Infection Control Manual 2012 - Veterans Affairs



?INFECTION CONTROL MANUALHospital and Medical Center Infection Control Policydepartment of veterans affairs MEDICAL CENTERRevised April 2013C. Diana Nicoll M.D., PhDMedical Center DirectorChief of StaffChair, Infection Control Committee Veterans Affairs Medical Center, San FranciscoInfection Control ManualImportant Phone NumbersVA Medical CenterInfection Control Manual [press cntl+CLick to follow link] Table of Contents TOC \o "1-3" \h \z \u SECTION 1 PAGEREF _Toc356562499 \h 9STANDARD PRECAUTIONS (SP) PAGEREF _Toc356562500 \h 9Part I - Basic Concepts PAGEREF _Toc356562501 \h 9Part II - Medical Center Policy PAGEREF _Toc356562502 \h 11Part III - Definitions PAGEREF _Toc356562503 \h 12SECTION 2 PAGEREF _Toc356562504 \h 13PPE/BARRIERS PAGEREF _Toc356562505 \h 13Hand washing PAGEREF _Toc356562506 \h 13Gloves PAGEREF _Toc356562507 \h 16Masks PAGEREF _Toc356562508 \h 19Eyewear PAGEREF _Toc356562509 \h 20Gowns PAGEREF _Toc356562510 \h 20SECTION 3 PAGEREF _Toc356562511 \h 20NEEDLES AND SHARPS PAGEREF _Toc356562512 \h 20Section 4 PAGEREF _Toc356562513 \h 22EMERGENCY RESUSCITATIVE DEVICES PAGEREF _Toc356562514 \h 22ENTERAL NUTRITION AND TOTAL PARENTERAL NUTRITION PAGEREF _Toc356562515 \h 22Section 5 PAGEREF _Toc356562516 \h 23LABORATORY SPECIMENS PAGEREF _Toc356562517 \h 23Section 6 PAGEREF _Toc356562518 \h 24Implementing Standard precautions (SP) PAGEREF _Toc356562519 \h 24Infection Control Guidelines for Room Assignments PAGEREF _Toc356562520 \h 24Initiating Contact Precautions for C diff patients PAGEREF _Toc356562521 \h 28AirBORNE Isolation PAGEREF _Toc356562522 \h 29DROPLET PRECAUTIONS (Influenza, meningococcal meningitis, group a streptococcus, upper respiratory viruses) PAGEREF _Toc356562523 \h 30Airborne Isolation PAGEREF _Toc356562524 \h 33Section 7 PAGEREF _Toc356562525 \h 35Reusable Medical Equipment PAGEREF _Toc356562526 \h 35Section 8 PAGEREF _Toc356562527 \h 36LAUNDRY PAGEREF _Toc356562528 \h 36SECTION 9 PAGEREF _Toc356562529 \h 37CLEANING AND DECONTAMINATION OF BLOOD AND BODY FLUID SPILLS PAGEREF _Toc356562530 \h 37SECTION 10 PAGEREF _Toc356562531 \h 37POST MORTEM PAGEREF _Toc356562532 \h 37SECTION 11 PAGEREF _Toc356562533 \h 38Regulated Medical Waste Disposal Policy PAGEREF _Toc356562534 \h 38SECTION 12 PAGEREF _Toc356562535 \h 41OCCUPATIONAL HEALTH PAGEREF _Toc356562536 \h 41Exposure to Specific Diseases PAGEREF _Toc356562537 \h 42Tuberculosis Control Program PAGEREF _Toc356562538 \h 44Employees with Contagious or Infectious Diseases PAGEREF _Toc356562539 \h 44SECTION 13 PAGEREF _Toc356562540 \h 50EMERGENCY MANAGEMENT - Influx of Infectious Patients PAGEREF _Toc356562541 \h 50SECTION 14 PAGEREF _Toc356562542 \h 51OUTBREAK MANAGEMENT PAGEREF _Toc356562543 \h 51SECTION 15 PAGEREF _Toc356562544 \h 52Departmental Infection Control Policies PAGEREF _Toc356562545 \h 52REFERENCES PAGEREF _Toc356562546 \h 52Appendix A: Risk AssessmentAppendix B: Barrier Techniques to Reduce Infection RiskAppendix C: Respiratory Isolation Negative Pressure RoomsINFECTION CONTROL MANUALJune 2011INTRODUCTIONInfection Control ProgramThe Infection Control Program is a multidisciplinary program, involving every aspect of patient care and employee welfare.? Every employee has a role to play in infection control and is an integral part in the prevention of nosocomial (hospital acquired) infections in our veteran patients.? The Medical Center also has a responsibility to maintain an "Infection Safe" environment for its employees and visitors. ??In these days of cost effective management, the goal of preventing morbidity and mortality from nosocomial infections is paramount.? To accomplish this goal, the Infection Control Program is composed of the following elements:? Clinical Practice:? The use of Standard Precautions (S.P.) in all patient care situations. ?In addition to Standard Precautions there are now 3 transmission-based precaution categories: airborne, droplet, and contact precautions.? Environmental Controls:? The use of engineering, housekeeping, and SPD interventions to minimize the spread of pathogens within the hospital environment.? Surveillance and Data Analysis:? The use of established methods to detect disease outbreaks, to identify potential infection hazards, and to design interventions to reduce or minimize their impact. All healthcare settings are affected by the emergence and transmission of multi-drug resistant organisms (MDRO’s). The severity and extent of disease caused by these pathogens varies by the population(s) affected and by the institution in which they are found. The approaches we apply to prevent and control these pathogens are tailored to the specific needs of our patient population and medical center. (See appendix A, Surveillance system.)?Education:? Ongoing education about infection control and prevention for all employees, visitors and patients.Quality Improvement:?? Continuous monitoring of our infection control program systems to identify and investigate new nosocomial problems, and to ensure that appropriate strategies are fully implemented, meet the needs of our population and institution and our infection control interventions are regularly measured for effectiveness such that a consistent decrease in the incidence of targeted infections and diseases is achieved. Community Involvement:? Recognize that any hospital’s infection control program is part of a larger community and public health system, and that to be truly effective, must communicate and share information with other facilities and agencies. It may also include participation in special projects, sitting on committees, and coordination of surveillance and educational programs between this institution and others. Employee Health:? Includes programs and services that integrate the principles of prevention and control of infections and promotion wellness in the workplace.?Product Evaluation: ?Includes participation in the evaluation of equipment and supplies that relate to control of infection in the hospital. Expert Consult Service:? The Infectious Disease consultation service is available to assist with identification and management of infectious diseases.? Additional details of the program are outlined in MCM 11-9 "Infection Control Program”, August 2007.? Infection Control CoordinatorOne full-time (1.0), Infection Control Coordinator one (0.8) Infection Control Practitioner and one full-time (1.0) MRSA Prevention Coordinator, assist the Medical Center Hospital Epidemiologist in the execution of the Infection Control Program.? The functions and activities of these individuals are as follows:?? Identify, analyze, and disseminate data on inpatient, outpatient and CLC infections;? Investigate potential infections and deviations from expected incidence and prevalence rates, recommend and coordinate the implementation of interventions, and evaluate the effectiveness of all prevention and control measures;? Provide infection control expertise to providers of patients with infectious diseases and to the medical center and CLC clinical and support staff regarding the control and prevention of infectious hazards;? Provide consultation on the development of policies and procedures through participation on the infection control committee, other medical center committees and individual interaction with patient care providers, managers and other support staff.?? Employee ResponsibilitiesThe Infection Control Program at VAMC is designed to minimize the risks of hospital-acquired infections in patients and the transmission of communicable diseases from patients to staff, and from staff to patients.? To accomplish this, every employee has the following responsibilities:? To maintain his/her own personal hygiene (bathing, clean uniform or clothing, trimmed/clean fingernails);To report any illness or on-the-job accident to one's supervisor;To stay home (or go home) when you are sick, no exceptions. See Section 11 Personnel Health, page 54;To practice hand disinfection before and after all patient activities and to be familiar with Required Hand Hygiene? Practices – VHA Directive 2005-02, January 13, 2005;To know and practice Standard Precautions on all patients at all times;To know the location of and the proper use of PPE (personal protective equipment), needed to protect themselves from exposure to blood borne and airborne pathogens;To know that it is policy that there is no eating, drinking, makeup application, food storage or preparation in any location where patient care is performed or where hazardous materials may be present. Hazardous materials include blood and other body fluids or tissue, chemical agents, radiological agents or any agent that may cause illness in the event of contamination or mistaken identify. Food and beverages may be stored in kitchenettes in designated food/beverage refrigerators. Employee and patient food/beverage will be kept separated. Reference: 29 CFR 1910.1030, “Bloodborne Pathogens Standard.” Compliance Directive on Bloodborne Pathogens and Selected Appendices (issued by the Occupational Safety and Health Administration, Dated Nov. 5, 1999).To know that they are eligible to receive Hepatitis B vaccine and seasonal influenza vaccination, which is strongly encouraged for all direct patient care providers.? Employees who decline must sign a statement that they are doing so;To participate in their service's and medical center education programs on infection control, (this is a Joint Commission, and VACO requirement)To maintain their immunity to certain infectious diseases by participating in the Employee Health service programs such as Tuberculosis (TB) skin testing, Varicella screening and annual influenza vaccination during flu season.? Immunity to Chicken Pox must be documented prior to starting employment.? Employees who are non-immune may be vaccinated, depending on their regular work assignment; Measles, Mumps and Rubella screening and vaccination or refusal is also required; all employees are offered Tdap or Td vaccination when due.To know their specific services’ infection prevention and infection control policies;To be familiar with the availability of and the safe use of “safer medical devices” (i.e., safety needles and syringes), depending on their regular duty assignment.? The Sharps Safety Webpage can be viewed by going to the VA Intranet Infection Control Webpage and clicking on the link, and To use the N-95 mask (respirator) when entering rooms of patients on airborne isolation precautions 00REMEMBER, HAND WASHING BETWEEN ALL PATIENT CONTACTS IS THE SINGLE MOST IMPORTANT PRACTICE IN REDUCING THE RISK OF SPREADING INFECTIONS IN THE HOSPITAL ENVIRONMENT.? STANDARD PRECAUTIONS ARE TO BE UTILIZED WITH ALL PATIENT CONTACT IN ALL AREAS OF THE MEDICAL CENTER, BY ALL PERSONNEL.00REMEMBER, HAND WASHING BETWEEN ALL PATIENT CONTACTS IS THE SINGLE MOST IMPORTANT PRACTICE IN REDUCING THE RISK OF SPREADING INFECTIONS IN THE HOSPITAL ENVIRONMENT.? STANDARD PRECAUTIONS ARE TO BE UTILIZED WITH ALL PATIENT CONTACT IN ALL AREAS OF THE MEDICAL CENTER, BY ALL PERSONNEL.Our goal is to maintain a safe environment for patients, staff and visitors.? Your cooperation and commitment to the Medical Center's Infection Control Program can accomplish this goal.? Each service is responsible for training in Standard Precautions and Infection Control.? Each supervisor is responsible for sending all new staff to “New Employee Orientation”.? A Copy of the Infection Control Manual is available on the VA Intranet under General Resources or on VISTA under document retrieval menu. All services have specific Infection Control policies for their work areas. It is your responsibility to be familiar with your service's policies.For questions, call the Medical Center Infection Control Nurses:INFECTION CONTROL MANUALOctober 2008SECTION 1STANDARD PRECAUTIONS (SP)Part I - Basic Concepts?????Standard Precautions is the name given to our isolation system of barrier precautions to be used by ALL personnel for contact with the blood and other moist body substances of ALL patients, regardless of the patient's diagnosis.? Standard Precautions is the foundation for preventing infection transmission during patient care in all health care settings.? ????? Isolation guidelines have evolved over the years from “diagnosis driven” systems to our current system of precautions aimed at preventing transmission of all pathogens in the hospital environment, regardless if the infectious agent is from a human source or inanimate environmental source. The Centers for Disease Control and Prevention (CDC) has taken the lead in promulgating these guidelines, but the evolution of isolation strategies over the years has been driven by the pathogens themselves, our understanding of their epidemiology, and appropriate concerns for health care worker safety.? ??????? The Medical Center has adopted a system that incorporates the use of barrier protection for all patient care, with transmission-based precautions for selected pathogens. Since the purpose of this document is to make infection control understandable, we have attempted to stress principles and not