ICG Draft 10jan10

AUSTRALIAN GUIDELINES FOR THE PREVENTION AND CONTROL OF INFECTION IN HEALTHCARE
CONSULTATION DRAFT 7 JANUARY 2010
CONSULTATIONDRAFTJANUARY2010 Contents Summaryofrecommendations.................................................................................................................... 7 Introduction .................................................................................................................................................. 13

PART A BASICS OF INFECTION CONTROL................................................................................................................... 19
A1 Infectioncontrolinthehealthcaresetting...................................................................................... 20 A1.1 Risksofcontractingahealthcareassociatedinfection.......................................................... 20 A1.2 Standardandtransmissionbasedprecautions ...................................................................... 22 A2 Overviewofriskmanagementininfectionpreventionandcontrol ......................................... 24 A2.1 Riskmanagementbasics ........................................................................................................... 24 A3 Apatientcentredapproach ............................................................................................................... 26 A3.1 Patientcentredhealthcare ....................................................................................................... 26 A3.2 Howdoespatientcentredcarerelatetoinfectioncontrol?.................................................. 26
PART B STANDARD AND TRANSMISSION-BASED PRECAUTIONS............................................................................... 28
B1 Standardprecautions .......................................................................................................................... 29 B1.1 Handhygieneandcoughetiquette ......................................................................................... 30 B1.2 Personalprotectiveequipment ................................................................................................ 36 B1.3 Handlinganddisposingofsharps........................................................................................... 47 B1.4 Routinemanagementofthephysicalenvironment .............................................................. 51 B1.5 Processingofinstrumentsandequipment ............................................................................. 63 B2 Transmissionbasedprecautions ...................................................................................................... 69 B2.1 Applicationoftransmissionbasedprecautions .................................................................... 70 B2.2 Contactprecautions ................................................................................................................... 71 B2.3 Dropletprecautions ................................................................................................................... 74 B2.4 Airborneprecautions................................................................................................................. 77 B2.5 Puttingitintopractice ............................................................................................................... 80 B3 Managementofresistantorganismsandoutbreaksituations .................................................... 89 B3.1 Managementofmultiresistantorganisms............................................................................. 90 B3.2 Outbreakinvestigationandmanagement .............................................................................. 99 B3.3 Puttingitintopractice ............................................................................................................. 106 B4 applyingstandardandtransmissionbasedprecautionsduringprocedures ......................... 107 B4.1 Takingariskmanagementapproachtoprocedures........................................................... 108 B4.2 Therapeuticdevices ................................................................................................................. 110 B4.3 Surgicalprocedures ................................................................................................................. 121 B4.4 Puttingitintopractice ............................................................................................................. 125
Contents 2
CONSULTATIONDRAFTJANUARY2010
PART C ORGANISATIONAL SUPPORT ........................................................................................................................ 126
C1 Managementandclinicalgovernance ........................................................................................... 127 C1.1 Clinicalgovernanceininfectioncontrol ............................................................................... 127 C1.2 Rolesandresponsibilities........................................................................................................ 129 C1.3 Infectionpreventionandcontrolprogram ........................................................................... 131 C1.4 Riskmanagement..................................................................................................................... 133 C1.5 Takinganorganisationalsystemsapproachtoriskmanagement .................................... 134 C2 Staffhealthandsafety...................................................................................................................... 136 C2.1 Rolesandresponsibilities........................................................................................................ 136 C2.2 Healthstatusscreeningandimmunisation .......................................................................... 137 C2.3 Exclusionperiodsforhealthcareworkerswithacuteinfections ....................................... 138 C2.4 Healthcareworkerswithspecificcircumstances................................................................. 140 C2.5 Exposureproneprocedures ................................................................................................... 141 C2.6 Occupationalhazardsforhealthcareworkers ..................................................................... 142 C3 Educationandtraining ..................................................................................................................... 145 C3.1 Teachingfacilities..................................................................................................................... 145 C3.2 Healthcarefacilities.................................................................................................................. 147 C3.3 Educationstrategies................................................................................................................. 148 C3.4 Exampleofeducationinpracticehandhygiene............................................................. 148 C3.5 Complianceandaccreditation................................................................................................ 150 C3.6 Patientengagement.................................................................................................................. 