G.K. Chesterton

• Two Tiered System

– Standard Precautions

– Transmission Based Precautions

Standard

Transmission

Primary strategy for reducing

infection risk in healthcare settings.

• Use for ALLpatients, all the time, regardless of presumed infection status.

• PPE should be easy to use, easy to find, and convenient.

If it is wet, yucky, gross and not yours…don’t touch it

• Gloves should always be worn for Direct Patient Care, regardless of Isolation Status.

• Masks, goggles and face shields should be worn to protect mucous membranes.

• Gowns, aprons, and other PPE may be required if there is a risk of splatter of blood or body fluids onto clothes or skin.

• Transmission

Based Isolation

• 2nd Tier-

Can transmit

disease/organism

to unprotected

• Patient placement:

Private room

Cohort patients

with the same

organism

• Per facility:

physician order or

nursing protocol

• Equipment Carts

• Stop Sign on Door

• Sticker on patient’s chart

• Alert/Flag patients

• Educating patients (NPSG)

STOP!!Airborne Precautions

➢Everyone must wear N95 respirator maskwhile in room.

➢Hand Hygiene is required.

➢The patient will wear a surgical mask whentransported outside the room.

• Organisms spread by droplet nuclei (small particles) that can remain in the air for long periods of time. Invisible to eye… rides on air currents and do not fall to the ground

• Organisms spread by this route:

▪ Mycobacterium tuberculosis (TB)

▪ Rubeola (measles)

▪ Varicella (chickenpox, shingles) add contact also

▪ Smallpox and SARS – add contact also

• Negative Pressure Room

• N-95 NIOSH Approved Mask

• Annual Fit Testing, for evaluation of changes

• Keep the Door Closed

• Document negative pressure

STOP!!Droplet Precautions

➢Everyone must wear a surgical mask with an eye shield while in patient's room.

➢Hand Hygiene is required.

➢The patient will wear a surgical maskwhen transported outside the room.

• Organisms transmitted by large droplets

• These droplets do not remain in the air but drop to horizontal surfaces

• Organisms spread by this route:▪ Mumps

▪ Rubella

▪ Influenza

▪ Bordetella Pertussis (whooping cough)

▪ Neisseria meningitidis

• Used for diseases

spread by contact of

the conjunctivae,

mucous membranes

of the nose or mouth

with large particle

droplets

• No special

ventilation required

• Door may remain

open

• Private room

• Wear mask with eye shield when entering the room

STOP!!Contact Precautions

➢Gown and gloves are worn when entering this room.

➢ Hand Hygiene is required.

➢The patient will wear clean gownand sheet when transported

outside the room.

• Most common Isolation Precaution

• Transmission: direct contact/

indirect contact

with patient or environment

• Organisms spread by this route:

▪ Multidrug-resistant organisms (MRSA, VRE)

▪ Respiratory syncytial virus (RSV), parainfluenza or enteroviral infections in infants & young children

▪ Clostridium difficile

▪ Lice & scabies

▪ Herpes simplex virus (neonatal or mucocutaneous)

•Contact precautions include

•Wearing gloves and gown to enter room every time. (2 hr. after patient in room the entire room is colonized)

•Organisms stick to you, your clothing, bedside table, IV, bed linens, etc

•Dedicate non-critical care items to patient, i.e., thermometer, B/P cuff and stethoscope

•Attention to environmental cleaning

•Door may remain open

Colonized Room

Remember green “X”s the next time you go into a patient’s room.

You do not have to touch the patient to contaminate your hands.

• Communication within the system

• Identifying the patient with MDRO

• Identify readmissions

• Notify IP

• Facility Specific (ie Standard Precautions ?)

• Multi Drug Resistant Organism

• Organism that has adapted to current antibiotics and are no longer susceptible or vulnerable to the effects of the antibiotics

• An organism that shows at least 2 different resistances on susceptibility testing

• Methicillin-resistant Staphylococcus (MRSA), Vancomycin-resistant Enterococcus(VRE), certain gram negative bacilli, Clostridium difficile have increased in prevalence in U.S. hospitals over the last three decades

• Limited treatment options become concern

• Increased length of stay

• HICPAC has approved guidelines for the control of MDROs.