nomenclature. During the online mandatory annual review (MAR) on Infection Control, we highlight any changes from evidence-based literature or CDC guidelines.????? New Elements of Standard Precautions ???? Infection Control problems identified in the course of outbreak investigations often indicates the need for new recommendations or reinforcement of existing infection control recommendations to protect patients. Three such areas of practice that have been added by the CDC are:? Respiratory Hygiene/Cough Etiquette, Safe Injection Practices and Use of Masks during Insertion of Catheters or Injection of Material into Spinal or Epidural Spaces via Lumbar Puncture Procedures. While most elements of Standard Precautions evolved from Universal Precautions that were developed for protection of healthcare personnel, these new elements of Standard Precautions focus on protection of patients.? See the explanation below in Part III Definitions.For those interested in reading about isolation systems in greater depth, an excellent summary can be found at (SP) and TRANSMISSION-BASED PRECAUTIONTRANSMISSION-BASED ISOLATION GUIDELINES FOR DISEASE PREVENTIONSTANDARD PRECAUTIONS?When to Use: Applies to all patients and all body fluidsElements:Frequent hand washingUse of alcohol based foam or gel hand-rubsUse of barriers (gloves, gowns, masks, eye protection)Patient placement Environmental controls and Personal Protective EquipmentCleaning and disinfection of patient-care devices and inanimate objects???? and surfacesRespiratory hygiene/cough etiquette (new CDC guidelines)Safe injection practices (new CDC guidelines)Use of masks during spinal, epidural and lumbar procedures (new CDC guidelines)Emphasize prevention: anticipate exposures???? ?CONTACT PRECAUTIONSWhen to Use: MRSA, VRE, C. difficile, ESBL organisms, Carbapenem resistant organismsElements:Blood/body fluid precautions Emphasis on disinfection of patient care equipment and use of gloves & gowns for direct patient care Strict enforcement of removing gowns, gloves, masks or other PPE prior to leaving the patient care room and disposing properly before exitingStrict enforcement of hand disinfection prior to donning gloves and after removing gloves??? AIRBORNE PRECAUTIONSWhen to Use:? TB, disseminated Zoster, Avian influenza, SARS ?Elements:Dry, airborne droplet nuclei or small particles (dust-like) in the respirable size range containing infectious agents which travel on air currents and remain infective over time and distancePlace patient in monitored negative pressure isolation roomMasks: particulate respirators (N-95) are used?If patients are to leave their room they are to wear an ordinary “ear loop” surgical mask?? DROPLET PRECAUTIONSWhen to Use: ?influenza, meningococcal meningitis, group A streptococcus, upper respiratory viruses (see CDC guidelines pg. 18)Elements: Wet droplets are generated by coughing, sneezing or talking and during certain procedures such as suctioningDroplets are propelled a short distance through the air (6 feet) so face protection required: eyes, nose & mouthMasks: ordinary “ear loop” surgical masks are adequate for respiratory droplet precautionsPrivate room isolation or cohorting patients with the same known illnessIf patients are to leave their room they are to wear an ordinary “ear loop” surgical maskSTANDARD PRECAUTIONS (SP)Part II - Medical Center Policy????? SP is to be followed by all personnel and shall be based on the degree of anticipated exposure to body substances.? Precautions for the care of ALL patients include routine use of appropriate barriers to protect skin and mucous membranes during exposure to body substances.????? 1.?? Each hospital department and clinic will incorporate SP into its departmental infection control policies and procedures.? Managers are responsible for assuring that departmental specific policies and procedures are known by the staff.? These will be reviewed by the Infection Control Committee (ICC) every three years or as changes occur.? New and renewing policies will be submitted to the ICC for approval.????? 2.? Information about SP principles will be given to all current and newly hired employees involved directly or indirectly in patient care.? These educational programs will be coordinated by the employee's department and reviewed by the ICC.? Updates will also be provided annually or as needed for new information or for reinforcement.? Documentation of training will be maintained at the department level?????? 3.?? Each department shall supervise its employees in SP-related practices, provide appropriate protective equipment and provide additional or remedial training as needed.? Compliance with SP will be incorporated into the individual employee evaluation process.????? 4.? The Infection Control Committee will incorporate SP into the hospital-wide Infection Control Manual with review and revision as needed.????? 5.? Patient and visitor education related to frequent hand washing, what precautions are for, whether they are contagious or if they are visiting someone who may be contagious and why a particular patient has been placed on precautions.?? STANDARD PRECAUTIONS (SP)? Part III - DefinitionsParenteral EXPOSURE: needle stick, cut or other wound inflicted by a sharp object contaminated with blood or body fluids from any patient.?Mucous Membrane EXPOSURE: splash or aerosol to the eyes, nose or mouth with blood or body fluids of any patient.Cutaneous EXPOSURE:? contact with blood or body fluids when exposed skin (unprotected by gloves or other barriers) is abraded, severely chapped or afflicted by dermatitis.ENGINEERING CONTROLS:? use of available technology and devices to isolate or remove hazards from the worker.? Examples include, but are not limited to: rigid puncture-resistant sharps containers, splash guards, mechanical pipetting, and self-sheathing needles.WORK PRACTICE CONTROLS: alterations in the manner in which a task is performed in an effort to reduce the likelihood of a worker's exposure to blood or other potentially infectious materials.PERSONAL PROTECTIVE EQUIPMENT (PPE): gloves, specialized clothing; paper or cloth gowns & barriers; ear loop surgical masks, eye shield masks, N95 respirators, or other equipment used by workers to protect themselves from direct exposure to blood or other potentially infectious materials.BLOODBORNE PATHOGENS (BBP): Hepatitis B, HIV, HepatitisRESPIRATORY HYGIENE/ COUGH ETIQUETTE : targeted at patients and accompanying family members and friends with undiagnosed transmissible respiratory infections and applies to any person with signs of illness when entering a healthcare facility.? The elements include education, posted signs, covering the mouth/nose with a tissue or using a surgical mask when coughing, hand hygiene after contact with respiratory secretions and >3 feet spatial separation of persons with respiratory infections in common waiting or triage areas.? Healthcare personnel are advised to observe droplet precautions prior to a diagnosis when examining and caring for patients who are coughing and have respiratory secretions.SAFE INJECTION PRACTICES: enforces adherence to basic principles of aseptic technique for the preparation and administration of parenteral medications. The elements include the use of a sterile, single-use, disposable needle and syringe for each injection given and prevention of contamination of injection equipment and medication.? Use of single-dose vials is preferred over multiple-dose vials, especially when medications will be administered to multiple patients.IC PRACTICES for SPECIAL LUMBAR PUNCTURE PROCEDURES: This strategy is targeted at the prevention of oral flora droplet transmission during spinal procedures by healthcare workers to patients. A mask is worn to limit the dispersal of oropharyngeal droplets.????? ????? In the following sections, PPE and barriers that have been shown to be effective in minimizing risk to hospital staff will be discussed.? For additional information, refer to Appendix B:? "Barrier Techniques to Reduce Infection Risk."? SECTION 2PPE/BARRIERSHAND WASHING, GLOVES, MASKS, EYEWEAR & gownsHand washing????? Body substances, wound infections, upper respiratory infection secretions or patient care areas which may contain micro-organisms can easily contaminate your hands.? Should these organisms enter an opening in the body via a break in the skin or be carried on your hands from patient to patient, for example, may cause infection. ?Hand washing is the single most important practice to reduce the transmission of infectious agents in healthcare settings. Hand washing facilities are located in all patient rooms and exam rooms throughout the Medical Center.? The term “hand hygiene” includes both handwashing using soap and alcohol-based hand-rubs.? In patient care areas where soap and water are not available, alcohol-based hand sanitizer (foam or gel) should be used to replace traditional hand washing, the 2002 CDC Hand Hygiene in Health Care Settings and VHA Directive 2005-02 Required Hand Hygiene Practices must be understood and followed by all employees at all times.????? According to Medical Center Policy, you should wash your hands:BEFORE donning gloves and after removing glovesBETWEEN all patient contactBEFORE eating or preparing foodBEFORE performing clean or sterile? proceduresBEFORE and AFTER touching wounds or other drainageAFTER contact with blood or body fluids, mucous membranes, secretions or ?excretions, such assalivaurinebloodfecesrespiratory secretionsvomitus????????????????????????????????????????????AFTER handling soiled linen or waste???????? AFTER handling devices or equipment soiled with body substances (urine collection containers, bedpans, etc.)???????? AFTER personal toiletingHands and other skin surfaces exposed to blood or body fluids should be washed as soon as patient safety permits.? Special ?Note about Fingernails:Fingernails should be clean and kept trimmed. All health care workers who provide direct, hands-on care to patients are not permitted to wear artificial fingernails or extenders; this includes non-supervisory and supervisory personnel who regularly or occasionally provide direct, hands-on care to patients.? Individuals wearing artificial nails have been shown to harbor more pathogenic organisms, especially gram negative bacilli and yeasts on the nails and in the subungual area than those without artificial nails.? According to CDC guidelines, hand contamination with potential pathogens is also increased with ring-wearing.???How to Wash Your HandsUse soap and running water at a comfortable temperature.? Work up a lather and use friction.? Wash between your fingers.? You need only scrub for 15 to 20 seconds unless you are in an area with a special protocol such as a surgical scrub.Use plenty of running water so that no soap remains on your hands.? Residual soap may cause skin irritation, dermatitis and chapping.Dry your hands well with a paper towel.? Air drying may cause chapping.? Use your towel to turn off the faucet.? ????? most important function of hand washing is to remove infectious organisms.? No single hand washing product kills all disease-causing organisms.? If properly used, any hand washing product approved by this hospital, whether antibacterial or not, will achieve this goal.A medicated lotion soap which is hospital approved, provided and restocked by EMS and should be used in this facility is always available in all patient care areas, patient rooms and medical center bathrooms.?Do not use other chemicals such as pure alcohol or bleach to wash your hands.? They may damage your skin and cause open or chapped areas which are more easily infected.PPE/ BARRIERS (HAND WASHING)ALCOHOL–BASED HAND SANITIZERAlcohol-based hand sanitizer is effective in “de-germing” the hands.? The alcohol-based hand sanitizer gels are available from SPD and are also stocked in the pyxis, they are pocket size and can easily go with you throughout the day. The alcohol-based hand sanitizer foams are mounted in patient care areas where a sink is not accessible and areas where staff must wash their hands frequently. ?EMS is responsible for distribution and storage of foam canisters. After several uses of these products, hands need washing with soap and water. ?Foam and gel are alcohol based hand-rubs and are interchangeable with personal preference or convenience.? These products are NOT adequate for disinfection of C. difficile toxin spores, soap and water should be used while caring for patients or working in rooms where patients have this diarrheal infection.??? LotionYour skin may become dry and chapped with frequent hand washing.? Use lotion to replace the oils removed by hand washing.Always wash your hands before using lotion.? If you use a lotion bottle while your hands are dirty, you may contaminate it and later, contaminate your hands each time you touch it. Use your own bottle of lotion.? Leave it in a locker or other location where you will be the sole user.Do not leave "community" lotion bottles in staff bathrooms or at any sink in the Medical Center.Do not use patients’ lotion on your own hands.The