150 C4 Healthcareassociatedinfectionsurveillance............................................................................... 152 C4.1 RoleofsurveillanceinreducingHAI.................................................................................... 152 C4.2 Typesofsurveillanceprograms ............................................................................................. 153 C4.3 Datacollectionandmanagement........................................................................................... 154 C4.4 Outbreaksurveillance ............................................................................................................. 155 C4.5 Diseasesurveillanceinofficebasedpractice ....................................................................... 155 C4.6 Notifiablediseases ................................................................................................................... 156 C5 Antibioticstewardship ..................................................................................................................... 157 C5.1 Background............................................................................................................................... 157 C5.2 Antibioticstewardshipprograms .......................................................................................... 158 C5.3 Antibioticstewardshipsurveillancemethods...................................................................... 159 C6 Influenceoffacilitydesignonhealthcareassociatedinfection ............................................... 161 C6.1 Facilitydesignanditsimpactoninfectioncontrol.............................................................. 161 C6.2 Mechanismsforinfluencinghealthcareassociatedinfectionthroughenvironmental design......................................................................................................................................... 162 C6.3 Thebenefitsofsinglebedroomsforpatientisolation....................................................... 166 C6.4 Constructionandrenovation................................................................................................. 167 C6.5 Guidancedocuments ............................................................................................................... 167
Contents 3
PART D STANDARDS, LEGISLATION AND OTHER RESOURCES .................................................................................. 168
D1 Generalinfectioncontrolresources ........................................................................................ 169 D2 Standardprecautions................................................................................................................ 170 D3 Transmissionbasedprecautions ............................................................................................ 172 D4 Devicemanagement ................................................................................................................. 173 D5 Involvingpatientsintheircare ............................................................................................... 174 D6 Staffhealthandsafety .............................................................................................................. 175 D7 Surveillance................................................................................................................................ 175 D8 Facilitydesign............................................................................................................................ 176
APPENDICES ................................................................................................................................................................... 177
1 MembershipandTermsofreferenceoftheWorkingCommittee............................................. 178 2 Processreport ....................................................................................................................................... 180 3 Exposureproneprocedures(EPP) .................................................................................................... 189 Glossary ....................................................................................................................................................... 194 Abbreviationsandacronyms ................................................................................................................... 200 References.................................................................................................................................................... 202 List of tables and figures
Tables
Table1: Table2: Table3: Table4: Table5:
Directoryofkeyinformationintheseguidelines ............................................................................... 11 Sourcesofevidencetosupportrecommendations ............................................................................. 14 NHMRCgradesofevidence.................................................................................................................. 16 Keytotypesofinformationhighlightedintheguidelines................................................................ 17 Topicsdiscussedintheguidelines........................................................................................................ 18
TableA1.1: Howstandardprecautionsareimplemented...................................................................................... 22 TableA1.2: Strategiesforimplementingtransmissionbasedprecautions .......................................................... 23 TableA2.1: Riskanalysismatrix ................................................................................................................................ 24 TableB1.1: Stepsincoughetiquette.......................................................................................................................... 32 TableB1.2: Useofalcoholbasedhandrub .............................................................................................................. 33 TableB1.3: Usingsoap(includingantimicrobialsoap)andwater ....................................................................... 33 TableB1.4: Characteristicsofaprons/gowns ........................................................................................................... 37 TableB1.5: Useoffaceandeyeprotectionaspartofstandardprecautions ....................................................... 38 TableB1.6: Propertiesofdifferenttypesofmask.................................................................................................... 38 TableB1.7: Selectionofglovetype............................................................................................................................ 41 TableB1.8: PuttingonandremovingPPE ............................................................................................................... 43 TableB1.9: Reducingrisksifasharpsinjuryissustained ..................................................................................... 48 TableB1.10: Characteristicsofdisinfectants..............................................................................................................52