• The MDRO and CDI modules of the NHSN can provide a tool to assist facilities in meeting some of the criteria outlined in the guidelines.

• Inappropriate prescribing practices

• Failure to complete prescription

• Tendency to take antibiotics until feeling better then stop taking them and save what is left for the next time

• Prescribing practices by groups of physicians (everybody prescribing the same antibiotics)

• Failure to adjust antibiotics according to susceptibility

• Educate patients and their guardians when appropriate

– The need to take entire prescription until it is gone

– Proper hand hygiene practices

– Proper environmental cleaning practices

– Importance of not taking another’s prescription of antibiotics

• Antibiotic Stewardship Program

STOP!!Special

Contact Precautions➢Gown and gloves are worn when entering

the patient’s room.

➢Hand Hygiene with Soap and Water only.

➢The patient will wear clean gown and sheet when transported

outside the room.

Clostridium difficile

➢ C. difficile infections continue to rise

➢ C. difficile infections linked to about 14,000 deaths each year.

➢ CDC Vital Signs

• Emerging Infections Program 2010

• 94% CDI were health care associated

• 75% had onset not currently hospitalized

• 52% POA but largely health-care related.

➢ Antibiotic use and healthcare exposure greatest risk factors.

Infection Control Strategies

• Hand hygiene (Soap and water not hand gel)

• Contact precautions

• Identify cases within hospital (appropriate hand

• hygiene and room disinfection)

• Environmental disinfection

• Appropriate use of antibiotics

• Laboratory-based alert system for immediate notification of positive test results

• Educate about CDI: HCP, housekeeping, administration, patients, families

Supplemental Infection Control Strategies

• Extend use of Contact Precautions beyond duration of diarrhea (e.g., 48 hours)*

• Presumptive isolation for symptomatic patients pending confirmation of CDI

• Evaluate and optimize testing for CDI

• Implement soap and water for hand hygiene before exiting room of a patient with CDI

• Implement universal glove use on units with high CDI rates*

• Use sodium hypochlorite (bleach) – containing agents for environmental cleaning

• Implement an antimicrobial stewardship program

• Isolated patients should leave their rooms for essential purposes only

• Reverse the process when patient comes out of the room

• Receiving departments should be informed of patient’s status ahead of time

• Reverse the isolation process when patient goes out of room…. ISOLATE THE SOURCE

• When possible use all disposable items

▪ Disinfect equipment coming out of room as in

X-ray machine, or EKG machine, Accucheck.

▪ Daily cleaning and disinfecting by housekeeping

▪ No wait time after room is cleaned

▪ Special cleaning for C. difficile spores (stabilized bleach product) Hand hygiene with soap and water recommended.

Environmental Services

• Avoid contact with clothing.

• Minimize motion.

• Bag soiled linens at the bedside

• Transport to linen chute/dirty utility room like other laundry. All linen within patients room considered contaminated.

• Laundry is processed using Standard Precautions.

• No special precautions needed for dishes or silverware (radiation is the exception)

• Trays are taken directly from patient’s room to tray cart

• Hot water and detergents used are sufficient to decontaminate dishes and utensils

http://www.cdc.gov/ncidod/dhqp/gl_isolation_ptII.html

• Refer to your State Regulations

• Texas has no restriction for isolation trash.

• Isolation trash may go to regular land field if no blood.