alcohol based foam and gel antimicrobial hand rubs contain an emollient that helps keep skin soft and smooth.?? ??PPE/ BARRIERS (GLOVES)????? Personal Protective Equipment (PPE) for healthcare personnel refers to a variety of barriers and respirators used alone or in combination to protect mucous membranes, airways, skin and clothing from contact with infectious agents.? The selection of PPE is based on the nature of the patient interaction and/or the likely mode(s) of transmission. A suggested procedure for donning and removing PPE that will prevent skin or clothing contamination is presented in Appendix B or at the CDC website: ncidod/dhap/pdf/ppe/ppeposter. Handwashing is always the final step after removing and disposing of PPE.? ????????????????GlovesGloves provide additional safety and should be worn whenever contact with blood or other body fluids or tissue is expected.? Vinyl and Nitrile gloves are suitable for patient care activities.? Each has approximately a 95% effectiveness rateWear GLOVES when touching:Body substances, mucous membranes, and non-intact skin.Surfaces and articles moist with blood or body substances.Environmental surfaces in rooms of patients on contact isolation.Wear GLOVES for performing venipuncture or other vascular access procedures.Wear STERILE GLOVES for all sterile procedures to protect both the patient and yourself.Wear NON-STERILE GLOVES for all non-sterile patient care procedures where worker protection is needed.Wear FINGER COTS or GLOVES to cover cuts, abrasions, rashes or minor infections on your hands while working.? If there is any uncertainty, consult Employee Health.Wear GLOVES when cleaning up blood spills and other contaminated areas.?GLOVES are an integral part of Standard Precautions that should always be employed when providing direct patient care.? Gloves protect both patients and healthcare personnel from exposure to infectious material that may be carried on hands.When gloves are worn in combination with other PPE, they are put on last.? Gloves that fit snugly around the wrist are preferred for use with an isolation gown because they will cover the gown cuff and provide a more reliable continuous barrier for the arms, wrists and hands.If your glove is torn or punctured by a needle-stick or other accident, remove the damaged glove, wash your hands and put on a new glove as promptly as patient safety permits.?? ???????If your gloves are contaminated, don’t touch telephone receivers, computer keyboards, other uncontaminated surfaces, or other areas of the patient which may be uncontaminated.????? When your gloves are on while performing patient care or touching patient equipment or their articles and you leave to obtain a supply, like gauze or IV equipment for that same patient you must remove your gloves, wash your hands, then obtain your supply and start over with new clean gloves.Gloves should be removed immediately, or as soon as possible upon leaving the work area, and disposed of in the nearest waste receptacle.? Hands are then disinfected with soap and water or an alcohol based hand-rub.????? Phlebotomy station staff and IV Team members should change gloves between patients and always wash or sanitize hands prior to donning a new pair of gloves.Quick Look-22860080010REREMOVE YOUR GLOVES AFTER COMPLETING TASKS REQUIRING THEIR USE AND WASH YOUR HANDS. WEARING GLOVES FOR PROLONGED PERIODS OF TIME MAY CAUSE DERMATITIS OR IRRITATION. IN ADDITION, THE CONTINUED WEARING OF GLOVES AFTER PERFORMING TASKS CONTAMINATES ALL ITEMS IN THE ENVIRONMENT.00REREMOVE YOUR GLOVES AFTER COMPLETING TASKS REQUIRING THEIR USE AND WASH YOUR HANDS. WEARING GLOVES FOR PROLONGED PERIODS OF TIME MAY CAUSE DERMATITIS OR IRRITATION. IN ADDITION, THE CONTINUED WEARING OF GLOVES AFTER PERFORMING TASKS CONTAMINATES ALL ITEMS IN THE ENVIRONMENT.?????? ????? NOTE:????? For infection control purposes, including the prevention of nosocomial infections with a patient’s own flora (colonization), gloves may need to be changed during the care of an individual patient.? For example, gloves should be changed after contact with a contaminated site (i.e., infected wound) and prior to contact with a clean site (i.e., i.v. insertion site) on the same patient, to avoid cross-contamination.? During patient care, transmission of infectious organisms can be reduced by adhering to the principles of working from “clean” to “dirty”, and confining or limiting contamination to surfaces that are directly needed for patient care. It may be necessary to change gloves during the care of a single patient to prevent cross-contamination of body sites. It is also necessary to change gloves if the patient interaction involves touching portable computer keyboards or other mobile equipment that is transported from room to room (an example would be the vital signs machine or the BCMA station and scanner).? ??PPE/ BARRIERS (gloves)Types of GlovesUTILITY?GLOVESGeneral-purpose, medium to heavy weight utility gloves such as rubber household gloves may be used for housekeeping chores involving potential blood contact or gross microbial contamination, as well as for instrument cleaning and decontamination procedures.? Utility gloves may be decontaminated and reused, but should be discarded if they are peeled, cracked or discolored, or if they have punctures, tears or other evidence of deterioration.? (Each employee should have their own gloves.)gloves ?for patient care:?? Vinyl or nitrile?The problem is not that the materials used are so different, but is that NO GLOVE, VINYL, LATEX OR NITRILE, HAS LESS THAN A 5% FAILURE RATE FOR HOLES AND TEARS WHEN NEW.? Gloves are not expected to be without flaws.? This is the basis for the Operating Room practice of a 10-minute surgical scrub prior to gloving.? For the care-provider, gloves are used to add an additional layer of protection beyond that of intact skin and hand washing. ALL GLOVES TEAR with heavy or prolonged use and should be replaced when torn as soon as patient safety permits. ?Patient care gloves should not be washed for reuse because microorganisms cannot be removed reliably from glove surfaces and continued glove integrity cannot be ensured.Double gloving is recommended for all surgical procedures as well as for autopsies.CUT RESISTANT GLOVESThese gloves should be used for personnel in activities such as autopsies and decontamination of sharp instruments.?The EPA recommends special gloves for protection against chemical substances involved in anti-neoplastic (cancer) therapy. Please refer to NSP#90 Administration of Chemotherapy and MCM 119-12 Preparation, Handling and Procurement of Anti-Neoplastic Drugs. ??There is no similar requirement for latex gloves or restriction against vinyl or nitrile gloves for infection control use.? Infection control requires protection against blood or body fluid contact with the skin.? Latex, vinyl or nitrile will provide equivalent barrier protection for this purpose.Therefore, after careful review of the data on gloves and the role they play in infection control, it continues to be an acceptable practice to use either latex, vinyl or nitrile gloves in direct patient care.Latex is a component of many medical devices, including surgical and examination gloves, catheters, intubation tubes, anesthesia masks, and dental dams. ??If latex sensitivity is suspected, consider using devices made with alternative materials, such as plastic, vinyl and nitrile.(Note:? Our Medical Center’s policy is to create a latex-free environment whenever possible, therefore, we are not stocking latex gloves in our SPD for general use.) For more information regarding Latex please refer to MCM 118-06 Medical Center Latex Sensitivity Protocol.????PPE/ Barriers (MASKS)MasksWhen to wear a Mask?Wear a mask to prevent exposure during procedures that are likely to generate aerosol droplets or splashes of blood or other body fluids.? Combination masks with attached face shields and protective eye goggles that can be used with masks are available in all patient care areas.?Wear a mask when engaged in procedures requiring sterile technique to protect patients from exposure to infectious agents carried in a healthcare worker’s mouth or nose.? Place a mask on coughing patients to limit potential dissemination of infectious respiratory secretions from the patient to others, (respiratory hygiene/cough etiquette).Types of Masks:Standard surgical masks (ear loop or tie)Particulate filter respirators (3M N95 or Technol PFR 95)Fluid resistant masks with attached face shieldAnyone who enters the room of a patient on respiratory precautions should wear a mask unless they know they are immune to that disease.? (Refer to Respiratory Isolation Section for type of mask and wearing instructions.)HOw to wear and dispose of a MaskMasks should cover both the nose and mouth.? Masks should fit close to the face so that air can be breathed only through the mask.? All employees whose duties require care of patients on respiratory precautions will be fit tested and have a self administered medical history.N-95 particulate filter respirators should be fit checked by the user each time they are worn. These respirators are used to prevent inhalation of small particles that may contain infectious agents transmitted via the airborne route.? N-95 particulate filter respirators may be used for 8 hours of patient care.? Dispose of them with regular waste at the time, if it becomes difficult to breathe or when they become soiled or wetPPE/ BARRIERS (EYEWEAR, APRONS AND GOWNS)EyewearGLASSES, GOGGLES or FACE SHIELDS should be worn for protection from splashes to your face.?Situations in which eyewear should be considered include bronchoscopies and endoscopies, invasive cardiology and radiology procedures, and dental and surgical procedures.?Any activity which involves measuring fluids, disconnecting tubing, suctioning patients, etc., can also create splashes?Face shields, glasses, goggles or masks with attached face shields are available either from SPD or are available on the units or clinic supply areas.?Devices should completely cover the eyes and have side shields.Eyewear that has been soiled but not damaged is reusable.?Eyewear should be washed with soap and water and dried.?Eyewear does not require decontamination by SPD.? GownsWear a GOWN during all procedures that are likely to generate splashes or soiling from blood or body fluids.Most bedside patient care activities do not require a gown.? Activities such as changing the bed of an incontinent patient, lifting and moving a dependent patient with draining wounds and certain diagnostic and therapeutic procedures which may result in splattering or contact with body fluids do require the use of a gown.? Gowns are also required during direct patient care of patients on Contact Precautions who have an Organism of Significance, (MRSA, VRE, ESBL, C. difficile or other infectious diarrhea).Remove the gown upon leaving the patient room or work area and dispose in an appropriate waste receptacle.? If reusable gowns are used, they are for single use only, and are to be placed in the regular laundry.? (Do not continue to wear the gown once the patient care is completed or when performing care for a different patient).SECTION 3NEEDLES AND SHARPSPreventing Needle sticksNeedle sticks are a problem for all hospital employees.? The following recommendations should help prevent them.Slow down when you handle needles.?Always think before you act.Become familiar with how to engage safety devices on needles and syringes.? Engage sharps safety devices after using.Dispose of needles properly in the rigid red plastic needle disposal containers immediately after using, in patient rooms, exam rooms and at nursing stations.? Needles left where they do not belong can injure workers, patients and visitors.Do not recap.? Recapping needles is a major source of injury to health care workers.? Safety syringes that permit safe coverage of the sharp are available in the most commonly used sizes.Never put a used needle in your pocket.Never try to remove or un-jam anything from a needle disposal container.? If a needle will not go in easily, use an object other than your hand (like a hemostat) to dislodge it.?If the container is full, replace it.? Do not overfill containers.? They are considered full when the contents reach the level indicated by an arrow (about 3” from the top).NEEDLES AND SHARPS (Preventing Needle sticks)If you encounter an unfamiliar needle or catheter device, check with your supervisor before using it.? The infection control, employee health, nursing education and IV team nurses are also available to instruct you in the use of safe devices.A listing of all approved devices is available on-line at CPRS Help or on the intranet Infection Control Manual, under the section “Sharps Safety Program”.If needles need to be removed from tubing for disposal purposes, use a hemostat or similar clamp to manipulate the needle.Be familiar with and use the needleless system. This system does not use needles for; a.) collection of bodily fluid or withdrawal of body fluids after initial venous or arterial access is