of the following patients is MOST concerning for possible avian influenza and should be placed in a negative pressure room with airborne and contact precautions? 44/48

A. 60 year old Vietnamese man returned from Vietnam one month ago and now presents with 3 days of fever, cough, and myalgias. B. 30 year old homeless man living in Seattle presents with nausea, emesis, and abdominal pain after eating raw chicken at a local restaurant. C. 21 year old Chinese exchange student presents with 3 days of rhinorrhea and sore throat without fever or shortness of breath. D. 21 year old University of Washington student presents with 3 days of fever, cough, and shortness of breath with bilateral infiltrates on CXR. She returned from a student exchange program in Indonesia 7 days ago where she lived with a family who raised their own chickens in the backyard. 6. A 35 year old man is admitted in January with 3 day history of fever 39.8 C, cough, myalgias, and general malaise. He lives in Seattle and has not traveled out of the area during the past year. Physical exam does not demonstrate conjunctivitis or rash. CXR is normal without infiltrates or effusions. What is your recommendation for managing this patient? A. Patient should be placed in airborne precautions with use of PAPR pending further evaluation. B. Patient should be placed in droplet and contact precautions with use of surgical mask, eye protection, gown and gloves pending further evaluation. C. Patient does not require any additional precautions since the CXR is normal. D. Patient may initially go to a regular bed, but should be placed in droplet precautions with the use of surgical mask if his nasopharyngeal PCR is positive for influenza. 7. Which of the following patients does NOT need to be placed in airborne precautions for evaluation of tuberculosis? A. 45 year old homeless man presents with 4 day history of acute onset of fever, chills, and cough. CXR with RML infiltrate. B. 35 year old software programmer with 2 month history of cough, nightsweats, and 20 lb weight loss. CXR demonstrates RUL infiltrate with cavitation. C. 40 year old man from Vietnam presents with 1 month history of non productive cough, fever, and night sweats. CXR demonstrates large right pleural effusion. D. 30 year old woman from Mexico with h/o HIV infection and CD4 20 presents with 1 month history of fever, cough, and 10 lb weight loss. CXR demonstrates necrotic mediastinal lymphadenopathy. 8. A 70 year old woman is admitted from a skilled nursing facility with 2 days of fever and uncontrolled diarrhea. One week ago she was treated with moxifloxacin for bronchitis. You also learn that several other residents at the same facility have developed a similar illness. Which of the following is correct? A. Patient probably has norovirus like illness so no additional precautions are necessary. B. Patient probably has C. difficile and should be placed in contact enteric precautions if her C. difficile test is positive. C. Patient should be placed in contact enteric precautions for uncontrollable diarrhea regardless of etiology while undergoing evaluation. D. Hand hygiene should be performed with alcohol containing products. 45/48

9. Documented immunity to which of the following pathogens is NOT required for healthcare workers? A. Measles B. Mumps C. Varicella D. Hepatitis B (or waiver) E. Streptococcus pneumoniae 10. Which of the following statements regarding TB screening of healthcare workers is correct? A. Healthcare workers who previously received BCG vaccination do not need to undergo TB screening. B. Healthcare workers must be screened every two years for TB. C. Healthcare workers must be screened annually for TB. D. Healthcare workers exposed to TB should immediately take INH for 9 months. 11. All of the following are indications for pneumococcal vaccination except: A. Patients with asplenia B. Patients older than age 50 C. Patients with alcoholism or chronic liver disease D. Patients with diabetes 12. Which of the following statements regarding influenza vaccination of healthcare workers is correct? A. Annual influenza vaccination is recommended for all healthcare workers. B. Current influenza vaccine formulation is associated with a significantly increased risk of Guillain Barre. C. Taking oseltamavir (Tamiflu) prophylaxis throughout influenza season is an alternative to influenza vaccination for those individuals who don't like needles. D. Influenza vaccination of healthcare workers has not been shown to be of benefit to patients. 13. Central venous catheters should be inserted using aseptic technique and Maximal Sterile Barrier Precautions, ie. a full sterile body/head drape and full surgical attire (sterile gloves and gowns, and surgical mask and cap). A. True B. False 14. Sterile gloves are required for all of the following "aseptic" procedures performed outside the operating room except: A. Inserting a central venous catheter B. Inserting a peripheral intravenous catheter 46/48

C. Inserting non vascular catheters (e.g. foley, chest tube) D. Lumbar puncture E. Thoracentesis, paracentesis, arthrocentesis 15. A sterile drape is required for all of the following "aseptic" procedures performed outside the operating room except: A. Inserting a central venous catheter B. Inserting a peripheral intravenous catheter C. Inserting non vascular catheters (e.g. foley, chest tube) D. Lumbar puncture E. Thoracentesis, paracentesis, arthrocentesis 16. In addition to surgical procedures, there are a wide array of procedures performed during the routine care of patients which require the rigorous practice of aseptic technique. These included preparation and administration of parenteral drugs; insertion of catheters; intravascular procedures, thoracentesis, paracentesis arthrocentesis and surgical site incision care. A. True B. False 17. An exposure to blood, tissue or other bodily fluids is considered to place the HCW at risk for a BBP infection in all of the following situations, with which exception? A. A percutaneous injury B. A mucocutaneous injury or exposure, such as a splash C. An exposure involving non intact skin D. An exposure involving intact skin E. A bite 18. What is the average risk of HIV transmission after a percutaneous exposure, a mucous membrane exposure, and a non intact skin exposure, respectively? A. 0.3%, 0.1% and <0.1%, respectively B. 3%, 1%, <1%, respectively C. 30%, 10%, <1%, respectively 19. A resident is punctured by a suture needle in the OR. After promptly removing his/her hands from the surgical field to avoid exposing the patient to his/her blood (called a "double exposure"), what should the resident do? A. Consider this exposure a trivial event, best ignored. 47/48

B. Keep operating and seek medical attention later. C. Promptly obtain a sample of the patient's blood for bloodborne pathogen (BBP) testing and selfprescribe the appropriate post exposure prophylaxis (PEP). D. Ask the surgical attending to obtain a sample of the patient's blood for BBP testing and to prescribe the appropriate PEP. E. Immediately clean the wound with soap and water; then go to the employee health service which will ascertain the BBP status of the source patient, and promptly evaluate the resident and administer the appropriate PEPA bite. 20. A healthcare worker experiences a needlestick from a patient with known active hepatitis C infection. What kind of prophylaxis should this healthcare worker receive? A. None B. Immunoglobulin C. Antiviral agents D. Both 21. A healthcare worker experiences a hollowbore bloody needlestick from a patient with HIV infection. What kind of prophylaxis should this healthcare worker receive? A. None B. A one drug antiretroviral regimen for 4 weeks started within 2 hours of the exposure C. A two drug regimen consisting of two nucleoside reverse transcriptase inhibitors (NRTIs) or one NRTI and one nucleotide reverse transcriptase inhibitors (NtRTIs) for 4 weeks started within 2 hours of the exposure D. A three drug regimen consisting of the same as c plus a protease inhibitor for 4 weeks started within 2 hours of the exposure 48/48