HCW education should focus on

▪ Mode of transmission & risk

▪ Appropriate use of PPE

▪ Cleaning routines for equipment

▪ Role of hand hygiene & gloves

▪ Components of an efficient program

Patient, visitor education should be provided

OSHA required Annual Blood borne pathogen training

Annual Isolation Precautions training, include in Annual Competency

Isolation Rounds for compliance-Sample included in packet

• What is your compliance rate?• How assessable is your alcohol gel?• What is the motivation for hand hygiene• Staff must develop the habit: Washing

hands as automatic as breathing• Foundation of the Infection Prevention

Program• If it is not important to leaders

It won’t be important to staff

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Dept Hand Hygiene Visual Audits

1st quarter 2nd Quarter 3rd Quarter

2006 Goal 95%

• No Artificial Nails• No Overlays• Natural Nails ¼ inch• Fresh Nail polish OK

but no chips• Literature showing

evidence of nails transmitting disease to patients

• Determine area of compliance in your hospital

• Coordinate with local hospitals on policy

• Option 1: Laboratory-Identified (LabID) Event Reporting

1A: MDRO LabID Event Reporting (MRSA Bloodstream Infection)

1B: Clostridium difficile (C. difficile) LabID Event Reporting

• Option 2: Infection Surveillance Reporting

2A: MDRO Infection Surveillance Reporting

2B: C. difficile Infection Surveillance Reporting

All reporting depends on your facility objectives and required reporting by state and regulatory agencies.

NOTE: LabID Event reporting and Infection Surveillance reporting are two separate and independent reporting options. See Appendix 3: Differentiating Between LabIDEvent and Infection Surveillance for key differences between

the two options.

Includes S. aureus cultured from any specimen that tests oxacillin-resistant, cefoxitin-resistant, or methicillin-resistant by standard susceptibility testing methods, or by a laboratory test that is FDA-approved for MRSA detection from isolated colonies; these methods may also include a positive result by any FDA-approved test for MRSA detection from specific sources.

MRSA positive blood specimen for a patient in a location with no prior MRSA positive blood specimen result collected within 14 days for the patient and location.

Duplicate MRSA Bacteremia LabID Event

Any MRSA blood isolate from the same patient and same location, following a previous positive MRSA blood laboratory result within the past 14 days.

Choose at least 1 reporting method

Method Numerator Data Reporting Denominator Data Reporting

Facility-wide by location (All Specimens)

Enter each MDRO LabID Event from all locations seperately

Report separate denominators for each location in the facility as specified in the NHSN Monthly Reporting Plan

Selected locations (All Specimens)

Ener each MDRO LabID Event from all inpatient locations seperately

Report separate denominators for each location monitored as specified in the NHSN Monthly Reporting Plan

Overall Facility-wide Inpatient (FacWideIN), All Specimens

Enter each MDRO LabID Event from all inpatient locations seperately

Report only one denominator for the entire facility (admissions, patient days)

Overall Facility -wide Outpatient (FacWideOUT)

Enter each MDRO LabID Event from all outpatient locations seperately

Report only one denominator for all outpatient locations (total number of encounters)

Overall Facility-wide Inpatient, Blood Specimens Only

Enter each MDRO LabID Blood Specimen Event from all inpatient locations seperately

Report only one denominator for the entire facility (admissions, patient days)

Overall Facility-wide Outpatient, Blood Specimens Only

Enter each MDRO LabID Blood Specimen Event from all outpatient locations seperately

Report only one denominator for all outpatient locations (total number of encounters)

NHSN DefinitionClostridium difficile

A positive laboratory test result for C. difficiletoxin A and/or B, (includes molecular assays (PCR) and/or toxin assays)

OR

A toxin producing C. difficile organism detected by culture or other laboratory means performed on a stool sample.

Choose one or more reporting choices

Method Numerator Data Reporting Denominator Data Reporting

Facility-wide by location

Enter each CDI LabID Event from all locations seperately

Report separate denominators for each location in the facility

Selected locationsEnter each CDI LabID Event from selected locations seperately.