established; b) administration of medication or fluids; c) any other procedure involving the potential for occupational exposure to BBP due to percutaneous injuries from contaminated sharps. Example: intravenous medication delivery systems? that administer medication or fluids through a catheter port or connector site using a blunt cannula or other non-needle connection. ??Be familiar with and use sharps with engineered sharps injury protections. A non-needle sharp or a needle device used for withdrawing body fluids, accessing vein or artery, or administering medications or other fluids with built-in safety features. Many are specially designed so that the needle can be covered with the attached safety part without recapping, a few examples are a blood gas kit for drawing blood gases and re-sheathable devices such as safety syringes, butterflies and IV catheters.? Needle boxes are picked up by Environmental Management personnel on a daily basis.? If the container is 2/3 full or reached the arrow level, remove the container from the room or cart, engage the self sealing lid, and place it in the dirty utility room for pick-up.? Please do not use these containers for trash disposal.?Quick Look00YOU ARE STUCK WITH A NEEDLE OR INJURED WITH ANY SHARP, WASH THE WOUND IMMEDIATELY DIAL 9 (OUTSIDE LINE) AND CALL THE 24 HOUR NEEDLE STICK HOTLINE NUMBER (415)469-4411Confidential follow-up is available00YOU ARE STUCK WITH A NEEDLE OR INJURED WITH ANY SHARP, WASH THE WOUND IMMEDIATELY DIAL 9 (OUTSIDE LINE) AND CALL THE 24 HOUR NEEDLE STICK HOTLINE NUMBER (415)469-4411Confidential follow-up is availableSection 4EMERGENCY RESUSCITATIVE DEVICESMouth to mask resuscitative devices are located in all inpatient rooms, clinic examining rooms and other patient care areas throughout the Medical Center. They are examined at least annually for expiration date and package integrity.? These devices are for single use only. When one is used during a code situation, it should be discarded and replaced. ENTERAL NUTRITION AND TOTAL PARENTERAL NUTRITIONEnteral Nutrition Infection Control policy follows Standard Precautions, this nutrition is either administered through a PEG (gastrostomy tubes) or J-tube (jejunostomy tubes) or a tube feeding placed into a nostril and passed through to the stomach (naso-enteric). Both of these methods of delivery are treated the same way. Aggressive hand hygiene to prevent cross contamination and glove usage is required. Flush tube with 60ml water every 6-8 hours during continuous feeding, before and after intermittent feedings, before and after giving medications and before and after checking gastric residuals. Aspiration assessment signs/symptoms should be observed throughout the feedings and at least every 4-8 hours.Peg and J-tube site care includes cleansing the area around the insertion site with soap and warm water daily. The site may need to be cleaned more often if there is a lot of drainage or if ordered by the physician.A continuous feeding with the closed system may hang for up to 24 hours. To prevent growth of bacteria, the nurse will change the feeding container, tubing, 60 ml piston irrigation set and Lopez Enteral Valve for patients with NET or NG tubes, every 24 hours. For patients or residents with PEG/PEJ, change the Lopez Enteral Valve at least every 14 days or as a class III medical device the Lopez valve may be used indefinitely and may be changed only when necessary as determined by the healthcare team. Label the container with the date and time of the change and initials of nurse performing the change.For more information and Nursing policy please refer to MCM No. 120-07 Special Nutritional Support, NSP-75A and NSP-75. A.S.P.E.N. Clinical Guidelines for the use of parenteral and enteral nutrition in adults is also a reference and source of more information.Total Parenteral NutritionNutrition calories and lipids are delivered via a Central Venous Catheter, usually a PICC line is used. These lines are inserted using the Central Line Bundle of care. TPN line associated infections are tracked and reported in real time to the IC Committee, Nutrition Committee and the specific service treating the patient. Whenever possible other sources of nutrition are explored. TPN line dressing changes are done per protocol and usually by the PICC Line Nurse Specialists. Nutrition consults on each patient, makes caloric recommendations and after 5-7 days also recommends that the TPN should be replaced by tube feedings or a gradual PO diet. This is done to decrease TPN line associate infections.Section 5LABORATORY SPECIMENSWhen transported to the laboratory, all patient specimen containers should be placed into a Ziploc or similar sealable plastic bag.? If the specimen container is too large to fit in a Ziploc, use tape to secure the cap and enclose the entire item in a plastic bag with a twist tie.? If the specimen container is not bagged or the bag is not visibly clean, the laboratory cannot accept the specimen. specimen containers transported outside the medical center or from a CBOC to the medical center must be labeled or color-coded with a “BIOHAZARD SIGN” and follow laboratory policy for transporting specimens to an outside facility. placed inside the pneumatic tube holder are to be bagged in Ziploc bags. ?For additional information about the safe use of the pneumatic tube system, refer to the instructions that are posted above each station or refer to the “Pneumatic Tube Policy” on the VA Intranet the lab slip to the outside of the bag with a paper clip, rubber band, or tape.? Be sure to label the actual specimen with the patient’s name and social security number, date, time collected and provider. Should a specimen spill occur in the tube system, do not send any more specimens from that station and initiate “Emergency Shutdown”.? Notify Engineering at ext. 2010. ?If no one answers, dial (“0”) for Operator and have the Engineer on call paged.Laboratory workers must use gloves for handling all specimens.?Section 6Implementing Standard precautions (SP)Infection Control Guidelines for Room AssignmentsPRIVATE VERSUS MULTIPLE ROOMMATES IN ACUTE CARE &CLCPatients may have roommates when the following two conditions are met:Patient does not soil articles in the room with blood, pus, feces, urine, or oral secretions.Neither roommate has an infection which requires a private room.?CRITERIA FOR ASSIGNING PRIVATE ROOMS IN ACUTE CARE“Rule out“ infections such as tuberculosis, varicella (primary infection, pneumonia or disseminated), influenza, meningococcal meningitis, C. difficile diarrhea or other infectious diarrhea require a private room until an infection has been ruled out. ?Scabies and lice require a private room.? Standard Precautions are always used with Contact, Airborne or Droplet precautions, depending on the infection transmission mode. This is referred to as Transmission Based Precautions.Any? active infection with MRSA, Vancomycin Resistant Enterococcus (VRE) or Extended Spectrum Betalactamase (ESBL), or Multi Drug Resistant Organism (MDRO) Diarrhea due to C. difficile. Severe burns or extensive dermatitis. Any infected patient who is unable to control secretions or excretions.Neutropenic patients (<500 absolute neutrophils). GUIDELINES FOR ROOM ASSIGNMENTS: Community Living Center (CLC)Standard Precautions should be used at all times with all residents. Transmission-based precautions in the CLC setting present a challenge due to 1) patients at increased risk for infection brought together in one setting for extended periods of time.2) a scarcity of private rooms, 3) 100% re-circulated air handling, and 4) a desire to provide a communal home-like setting Since negative pressure isolation rooms cannot be engineered, patients requiring airborne isolation may not be cared for in the CLC.For patients requiring contact precautions, a private room is used when possible or patients with the same infection may be cohorted. For active wound or skin infection (not colonization) care must be taken when performing dressing changes and when disposing of soiled dressings.? Each patient should have their own dressing materials.? When contact with other residents is anticipated (meals & group activities) an occlusive dressing should completely cover the infected area to minimize environmental contamination. ?Sharing of personal or communal objects should be curtailed and discretionary contact with other patients minimized. Consideration should be given to bathing the patient with an antibacterial soap to reduce shedding until the wound is healed. For patients requiring droplet precautions a private room is used when possible or patients with the same infection may be cohorted. For infections spread by respiratory droplets (eg. Flu, adenovirus, rhinovirus) care should be taken to prevent travel from the infected person’s respiratory tract to mucosal surfaces in those not infected. If Influenza is suspected, a rapid respiratory pathogen screen should be sent immediately.? Transfer to acute care should be considered on a case-by-case basis.? Consult infection control or the infectious diseases on-call fellow (415) 207-3614. Patients with new symptoms of diarrhea should not use shared bathroom facilities but be given a bedside commode until their symptoms have resolved. Commodes and bedpans should be carefully emptied and are NEVER cleaned using spray. EMS will clean bathrooms with a sodium hypochlorite solution twice a day. Other transmission-based precautions will be evaluated on a case-by-case basis by CLC providers, infectious disease and infection control staff.? PATIENT TEACHINGAll patients will be instructed by all health care providers that potentially infectious agents may be present in their body substances and that they may be susceptible to infections from others. Hand washing and good personal hygiene will be emphasized for their protection and the protection of others. ?TRANSPORT TO OTHER DEPARTMENTSPatients with diseases transmitted by airborne route should not be transported unnecessarily to other departments. If this becomes necessary, the patient should wear a surgical ear loop mask. The receiving department must be notified in advance of receiving any patients on isolation precautions so that receiving personnel can take appropriate action.?IMPLEMENTING ISOLATION PRECAUTIONSIsolation Precautions (Contact, Droplet, and Airborne) may be implemented by:The medical or surgical care physician, MD order The charge nurse or the nurse taking care of the patient (without an MD order) Infection control staffRemoval of isolation precautions requires a physicians order, Infection Control or Infectious Diseases physician consultation. CONTACT PRECAUTIONSPatients with active Multi-Drug Resistant Organism (MDRO) infections, including Methicillin Resistant Staphylococcus aureus, Vancomycin Resistant Enterococcus (VRE), Clostridium difficile and Emerging Multi-Drug Resistant Organisms need to be placed on Contact Precautions.?? Infection Control will contact the Acute Care Unit on identification of a patient with one of these infections to ensure Contact Precautions is initiated.? Contact Precautions may be initiated by: MD order; the charge nurse or staff nurse taking care of the patient; or Infection Control.? Once there is no risk of transmission of the infectious organism, the patient may be taken off Contact Precautions by MD order or Infection Control consultation.Vancomycin Resistant Enterococcus (VRE), Methicillin Resistant Staphylococcus aureus (MRSA), Clostridium difficile (Cd) and emerging Multi-Drug Resistant Organisms (MDRO) are important hospital acquired pathogens. Transmission occurs by:1) patient-to-patient contact, 2) carriage on the hands or gloves of personnel, 3) from contaminated patient care equipment and 4) from contaminated environmental surfaces.? Placing Patients on Contact Precautions:Patients infected with any of these organisms should be placed in a private room whenever possible. If this is not possible, they may share a room with a similarly infected patient. This is referred to as “cohorting”. Symptomatic VRE and C difficile patients may not share a bathroom with a non-VRE or C difficile patient if they have diarrhea because these organisms are shed in stool. They must use a bedside commode until their diarrhea has resolved. Never use water under pressure to rinse a bedpan.Place a Contact Precautions sign (bright green) on the door. Use contact precaution procedures: gown & gloves for contact with infected patients or potentially contaminated areas in the patient’s environment. Wash hands with soap and water. Alcohol based foams or gels may be substituted for soap and water, with the exception of spore producing organisms such as Clostridium difficile.Assign separate patient care items such as stethoscopes, thermometers to patients infected with any MDRO or Clostridium difficile. Any shared devices, such as blood pressure cuffs, pulse-oximetry probes and Doppler transducers must be thoroughly cleaned and disinfected with a hospital approved disinfectant between patients. Clean personal stethoscope using a hospital approved disinfectant between patients, 1:10 Beach Wipes, PDI Wipes or Wexcide. Instruct or assist patients in washing their hands thoroughly after using the commode. Patients on Contact Precautions may ambulate in the hall and shower, but should not use common waiting and kitchen areas.? Patients are to be instructed to wash their hands before leaving their room.Notify receiving services (radiology, OT, PT, lab, etc.) when patients are sent for procedures or treatments, or are transferred to another ward or unit.Minimize unnecessary healthcare worker traffic in and out of patient’s room.Visitors should wear a gown and gloves on entry to the room, and be instructed to remove these and perform hand hygiene before exiting the room.There is no need for special dietary trays.? Keep over-bed tables free of patient care items so that dietary personnel can deliver trays. Soiled linen does not need special handling.? Bag soiled linen in the patient's room and dispose of normally in the linen chute.? No special handling of trash is necessary.CLOSTRIDIUM DIFFICILE PATIENTSPatients with active Clostridium difficile infections will be placed on Contact Precautions. A patient with "active C diff infection" is anyone who has 3 or more loose stools in a 24 hour period. Initiating Contact Precautions for C diff patientsNurses may initiate Contact Precautions for patients suspected of having C diff loose stools.Any rule out C diff patients should be placed on Contact Precautions.If a patient is in a shared room and this patient is suspected of having C diff loose stools, this patient should be transferred to a private room. This patient's old bed and area (floor, bathroom, bedside table) needs to be cleaned with Dispatch and PDI bleach wipes. Place both “Contact Precautions” and Large Brown “Enhanced Handwashing” signs on door. Handwashing with soap and water for 15-20 seconds after patient contact. **Purell alcohol gel does not kill C diff spores.