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CONSULTATIONDRAFTJANUARY2010 TableB1.11: Managementofbloodorbodysubstancespills..................................................................................55 TableB1.12 Recommendedroutinecleaningfrequenciesforclinical,patientandresidentareas.................... 56 TableB1.13: Categoriesofitemsforpatientcare ...................................................................................................... 63 TableB1.14: Generalcriteriaforreprocessingandstorageofequipmentandinstrumentsinhealthcare settings ...................................................................................................................................................... 66 TableB2.1: Applicationofstandardandtransmissionbasedprecautions ......................................................... 81 TableB2.2: Infectionswarrantingtransmissionbasedprecautionsbeforelaboratoryconfirmationof infection .................................................................................................................................................... 82 TableB2.3: Typeanddurationofprecautionsforspecificinfectionsandconditions ....................................... 83 TableB3.1 SuggestedapproachtoscreeningforMRSA ....................................................................................... 93 TableB3.2 SuggestedapproachtoscreeningforVREandMRGNdependentonlocalacquisitionrates ..... 94 TableB3.3: ExampleofasuccessfulstrategytopreventendemicityofMRSAinatertiaryhospitalinWA . 96 TableB3.4: ExampleofasuccessfulstrategytopreventendemicityofVREinatertiaryhospitalinWA..... 96 TableB3.5: Stepsinanoutbreakinvestigation...................................................................................................... 100 TableB4.1: Levelofrisktopatientsfromdifferenttypesofprocedures........................................................... 108 TableB4.2: Summaryofprocessesforappropriateuseofdevices..................................................................... 109 TableB4.3: Keyconceptsinminimisingtheriskofinfectionrelatedtotheuseofinvasivedevices ............ 110 TableB4.4: Summaryofprocessesforurethralcatheterinsertionandmaintenance ...................................... 112 TableB4.5: CAUTImaintenancebundle ................................................................................................................ 113 TableB4.6: RiskfactorsforIVDrelatedBSI .......................................................................................................... 114 TableB4.7: Centralvenouscatheterdecisiontreeforadults............................................................................... 114 TableB4.8: Summaryofprocessesforinsertionandmaintenanceofintravascularaccessdevices .............. 117 TableB4.9: SummaryofstrategiesforpreventingVAP ...................................................................................... 119 TableB4.10: VAPcarebundle.................................................................................................................................... 119 TableB4.11: Summaryofprocessesforusingenteralfeedingtubes.................................................................... 120 TableB4.12: Summaryofprocessespresurgicalprocedure ................................................................................. 122 TableB4.13: Summaryofprocessesduringasurgicalprocedure ........................................................................ 123 TableB4.14: Summaryofprocessesfollowingasurgicalprocedure ................................................................... 124 TableB4.15: Checklistofstandardprecautionsforprocedures............................................................................ 125 TableC1: TableC2: TableC3: TableC4: Recommendedvaccinationsforallhealthcareworkers .................................................................. 138 Staffexclusionperiodsforinfectiousillnesses.................................................................................. 139 Categoriesofexposureproneprocedures ......................................................................................... 141 Keyrequirementsofahospitalantibioticstewardshipprogram ................................................... 158
TableApp2.1:Clinicalquestionsforsystematicreview ......................................................................................... 183

Figures
FigureA1.1:Riskmanagementflowchart .................................................................................................................. 25 FigureB1.1: Importanceofhandhygiene.................................................................................................................. 30 FigureB1.2: The5momentsofhandhygiene ........................................................................................................... 31

Contents 5
CONSULTATIONDRAFTJANUARY2010 FigureB1.3: Processesforroutinecleaning ............................................................................................................... 51
Contents 6
CONSULTATIONDRAFTJANUARY2010 SUMMARY OF RECOMMENDATIONS Theseguidelinesproviderecommendationsthatoutlinethecriticalaspectsofinfectionpreventionand control.TherecommendationsweredevelopedbytheInfectionControlSteeringCommittee 1basedon systematicreviewsoftheliteratureundertakenspecificallyfortheseguidelinesoronguidelinesdeveloped byotheradvisorybodies.Theyshouldbereadinthecontextoftheevidencebase.Thisisdiscussedin SectionsB1,B2andB3,whichalsoincludeadviceonthepracticalapplicationoftherecommendations.The tablebelowlistsrecommendationsandthesectionoftheguidelinesinwhichtheyarediscussed.
Recommendation Standard precautions Hand hygiene 1 Routine hand hygiene Hand hygiene must be performed before and after every episode of patient contact. This includes: before touching a patient; before a procedure; after a procedure or body fluid exposure risk; after touching a patient; and after touching a patients surroundings. Section B1.1.2 Page 30 Refer to:
Hand hygiene must also be performed after removal of gloves. 2 Choice of product for routine hand hygiene practices Alcohol-based hand rubs containing at least 70% v/v ethanol or equivalent should be used for all routine hand hygiene practices in the healthcare environment. Choice of hand hygiene product when hands are visibly soiled If hands are visibly soiled, hand hygiene should be performed using soap and water. Section B1.1.3 Page 32
Section B1.1.3 Page 32
Personal protective equipment 4 Wearing of aprons/gowns Aprons or gowns should be appropriate to the task being undertaken. They should be worn for a single procedure or episode of patient care and removed in the area where the episode of care takes place. Use of face and eye protection for procedures A surgical mask and goggles must be worn during procedures that generate aerosols, splashes or sprays of blood, body fluids, secretions or excretions into the face and eyes. Wearing of gloves Gloves must be worn as a single-use item for: each invasive procedure; contact with sterile sites and non-intact skin or mucous membranes; and any activity that has been assessed as carrying a risk of exposure to blood, body fluids, secretions and excretions. Section B1.2.3 Page 37
Gloves must be changed between patients and after every episode of individual patient care.
MembershipandtermsofreferenceoftheInfectionControlSteeringCommitteearegiveninAppendix1.