Report separate denominators for each location monitored as specified in the NHSN Monthly Reporting Plan

Overall Facility-wide Inpatient (FacWideIN)

Enter each CDI LabID Event from all inpatient locations seperately

Report only one denominator for the entire facility (e.g., total number admissions and total number of patient days)

Overall Facility-wide Outpatient (FacWideOUT)

Enter each CDI LabID Event from all outpatient locations seperately

Report only one denominator for all outpatient locations (e.g., total number of encounters)

C. difficile Surveillance NOT performed in

• NICU

• Specialty Care Nurseries

• Babies in LDRP

• Well baby nurseries

C. Difficile Laboratory-Identified (LabID) Event

All non-duplicate C. difficile toxin-positive laboratory results. Can include specimens collected in the Emergency Department of the admitting facility or other affiliated outpatient location, if collected same calendar day as patient admission.

CDI Data Analysis LabID only)Community Onset

Positve cultures obtained on day 1 (admission date), day 2, and day 3 of admission.

Hospital Onset

Positive cultures obtained on or after day 4

Community-Onset Healthcare Facility-Associated

Positive culture collected from a patient discharged from the facility < 4 weeks prior to current date of stool specimen collection.

Hospital Acquired Infection for C. difficilesurveillance is on or after day 3.

MRSA blood isolate / C. difficile specimen per patient and location

Yes

LabID Event

No

Duplicate MRSA

Bloodstream isolate / C. difficile test

Not a LabIDEvent

Prior (+) MRSA from blood / C.

difficile in <2 weeks from

same patient and location

(including across

calendar months)

MRSA Bloodstream and C. difficile Test Result Algorithm for LabID Events

1. Drug addict known to have + HIV and +HBV admitted for knife wound

What type of Isolation is needed?

2. Patient with GI Bleed, lost 4 pints of blood in surgery known to have + Hep C

What special precautions do you tell the housekeeper to take before cleaning the room?

• 6 month old has paroxysmal cough, and fever• 18 yr old college student with symptoms of

high fever, light phobia, and stiff neck• 31 yr old admitted with “spider bite” abscess

to his leg, culture pending• 68 yr old previous admission being treated

with 3 antibiotics admitted for severe diarrhea

• 40 yr old with cough, blood in sputum and weight loss. Came from Vietnam 2 years ago

• 3 year old fever and unidentified rash

• Hospital is full. Female Patient with diarrhea… culture pending…. Choices:

234 Fe Hernia Post op Surgery patient

256 Fe Post Abd Hyst patient

210 Fe + Shigella patient

245 Fe + MRSA patient

What room does she best go to?

IndexHospital Infection Control Practices Advisory Committee Membership List

Part I. Evolution of Isolation Practices

Part II. Recommendations for Isolation Precautions in Hospitals

Table I. Synopsis of Types of Precautions and Patients Requiring the

Precautions

Table II. Clinical Syndromes or Conditions Warranting

Additional Empiric Precautions to Prevent Transmission of

Epidemiologically Important

Pathogens Pending Confirmation of Diagnosis

Appendix A. Type and Duration of Precautions Needed for

Selected Infections and Conditions

References

Reviewers

Web-based Excerpts (added 7/2012)

Standard Precautions

Contact Precautions

Droplet Precautions

Airborne Precautions

http://www.cdc.gov/ncidod/dhqp/gl_isolation.html

– www.apic.org (APIC home page) see practice guidelines

– http://www.cdc.gov/ncidod/dhqp/gl_isolation.html. Guideline for Isolation Precautions in Hospitals

– http://www.apic.org/AM/Template.cfm?Section=Search&section=Non_APIC_Education_Infor&template=/CM/ContentDisplay.cfm&ContentFileID=4525

How to toolkit for improving Hand Hygiene

– http://www.cdc.gov/ncidod/hip/ARESIST/mrsa_spotlight.htm (MRSA spotlight)

– http://www1.va.gov/vasafety/docs/Engineering.ppt

(TB Control power point)

_ Fit test annual medical evaluationhttp://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417

a1.htm?s_cid=rr5417a1_e

I alone cannot change the world,

but I can cast a stone across the waters to create

many ripples.Mother Teresa