**Use disposable equipment in patient room (disposable BP cuffs, stethoscopes) and PDI Bleach wipes. These are found in the acute care OmniCells. If these are missing, please call SPD. Gown and gloves should be worn if the staff anticipates any contact with the patient or any environmental surfaces. Staff may not need to wear gown and gloves if staff does not touch any environmental surfaces or touch the patient. (For example, just interviewing patient without touching anything in the room). Limit traffic into room.Wipe down equipment and high touch areas (bedside commode, bedside table, bedrails, etc.) with PDI Bleach wipes after use.Patient and visitor teaching regarding handwashing with soap and water.Special note to EMS staff: When EMS staff see the Handwashing sign, this is a signal to them that this room is a C diff room and needs to be cleaned with Dispatch and PDI Bleach Wipes. Bathrooms need to be cleaned once a day with Dispatch and any “high touch” areas wiped down with PDI Bleach wipes daily.Terminal cleaning with Dispatch and PDI bleach wipes after patient is discharged or transferred to another room.EMS staff to wear disposable gown and gloves when cleaning in a C diff room.**Only EMS staff will take down the Green Contact Precautions and Brown "Handwashing Sign" (Reason: only EMS staff will know whether the room has been cleaned with Dispatch.)** Instructions on Discontinuing Contact Precautions for C diff patientsContact Precautions may be discontinued by physician, ID Fellow, or Infection Control staff after patient no longer has loose stools for over 24 hours. If patient's symptoms resolve before discharge, Contact Precautions may be dc'd only after patient moves to a new room. The patient's old room needs to be terminally cleaned with Dispatch (1:10 hypochlorite solution) and PDI Bleach wipes. (Reason: C diff spores can live on environmental surfaces, i.e. bedrails, toilets, floors, bedside tables, for weeks to months. Only hypochlorite will kill the C diff spores.) AirBORNE IsolationAirborne precautions prevent the transmission of infectious agents that remain infectious over long periods of time when suspended in the air.Use a monitored negative pressure room; keep door and windows closed. Nursing staff will activate room before accepting patient.Place Airborne Precautions Sign on Door.Require staff to wear an N-95 particulate respirator mask.Place a surgical ear loop mask on patient when they must leave room for any reason.Use Standard Precautions PLUS Airborne Precautions.? Droplet and Contact may also be required on a case-by-case basis.Visitors should be discouraged entry into Airborne Isolation rooms until 3 AFB sputum smears from the patients are found to be negative. Thereafter, visitors may enter the room wearing a loop mask.?Placing patients ON RESPIRATORY (Airborne) isolationMedical and Nursing staff will consider the diagnosis of TB in all patients who present with fever and respiratory symptoms and will promptly place those patients on respiratory precautions until the diagnosis has been ruled out or established, appropriately treated, and the patient is deemed to be non-infectious. Any nurse may initiate airborne precautions without a physician’s order; however, removal of airborne precautions will require a physician’s order. ?Nursing staff will place the patient in a negative pressure room and activate the alarm.? With the exception of the 2B & 3B rooms which are always negative, they will turn the alarm from neutral to negative.? Each Nurse Manager has been issued a key.? The unit will notify Engineering Service (X 2009) who will respond to check the room air exchanges and alarm and make sure the room has negative pressure no later than the next business day. A list of monitored negative pressure rooms can be found on the VA intranet, MCM 138-18 and is also attached to this manual in Appendix C.The Airborne Precautions Sign will be placed on the door to the patient's room.? The sign requires any visitors to "Check with nurse before entering".The nurse is responsible for informing any person about to enter the room as to what these precautions entail. Removing patients from ?Airborne isolationIn the case of TB, the reasons for removing a patient from isolation will depend on a number of factors described in a later section. Patients may only be taken off isolation on the written order of a physician. ?DROPLET PRECAUTIONS (Influenza, meningococcal meningitis, group a streptococcus, upper respiratory viruses)Quick LookDiseases spread by the droplet route do not require a negative pressure room and staff are to wear a surgical ear loop mask and eye protection.The diseases listed in the following table are transmitted in whole or in part by the respiratory route.? All providers and visitors who are unsure of their own immunity to varicella, measles, mumps, or rubella should not enter the room of patients suspected or proven to have one of these infections because masks do not guarantee protection. Diseases spread by the droplet route do not require a negative pressure room and staff are to wear a surgical ear loop mask and eye protection. Visitors should also wear a surgical ear loop mask while in the patient’s room.The diseases listed in the following table are transmitted in whole or in part by the respiratory route.? All providers and visitors who are unsure of their own immunity to varicella, measles, mumps, or rubella should not enter the room of patients suspected or proven to have one of these infections because masks do not guarantee protection. ?DiseaseIsolationTypes*DurationAvian influenzaA, C, D SDuration of illness. Eye protection when < 3 feet from patient.Diphtheria, pharyngealDiptheria cutaneousDC2 neg. cultures, >24 hr after stopping antibioticsInfluenzaD?5 days after onset or 24 hours after resolutions of sx’s in immunocompetent patient.Duration of illness in immunocompromised patient. Single patient room or cohort.Measles (Rubeola)D5 days after onset of rash???Meningitis:?24 hours after the initiation of rx AsepticSContact for infants and young childrenBacterialS?FungalS?Haemophilus influenzae type B known or suspected.DFor 24 hours after the initiation of treatmentNeisseria meningitides(meningococcal) known or suspected.DFor 24 hours after initiation of treatmentStreptococcal pneumoniaeS?MumpsD5 days after onset of symptomsPertussisD5 days after start of antibioticsPlague, pneumonicD2 days after start of antibiotics. Prophylaxis for exposed HCW’s.Plague, bubonicS?Respiratory Syncitial Virus (RSV) in infants, young children and immunocompromised adultsD,CDuration of illnessRubellaD7 days after onset of rashSARSA, C, DDuration of illness plus 10 days after theresolution of fever, provided respiratorysymptoms are absent or improvingTB, “+“ smear, “+” RxA2 weeksTB, “-” smear, “+” RxA5 daysTB, High Prob, “-“ smear, “-“RxA3 negative smears on 3 consecutive daysTB, Low Prob, “-“ smear, “-“ RxA1 negative smearTB Extrapulmonary with draining lesion.A CUntil patient has improved and drainage has ceased. Examine patient for evidence of active pulmonary TBTB MeningitisSExamine patient for evidence of active pulmonary TBVaricella, disseminated zoster(shingles) in any patient, localized disease in immunocompromised patient until disseminated infection is ruled out.ACUntil lesions have crusted. Contact ID for questions related to specific patients.Varicella, pneumoniaA7 days of antiviral therapyVaricella, primary, chickenpoxA, CUntil lesions have crusted*A = Airborne, C = Contact, D = Droplet, S= Standard airborne IsolationTuberculosisSelected Infection Control Facts about TuberculosisRespiratory isolation (airborne) for pulmonary TB may be implemented by:1.????? The medical or surgical care team.2.????? The charge nurse or the nurse taking care of the patient.3.????? Infection control staff.Removal of respiratory precautions requires a physicians order, Infection Control or Infectious Diseases physician. Because TB is spread by aerosol (travels on air currents), adequate air circulation, dilution, and ventilation are the most important factors in preventing transmission of TB in the hospital setting.? Masks have long been regarded as important in the control of nosocomial transmission of TB, but they are far less effective than good air exchange.? To be effective, masks must be used appropriately by patients and care providers alike. ?1.????? Masks that are used on patients are designed to prevent the release of organisms into the surrounding air by trapping exhaled water particles containing TB organisms (droplet nuclei).? Standard ear loop surgical masks are therefore appropriate for patients.2.????? Care providers, on the other hand, wear masks to prevent infection, and therefore need masks that are efficient filters of inhaled air.? The ability of a mask to reduce infection depends on the amount of leakage around the mask, and, to a lesser extent, upon its efficiency as a filter.? For this reason, tight-fitting masks, not surgical masks, are indicated for care providers.3.????? Two types of approved masks are available for staff: the 3M N95 and the Technol PFR 95.? Both masks come in two sizes.? These masks provide at least 95% protection against airborne TB bacilli.? Staff caring for patients on respiratory isolation for pulmonary TB must wear one of these particulate filter masks (also called “N95 respirators”).4.????? All direct care providers at risk of exposure to suspected or proven pulmonary TB must receive instruction and fit testing for the care and proper size N-95 mask. ?This is normally done during New Employee Orientation. Anyone who has been Fit Tested must “Fit Check” the N95 respirator before entering the patient’s room.? Each Service with at risk employees has an assigned staff member who is responsible for fit-testing. ?This program is under our Environmental Health and Safety Office. Sputum induction for the diagnosis of TB may only be done in a respiratory isolation patient room, the bronchoscopy suite or the aerosolized pentamidine booth in ID clinic (1B-23).? Routine, non-induced, bedside sputum collection requires no special room.IMPLEMENTING ISOLATION PRACTICESAirborne Isolation?PPD surveillance is indicated for employees in areas where risk of exposure to TB is high (based on the medical center annual TB risk assessment).? These areas include bronchoscopy and sputum induction areas (e.g., Pulmonary Function Testing Lab, Bronchoscopy suite), ID Clinic, Respiratory Therapy, ICU, TCU, Ward 1A (where most TB patients are admitted), Chest Clinic, the Homeless Vet CBOC at 401 3rd St. and the E&A.? All other employees will be surveyed annually (skin test or symptom check list).?Guidelines for airborne isolation in patients with suspected or proven pulmonary TBUse monitored negative pressure room; keep door and windows closed and call Engineering (x2009) to activate room before accepting patient.Place Airborne Precautions Sign on door.Require staff to wear an N-95 particulate respirator mask.Require visitors and family to wear a surgical ear loop mask when entering the room.Place a surgical ear loop mask on patient when they must leave room for any reasonPractice Standard PLUS Airborne Precautions.? Droplet and Contact may also be required on a case-by-case basis.Patients who are suspected of having active pulmonary TB must be placed and kept in respiratory isolation.As soon as possible, sputum specimens for AFB smear and culture should be sent to the microbiology laboratory.Collect 3 separate sputum specimens for AFB obtained at 8-12 hour intervals (at least one specimen must be an early morning specimen).For smear positive patients, respiratory isolation should continue for a minimum of two weeks after the initiation of anti-TB therapy.? This does not mean that patients with tuberculosis must be hospitalized for two weeks; most can go home whenever medically appropriate.? However, a patient cannot be discharged to an institutional setting (e.g., jail, board and care facility, hospice, snf, etc.) until they have completed at least two weeks of appropriate therapy, and have demonstrated clinical improvement.? California State law mandates that physicians make a plan for care after discharge to assure compliance with medication administration. The San Francisco TB Control Office provides Directly Observed Therapy (DOT) for selected patients.? Contact the Infection Control Nurse for additional information (see Table on page 45).For patients who have three negative smears but for whom the suspicion of TB is high enough to initiate anti-TB therapy, isolation can be discontinued after 5 days of appropriate treatment, at the discretion of the physician.If the patient is considered only a possible diagnosis (anti-TB therapy not started), the patient may be removed from respiratory isolation after three (3) negative smears on three separate days have been confirmed.If tuberculosis is not likely but is being ruled out as a possible diagnosis, the patient may be taken off respiratory isolation after one negative sputum smear has been confirmed.The following steps should be taken when instituting respiratory isolation for TB:1.????? Suspected TB patients should be placed in a monitored negative pressure room.? This is the major indication for the use of these rooms; patients not requiring respiratory isolation must be moved to accommodate those who do.2.????? Before admitting the patient, Nursing Service will activate the negative pressure alarm. (See MCM #138-18). Engineering Service will verify that the room is negative pressure and that the alarm is working no later than the next business day.3.????? The door and windows of negative pressure rooms must be kept closed for the negative pressure to be effective.? The alarm will sound if this is not being done.4.????? Post a red respiratory STOP sign on the door.5.????? A particulate filter respirator (N-95) must be worn by all care providers entering the room. ?Standard surgical type isolation masks are not to be worn by care providers.6.????? Place a standard surgical type isolation mask (blue or yellow with ear loops) on the patient when they must leave their rooms, e.g., transporting to lab, x-ray.? The mask must be securely placed on the patient and the patient informed as to why it must be worn.7.????? Patients on respiratory isolation should remain in their room as much as possible.? Casual trips to other wards, the canteen, etc. are not permitted.? Security may be called for uncooperative patients or visitors (see TB Exposure Control Plan MCM #111W-6).8.????? Call Infection Control (ext 3762/2728/2593) or the on-call Infectious Diseases Fellow (pager 207-3614) with questionsSection 7Reusable Medical EquipmentRME is any piece of equipment that is designed to be used by more than one patient. The equipment is broken down into three levels: Critical, Semi-Critical and Non-Critical. The classifications of these risk levels are based on the Spaulding Classification system and adopted for use by the Centers for Disease Control and Prevention (CDC).Critical RMECritical devices carry a high risk of infection. Critical items enter into the blood stream and must be sterilized before use on patients. Examples of critical items include surgical instruments, implantable devices and dental handpieces and instruments.Semi-CriticalSemi-critical items require high level disinfection (HLD). HLD destroys many or all microorganisms, except for bacterial spores.These items come in contact with intact mucous membranes or non-intact skin. Examples of semi-critical devices are GI/GU endoscopes, respiratory therapy equipment and anesthesia equipment.Non-CriticalNon-critical reusable medical equipment has a low risk of infection. These devices require low level disinfection.Cleaning and low level disinfection involves manual or mechanical removal of visible soil. Non-critical items only come in contact with intact skin.Examples of non-critical reusable medical equipment are blood pressure cuffs, patient furniture, stethoscopes and ambulatory assistive devices.Non-critical RME can be cleaned at the site of use by the user, or sent to Sterile Processing Services (SPS) for reprocessing. It is important that all employees understand and follow the proper procedures for cleaning RME.Responsibility It is important for all employees at the San Francisco VA Medical Center to understand their responsibility pertaining to reusable medical equipment.Always follow manufacturer’s guidelines when cleaning any reusable medical equipment.Wear appropriate Personal Protective Equipment (PPE) when cleaning equipment.Clean equipment with the correct cleaning solution .All equipment must be cleaned before being sent to Biomedical Engineering for repair. Section 8LAUNDRYBecause the risk of disease transmission from soiled linen is negligible, the storage and processing of both clean and soiled linen requires only simple hygiene practices and common sense. Clean and soiled linen may never be stored in the same physical area, but must be segregated in clearly marked separate areas. Clean linen should remain on the covered carts until used.? If clean linen is placed on a small cart during morning care, the cart is to be covered with a sheet.? Linen must remain on the small cart until used and not replaced on the large cart.?Soiled Linen?All soiled linen should be bagged at the location in which it is used and handled as little as possible.Linen should not be sorted in patient care areas.Double bagging of linen is not necessary.? Linen that is soiled with blood or body fluids should be placed and transported in bags that cannot leak.? All persons who handle soiled linen should wear protective apparel such as gloves and either gowns or aprons to reduce their risk of skin contact and soiling of their clothing with blood and body fluids. Contract Linen and laundry service is inspected annually by EMS for compliance with infection control practices.? SECTION 9CLEANING AND DECONTAMINATION OF BLOOD AND BODY FLUID SPILLSBlood and body fluid spills should be decontaminated with any chemical disinfectant, (like Wexcide) that has been approved for use in this Medical Center. ?When there are spills of concentrated infectious agents such as blood, the contaminated area should first be flooded with a hospital approved disinfectant covered with paper towels and then physically cleaned and decontaminated with a fresh germicidal chemical.For large spills contact Environmental Management Service x 2310 7:00- 3:30am. ?If a large spill occurs on the evening or night shift page EMS at 716-7388 or 725-5191 respectively.Gloves and proper PPE must be worn during all cleaning and decontamination procedures.Paper towels soaked with blood are to be placed in a biohazard red bag and disposed as biohazard waste.SECTION 10POST MORTEMDuring the post mortem handling of bodies, it is important to utilize Standard Precautions while preparing the body for transport and performing autopsies.? Refer to Department of Anatomic Pathology for a complete Infection Control Policy. (Infection Control in the Dept. of Pathology 2/07).?SECTION 11Regulated Medical Waste Disposal PolicyDefinitionsREGULATED (INFECTIOUS OR BIOHAZARD) HEALTH CARE waste includes any waste material or article which harbors pathogens which may produce disease in healthy individuals.? This waste should be properly identified, treated and disposed of as soon as possible after generation and transported in leak proof, cleanable carts. Health Care Waste generally includes all liquid waste that is potentially contaminated with blood or body fluids and includes (but is not limited to) the following examples.Dialysis waste material, including lines and dialysis membranes prior to disinfection.Laboratory waste – blood, plasma and serum specimens or microbiologic cultures and discarded, used culture media.Blood – Blood containers or equipment containing blood that is liquid including blood transfusion bags and tubing and vacutainer tubes.Sharps – syringes, needles, blades, broken glass items that have been in contact with blood such as pipettes, vacutainer tubes, dental and surgical sharps.? These must be placed in puncture proof sharps containers.Contaminated animals – carcasses, body parts and bedding materials that are suspect or known by the attending veterinarian of being contaminated with infectious agents.Surgical specimens – human or animal parts or tissues removed surgically or by autopsy. Laboratory waste containing live cultures of microorganisms and agents of bioterrorism must be destroyed before transport out of the laboratory.ORDINARY TRASH is defined as dry, non-bloody refuse including most medical disposables such as dressings, urinary catheters, empty syringes without needles, Band-Aids, chux, and G.U. or NG tubing.? This includes these items coming from patients who are on Respiratory or Special Organism Precautions.Regulated Medical WASTE DISPOSALProceduresBiohazardous and Non-biohazardous waste should be separated. If wastes are inadvertently mixed, the non-biohazardous waste is considered biohazardous.Most biohazardous waste can be placed in a single leak-resistant red plastic bag. If punctured or contaminated, the bag is placed into a second bag. All bags must be securely closed when filled. Except for Sharps Containers (see #5 below), all regulated medical waste will be placed in rigid, leak proof red barrels that are marked with the biohazard label.? Non-glass biohazardous wastes will be placed in the red and square containers located in the soiled utility rooms. All glass biohazardous wastes (such as TPN, lipid and vacuum glass bottles) will be placed in the red and round containers also located in the soiled utility rooms. For glass biohazardous wastes, the following label will be affixed to these red and round containers: These red large waste containers are located in soiled utility rooms, or, in the case of laboratories, as close as possible to the area of use.? They must not be overfilled because it puts the person at risk for an exposure who is preparing the canister for pick/up and disposal. Red biohazard plastic liners are used to contain liquid waste, etc. and must be left in place – plastic bags should never be removed from their rigid container. Whenever there is a chance of leakage from any container, before it is placed in the waste container it should be put in a second, closable leak-proof container or bag (labeled or color coded) to minimize the risk of exposure to EMS personnel from leakage during handling, storage and transport. Delivery of this waste to a large container for final disposal should be done mechanically to minimize the risk to those doing disposal.Labels used to identify regulated waste must be bright orange or orange-red, and contain the BIOHAZARD warning symbol.? This symbol must be able to be viewed on the top of the biohazard container and on all 4 sides. This label must be securely affixed to the container and secured to prevent it from coming off or being unintentionally removed during handling.The biohazard rooms (soiled utility rooms) must also be identified as such by affixing the biohazard warning sign to the outside of the door. These room must be secured.Small sharps containers are to be located as close as possible to point of use and are for the disposal of syringes, needles and small disposable sharp instruments (e.g.: scalpels, scissors, probes, tweezers), pipettes (glass or plastic), and broken glass.?These containers must be emptied when ? full, secured in a manner to prevent tipping over, and never reused. Do not use them to dispose of paper, band-aids or any other trash, etc.Per lab protocol, highly resistant organisms from the clinical microbiology laboratory will be decontaminated by sterilization before disposal in BIOHAZARD waste containers.Human parts from anatomic pathology and the morgue are double-bagged and treated as regulated waste.? Animal carcasses from research are high temperature incinerated on-site. ?The OR uses a liquid waste disposal system called Dornoch. This system delivers liquid waste from surgical procedures directly in to the City sewer system.?Environmental Management Service will be responsible for the collection of regulated medical waste containers. As of June 2006, an EMS biohazard waste sterilizer system (SaniPak) was installed at the back loading dock and has eliminated the need for an outside contractor. An Attest Rapid Readout Biological Indicator Steam Pack 1292 for Geobacillus stearonthermophilus is conducted twice a month. The specimen is collected by EMS, read by the Micro Lab and reported to Infection Control.? SECTION 12OCCUPATIONAL HEALTHOccupational Health Policy on Infection Control for Medical Center Employees I.???? Occupational Health. The following services pertinent to Infection Control are available through Occupational Health:?????? A.? Physical Examinations1. ?Initial and subsequent VA physical examinations for personnel, including determining employee’s physical fitness for continued employment; see Attachment A to Medical Center Memorandum 05-23, Employee Health Service.2. Determining, after a period of illness, whether an employee is able to resume his/her regular duties without impairing his/her health or the health of others. 3. Coordination with Infection Control when there are clusters of infections in employees (eg. Norovirus, Conjunctivitis, Scabies).4. Coordination with Infection Control during an influx of infectious patients.?????? B.? Preventive Measures?1.?? Detecting unhealthful working conditions, detecting and controlling diseases in their incipiency.2.?? Providing health education to encourage employees to maintain personal health.3.?? Providing immunizations and vaccinations against tetanus and pertussis (Tdap); influenza; measles, mumps, and rubella (MMR); Hepatitis B, and varicella.? II.??? Employee exposure to infectious or communicable diseases??????? A.? Pregnant employees should not attend to patients with suspected communicable diseases known to be harmful to the fetus, particularly cases of Rubella or Varicella, unless the employee can demonstrate prior immunity.???????? B.?? In special circumstances the Occupational Health Service provides treatment of employees exposed to hepatitis, meningococcal disease, tuberculosis, human immunodeficiency virus, scabies and lice, (see Medical Center Memorandum 111W-4 “Blood Borne Pathogens Exposure Control Plan”).OCCUPATIONAL HEALTH (SPECIFIC DISEASES)Exposure to Specific DiseasesINFLUENZA: Influenza vaccine should be offered annually. During institutional outbreaks, chemoprophylaxis should be offered to unvaccinated staff members who provide care to persons at high risk of complications. Chemoprophylaxis should be considered for all employees, regardless of their influenza vaccination status, if indications exist that the outbreak is caused by a strain of influenza virus that is not well matched by the vaccine. Hepatitis B & C virus: Accidental needle sticks or splashes to the eyes or mouth should be reported to the Needle stick Hotline for appropriate evaluation and treatment, and an "Incident Report 2162" will be completed.? Hepatitis B vaccine is offered to all Medical Center Employees free of charge and is administered through Occupational Health on a voluntary basis.? An employee who does not wish to receive Hepatitis B vaccine will be required to sign a declination form. To date there is no vaccine or post exposure treatment available to those exposed to Hepatitis C.HEPATITIS A virus: Personnel who have exposure to Hepatitis A via direct contact with an infected patient or with their secretions (e.g., blood, stool, urine, vomit, saliva), will be offered prophylactic Immune Serum Globulin.Meningococcal Disease:? Personnel having unprotected intimate contact with a patient with invasive meningococcal disease at a VA Facility should be considered for chemoprophylaxis.? Unprotected means without wearing a mask, and examples of intimate contact include persons sharing the same lodging, or hospital personnel performing: mouth-to-mouth resuscitation; close examination of the oropharynx; or endotracheal intubation or tube management on a patient with the disease.? Antimicrobial prophylaxis is not indicated for hospital personnel providing routine patient care, housecleaning, or laboratory exposure to clinical specimens.VARICELLA:? Vaccine will be offered to all?employees who have negative history of childhood chicken pox, do not have written documentation of vaccination with two doses of varicella vaccine, or have a negative varicella antibody test.PULMONARY Tuberculosis:? Employees who are exposed to a case of pulmonary tuberculosis will be evaluated on an individual basis by Occupational Health as follows:Known PPD-negative employees will be given a tuberculin (PPD) skin test or a whole blood test (Quantiferon) immediately and again in eight to twelve weeks.? Further follow-up examinations will be done subsequently as indicated by their job description risk category.Known PPD-positive employees do not require repeat skin test or chest radiograph unless they have symptoms suggestive of tuberculosis, however they may receive a Quantiferon blood test. These employees will receive an annual TB symptom questionnaireEmployees who have converted their PPD skin test are candidates for treatment of latent tuberculosis infection (LTBI). These employees and employees who have abnormal chest radiographs will be evaluated by Occupational Health. These employees should follow up with their primary medical providers for treatment of LTBI after discussing the risk and benefits.MEASLES & RUBELLA: MMR vaccine should be offered to all healthcare personnel born in 1957 or later without serologic evidence of immunity or prior vaccination.PERTUSSIS: Health-care workers who are close contacts of a pertussis case will be offered chemoprophylaxis. All healthcare personnel who have not or are unsure if they have previously received a dose of Tdap should receive a one-time dose of Tdap as soon as feasible, without regard to the interval since the previous dose of Td. HUMAN IMMUNODEFICIENCY VIRUS (hiv): Employees who have had exposure to blood or body fluids in the setting of the care of a patient infected with HIV should be treated according to the Medical Center Blood Borne Pathogens Exposure Control Plan.Since occupational exposure to patients infected with HIV does not pose a significant risk to health care workers, personnel will not be excused at their own request from delivering care to these patients.? Employees who believe they are at risk for infection are encouraged to discuss their work responsibilities with their personal physician and with members of this Medical Center's Infectious Disease Section.? Any adjustment in the employee's duties will be based upon medical as well as administrative considerations within the employee's service.HIV Antibody Testing:? If dictated by either infection control considerations or public health mandate, the antibody status of an employee at this Medical Center may be determined through HIV testing.All employees who have exposures to known HIV+ or high-risk source patients will be offered prophylaxis through Occupational Health in accordance with the Medical Center Blood borne Pathogens Exposure Control Plan.OCCUPATIONAL HEALTH (TUBERCULOSIS CONTROL)Tuberculosis Control ProgramIn order to monitor Medical Center employees who are at risk of contracting TB during the course of their duties, this Medical Center will pursue TB screening on an annual basis.? All employees will undergo initial TB screening during pre-employment physical examination.? This will include an initial TB skin test and a “boost” in 7 days. Employees working in certain high risk exposure areas will be tested on a six-month basis or as determined by the annual TB risk assessment of the Medical Center.? "At risk" refers to situations in which health care workers are regularly and repeatedly in direct, face-to-face contact with patients who are suspected or known to be infected with tuberculosis.? Details can be found in the Medical Center Tuberculosis Control Plan.Employees whose PPD skin test reaction converts from negative to positive shall be referred to their personal physician for evaluation and therapy after discussing the risk and benefits of LTBI treatment.? Pregnant HCWs should be included in serial skin testing as part of an infection-control program or a contact investigation because no contraindication for skin testing exists. Guidelines issued by the American College of Obstetricians and Gynecologists (ACOG) emphasize that postponement of the diagnosis of infection with M. tuberculosis during pregnancy is unacceptable. Because TB disease is dangerous to both mother and fetus, pregnant women who have a positive TST result or who are suspected of having TB disease, as indicated by symptoms or other concerns, should receive chest radiographs (with shielding consistent with safety guidelines) as soon as feasible, even during the first trimester of pregnancy.OCCUPATIONAL HEALTH (EMPLOYEE ILLNESS)Employees with Contagious or Infectious DiseasesSupervisors should refer employees who show signs or symptoms of contagious or infectious diseases while at work to Occupational Health Service for diagnosis, treatment, and determination of suitability to continue work. The employee may be relieved of duty depending upon the severity of the illness, and must report to Occupational Health before returning to duty. The following are some of the common problems which may arise:?Respiratory infections with cough, rhinorrhea, or pharyngitis and FluHerpes simplex and herpes zoster (shingles)Draining skin lesions (boils, carbuncles, infected cuts or sores)Diarrheal illnessConjunctivitisScabiesThe diagnosis of HIV infection does not preclude employment at this Medical Center.? However, employees so diagnosed should be instructed on precautions similar to those given to employees who have had Hepatitis B & C.? Employees with HIV infection may be at risk for certain opportunistic infections and should review with their personal physician the nature of their patient care contacts in order to minimize the risks associated with their susceptibility.Health Care Worker Restrictions for Infectious Diseases TableEtiological AgentIncubation PeriodExposure CriteriaPeriod of CommunicabilityWork RestrictionsHepatitis A VirusUsually 25-0 days Range 15-50 daysConsuming uncooked food prepared by an infected person.Contact with stool of infected person without wearing gloves.Viral shedding stool lasts 1-3 weeks.Highest viral titers are found in stool 1-2 weeks before onset of symptoms.Risk of transmission is minimal 1 week after onset of symptoms.Exposed: NoneInfected: May return to work 7 days after onset of jaundice or other clinical symptoms.Influenza Virus and other Respiratory Viruses; RSV, Para-influenza, Adeno-virus, HMP virusUsually 1-3 daysContact within 3 feet of infected person without wearing a mask. Direct contact with secretions from respiratory tract, infected person or items contaminated with these secretions without wearing gloves.Most infectious 24 hours before onset of symptoms.Viral shedding usually ceases within 7 days but can persist longer in children.5 days from onset of first symptom OR 24 hours after their last symptom which-ever is longerExposed: Has not been defined for non-immune healthcare workers exposed to persons with influenza.Infected: Febrile healthcare workers should not work until acute symptoms have resolved for at least 24 hours.Lice6-10 daysHead lice: Hair-to-hair contact with infected person.Body lice: Contact with linen or clothes of infected person without wearing gloves.Pubic lice: Sexual contact.As long as lice or eggs remain alive on infected person, clothing or personal items.Survival time for lice away from the host: 10 days for head lice, 10 days for body lice, 2 days for pubic lice. Nits > 10mm from scalp have been present > 2 weeks and may not be viable.Exposed: NoneInfected: Immediate restriction until 24 hours after treatment.Measles Virus aka Rubeola, Hard measles, Red measles10 days, may be 7-18 days from exposure to onset of fever, usually 14 days before rash onsetSpent time in room with an infected person without wearing a respirator.If air is recirculated, spent time in the area supplied by the air handling system while infected person was present or within one hour after the person’s departure.Contact with nasal or oral secretions from an infected person or items contaminated with these secretions without wearing gloves.3-5 days before rash begins and 4-7 days after rash appears, but transmission is minimal 2-4 days after rash appears.Exposed: Days 1-4 - NoneDays 5-12 for a single exposure or Day 5 for first exposure through day 21 of last exposure, healthcare workers must either:Not work; or,Have no direct patient contact and work only with immune persons away from patient care areas.Infected: May return to work 4 days after developing rash.Mumps Virus Infectious Parotitis15-18 days Range 14-25Contact within 3 feet of infected person without wearing a mask.Contact with saliva or items contaminated with saliva from an infected person without wearing gloves.Most communicable 48 hours before onset of illness, but may begin as early as 7 days before onset of overt parotitis and/or orchitis and continue 5-9 days (average 5 days) thereafter.Exposed:Days 1-10 - NoneDays 11-26 for a single exposure or Day 11 of first exposure through Day 26 of last exposure, healthcare workers must either:Not work; or,Have no direct patient contact and work only with immune persons away from patient-care areas.Infected: May return to work 9 days after onset of parotid gland swelling.We recommend that during the incubation period an exposed worker should not work with patients at high risk of complications.Norovirus Norwalk agent diseaseUsually 24-48 hours Range 10-50 hoursFecal-oral route, contact or airborne transmission from vomit and fomitesDuring acute stage of disease and up to 48 hours after Norwalk virus diarrhea stopsExposed: None Infected: 48 hours after last diarrhea stoolBacterial gastroenteritisUsually 10-50 hoursFecal-oral route, contact with fomites If vomiting, vomitus sprayDuring acute stage of disease and up to 48 hours after last diarrhea stool Symptoms can be: nausea, vomiting, diarrhea, abdominal pain, myalgia, headache, malaise, low grade feverExposed: None Infected: 24-48 hours after last diarrhea stoolMRSA InfectionsUsually 4-24 hours, has rapid onsetContact with open wound or drainage without wearing glovesDuring acute stage of infection where wound is open and draining fluid into the environmentExposed: NoneInfected: Varies as to healing time and treatment. May return to work once drainage has stopped or is contained. Consult with OHS to discuss work assignment.Mycobacterium Tuberculosis2-10 weeks from exposure to detection of reactive PPD. Risk of developing active disease is greatest in first 2 years after infection.Spent time in a room with a person who has active disease without wearing a respirator.Packing or irrigating wounds infected with M. Tuberculosis without wearing a respirator.Persons are infectious until they have taken 2 weeks of effective antituberculosis chemotherapy.Persons whose smears are Acid Fast Bacillus (AFB) positive are 20 times more likely to cause secondary infection than persons who are smear negative.Exposed: NoneInfected: Restrict healthcare workers with active TB until after they have taken 2 weeks of effective antituberculosis chemotherapy.Neisseria MeningitidesUsually < 4 days Range 1-10 daysExtensive contact with respiratory secretions from an infected person without wearing a mask, particularly during:SuctioningResuscitationIntubationClose examination of the oropharynxPersons are infectious until they have taken 24 hours of effective antibiotic therapy.Exposed: NoneRubella Virus aka German Measles14-17 days Range 14-21 daysContact within 3 feet of infected person without wearing a mask. Contact with nasopharyngeal secretions from an infected person or items contaminated with these secretions without wearing gloves.7 days before rash to 7 days after rash appears. Highly communicable.Exposed: Days 1-6 - NoneDays 7-21 for a single exposure or Day 7 of first exposure through Day 21 of last exposure, healthcare workers must either:Not work; or,Have no direct patient contact and work only with immune persons away from patient-care areas.Infected: May return to work 7 days after developing rash.Scabies4-5 weeks if no previous infestation. 1-4 days if previous infestation.Direct skin-to-skin contact.Minimal direct contact with crusted scabies can result in transmission.Transmission can occur before the onset of symptoms.Person remains contagious until treated.Exposed: None after scabicide used.Infected: Immediate restriction until 24 hours after treatment.Varicella Zoster VirusUsually 14-16 days Range 10-21 daysUp to 28 days in persons who received VZIG.Chickenpox or disseminated zosterContinuous household contact.>5 minutes face-to-face contact with infected person without wearing a respirator.Direct contact with vesicle fluid without wearing gloves.ShinglesDirect contact with vesicle fluid without wearing gloves.ChickenpoxMost contagious 1-2 days before and shortly after rash appears.Transmission can occur up to 5 days after onset or rash.Immunocompromised persons may be contagious as long as new lesions are appearing.Shingles24 hours before the first lesion appears and up to 48 hours after final lesion appears.Exposed:Days 1-7 - NoneDays 8-21 for a single exposure or Day 8 of first exposure through Day 21 of last exposure, HCW must either:Not work; or,Have no direct patient contact and work only with immune persons away from patient-care areas.Infected: May return to work after all lesions are dry and crusted.Group A Streptococcal (Aka Strep Throat)Usually 2-5 days for pharyngitis. 7-10 days for skin infection.Direct or intimate contact with patients or carriers.Untreated: 10-21 daysTreated: 1-2 daysExposed: NoneInfected: May return to work after 24 hours of adequate treatment.Conjunctivitis, Bacterial24-72 hoursDirect contact with eye drainage or upper respiratory tract secretions.Direct contact with contaminated equipment, cosmetics, or multi-dose solutions.During course of active infection.Exposed: NoneInfected: Restrict healthcare workers until signs and symptoms subside (purulent drainage).Pertussis4-21 days (median 7-10 days)Contact with coughing patient at a distance of 5 feet or less.Early catarrhal stage and before the paroxysmal cough stage, thereafter communicability gradually decreases and becomes negligible in about 3 weeks. When treated with Erythro-mycin the period of infectiousness is usually 5 days after first antibiotic dose.Exposed: None, prophylaxis recommendedInfected: From start of catarrhal stage through third week after onset of paroxysms or until 5 days after start of effective antimicrobial therapy.Herpes SimplexGenital: 2-12 daysHands and Orofacial: 1-26 days (6-8 days median)Close/Direct contact with herpetic lesions or oral secretions. During symptomatic period.Exposed: NoneInfected: Genital-No restrictionHands (herpetic whitlow)-restrict from patient contact until lesions heal.Orofacial-restrict from care of big risk patients until lesions heal.Hepatitis B Virus45-160 days Average 120 daysPercutaneous injury through contaminated needles or sharps.Mucous membrane exposure to contaminated blood or body fluids.As long as blood tests positive for hepatitis B surface antigen.Exposed: NoneInfected: NoneReferences: “Control of Communicable Diseases Manual”, James Chin, MD, MPH, Editor, 17th Edition, 2000, American Public Health AssociationMRSA IL10-2010-003 1/25/10Mm 3/29/13SECTION 13EMERGENCY MANAGEMENT - Influx of Infectious PatientsVA Medical Center will follow the Emergency Operations Plan (EOP) and Appendix 12: Highly Communicable Infectious Diseases and Pandemic Influenza Influx, which focuses on the Operations that must be accomplished to successfully respond to an influx of Highly Communicable Infectious Disease patients including:Responsibilities of various providers and departmentsUnique planning needsEssential operations (E.g. ordering cultures, isolation, unit closing, halting services, quarantine)Events limited in scope will be managed through the Chief of Staff’s Office and the Infection Control team with daily briefings to leadership. This team will include the Chief of Infection Control, Infection Control Staff, Chief of Emergency Department, Microbiology, Emergency Management Coordinator, and all other applicable Service Chiefs.The Infection Control Officer is responsible for:Verifying the occurrence and nature of the infectious disease process, geographic location, formulating a case definition and transmission routeAdvising the Director, Chief of Staff, Incident Commander, or Designee as appropriateEnsuring Infection Control representation in the EOC if activatedTracking confirmed and potential casesMaintaining Transmission Based Precautions; Contact Precautions, Droplet and Airborne Isolation using a private room with monitored negative pressure. Infectious Disease transmission prevention may include cohorting (isolation of infectious patients together) and subsequent development of isolation wards for major influx of cases Working with and reporting to local and state Public Health agenciesServing as information resource on changing public health recommendations, and on the community outbreak, including reporting to Public Information and Liaison Officers for public/community information distribution Assisting with vaccination decisions affecting staff and patientsAdvising on mass distribution system for vaccine, antibiotic, and antiviral medicationsLink to Emergency Operations Plan (EOP) and Appendix 12: Highly Communicable Infectious Diseases and Pandemic Influenza Influx: INFECTIOUS DISEASE / PANDEMIC INFLUXSECTION 14OUTBREAK MANAGEMENT The Medical Center will provide all measures possible to promptly investigate and control the outbreak of infectious diseases among patients and/or health care workers.Infection Control is responsible for:Informing the ID/Chair of ICC when available information suggests an outbreak.Collecting critical data, establishing a case definition and formulating hypothesis in collaboration with the Chief of Infection Control.Collaborating with ID/Chair of ICC in recommending appropriate strategies to manage outbreak of infectious municating to Leadership.Recommending infection control measures and collaborating with Leadership, Nursing Services, EMS, SPS and other appropriate departments to implement interventions to manage outbreak. Notifying appropriate agencies as indicated.Collaborating with Medical Services, Nursing Services, EMS and other critical departments to institute interim control measures. Controls will be initiated based on the suspect route of transmission and may include:Hand hygiene/standard precautions re-emphasized.Additional precautions are instituted as needed.Use of cohorting may be necessary.Restriction of certain activities (leaving unit for therapy) depending on risk of transmission.Ward/area may be closed to new patients.Designation of specific staff to care for specific patients/areas.Sending staff home and outlining recommendations of returning to work.Patients may be discharged if possible.Product may be removed or recalled.Initiating additional cleaning or change in cleaning of environment.Restricting/limiting visitors.The ID/Chair ICC is responsible for recommending appropriate strategies to manage outbreak of infectious diseases. Providers are responsible for ordering tests as recommended.Microbiology is responsible for obtaining, performing and repeating tests as ordered.Pharmacy is responsible for assuring adequate medications are available. Occupational Health is responsible for screening/reporting/treating employees as needed and assess staff to allow them to return to work. SECTION 15Departmental Infection Control Policies: All Infection Control MCMs, policies, IC Manual, and Hand Hygiene guidelines will be followed by ALL staff at all times. Certain departments have unit-specific infection control policies that may be found on the SFVA Infection Control SharePoint site. Departments without unit-specific infection control policies are listed below and will follow guidelines as set in this Infection Control Manual. Specific departmental guidelines:Ambulatory Care (includes: ENT Clinic, Dermatology, Podiatry, CBOCs, Emergency Department)Patient Assessment and Triage: Patients in ambulatory settings are often congregated in common waiting areas where diseases may be passed via the airborne or droplet route. Patients arriving with a cough or respiratory symptoms are to be provided with tissue or surgical masks and asked to cover their cough. They must be asked to wash their hands frequently. Anyone arriving with a productive cough, diarrhea, undiagnosed rash, bleeding, or wound or eye drainage should be assessed by staff as soon as possible and isolated from other patients.ICU: Plants are not allowed in the ICU.No visitors under the age of 16 are allowed in the ICU, except under the discretion of the Charge Nurse, Nurse Manager or ICU Director (or designee).EKG/Treadmill/HolterBusiness ServicesREFERENCES1.?Employee Health Services MCM 05-23, 4/20092. APIC Text of Infection Control and Epidemiology 2009 3.??MCM 111W-4 Medical Center Exposure Control Plan 5/2009 4. MCM 111W-6 Tuberculosis Exposure Control Plan 6/2010 5. MCM 11-09 Infection Control Program 12/106.?MCM 111W-02 Reportable Diseases 7.MCM 00-09 Appendix 17 Surveillance Prevention and Control of Infection Functional Team 8/078.Guidelines for Hand Hygiene in Health-Care Settings, Recommendations of the Health Care Infection Control practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and reports Oct 25,2002 Vol. 51, No. RR?9.?VHA Directive 2005-002 Required Hand Hygiene Practices 1/05 10. Department of Pathology Policy “Infection Control in the Dept. of Pathology 10/07 11. CLC policy # 21 “TB Screening” 12/201112. Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings, 2007, CDC. 13. Management of Multi Drug Resistant Organisms (MDRO) in Health Care Settings, 2006? 14. Emergency Operations Plan (EOP) Appendix 12: Highly Communicable Infectious Diseases and Pandemic Influenza Influx ................
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