Summary of recommendations 7
Recommendation 7 Sterile gloves Sterile gloves must be used for aseptic procedures and contact with sterile sites. Refer to: Section B1.2.5 Page 40
Handling and disposal of sharps 8 Safe handling of sharps Sharps must not be passed directly from hand to hand and handling should be kept to a minimum. Needles must not be recapped, bent, broken or disassembled after use. 9 Disposal of sharps The person who has used the sharp must be responsible for its immediate safe disposal. Used sharps must be discarded into an approved sharps container at the point-of-use. These must not be filled above the mark that indicates the bin is three-quarters full. Section B1.3.3 Page 48 Section B1.3.2 Page 47
Routine environmental cleaning 10 Routine cleaning of surfaces Clean frequently touched surfaces with detergent solution at least daily, and when visibly soiled and after every known contamination. Clean general surfaces and fittings when visibly soiled and immediately after spillage. 11 Cleaning of shared clinical equipment Clean touched surfaces of shared clinical equipment between patient uses, with detergent solution. Exceptions to this should be justified by risk assessment. 12 Surface barriers Use surface barriers to protect clinical surfaces (including equipment) that are: touched frequently with gloved hands during the delivery of patient care; likely to become contaminated with blood or body substances; or difficult to clean (e.g. computer keyboards). Section B1.4.2 Page 51 Section B1.4.2 Page 51 Section B1.4.2 Page 51
Exceptions to this should be justified by risk assessment. 13 Site decontamination after spills of blood or other potentially infectious materials Spills of blood or other potentially infectious materials should be promptly cleaned as follows: wear utility gloves and other PPE appropriate to the task; confine and contain spill, clean visible matter with disposable absorbent material and discard the used cleaning materials in the appropriate waste container; clean the spill area with a cloth or paper towels using detergent solution. Section B1.4.3 Page 54
Use of chemical disinfectants such as sodium hypochlorite should be based on assessment of risk of transmission of infectious agents from that spill. Transmission-based precautions (see Section B2) Contact precautions
Recommendation 14 Implementation of contact precautions In addition to standard precautions, implement contact precautions in the presence of known or suspected infectious agents that are spread by direct or indirect contact with the patient or the patients environment. Hand hygiene and personal protective equipment to prevent contact transmission When working with patients who require contact precautions: perform hand hygiene; put on gloves and gown upon entry to the patient care area; ensure that clothing and skin do not contact potentially contaminated environmental surfaces; and remove gown and gloves and perform hand hygiene before leaving the patient care area. Section B2.2.3 Page 71 Refer to: Section B2.2.2 Page 71
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Hand hygiene when Clostridium difficile is suspected or known to be present To facilitate the mechanical removal of spores, meticulously wash hands with soap and water and pat dry with single-use towels. Use of alcohol-based hand rubs alone may not be sufficient to reduce transmission of Clostridium difficile.
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Patient care equipment for patients on contact precautions Use patient dedicated equipment or single-use non-critical patient care equipment (e.g. blood pressure cuffs). If common use of equipment for multiple patients is unavoidable, clean the equipment and allow it to dry before use on another patient.
Droplet precautions 18 Implementation of droplet precautions In addition to standard precautions, implement droplet precautions for patients known or suspected to be infected with agents transmitted by respiratory droplets (ie largeparticle droplets >5 in size) that are generated by a patient when coughing, sneezing, talking, or during suctioning. Personal protective equipment to prevent droplet transmission When entering the patient care environment, put on a surgical mask. Section B2.3.2 Page 74
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Placement of patients requiring droplet precautions Place patients who require droplet precautions in a single-patient room when available.
Airborne precautions 21 Implementation of airborne precautions In addition to standard precautions, implement airborne precautions for patients known or suspected to be infected with infectious agents transmitted person-to-person by the airborne route (ie airborne droplet nuclei or particles <5 in size). Personal protective equipment to prevent airborne transmission Wear a correctly fitted P2 (N95) respirator when entering the patient care area when an airborne-transmissible infectious agent is known or suspected.
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Recommendation 23 Placement of patients requiring airborne precautions Patients on airborne precautions should be placed in negative pressure rooms or in a room from which the air does not circulate to other areas. Exceptions to this should be justified by risk assessment. Multidrug resistant organisms (see Section B3) 24 Implementation of core strategies in the control of multi-resistant organisms (MRSA, MRGN, VRE) Implement transmission-based precautions for all patients colonised or infected with a multi-resistant organism, including: putting on gloves and gowns before entering the patient care area; using patient dedicated or single-use non-critical patient care equipment (e.g. blood pressure cuff, stethoscope); using a single-patient room or, if unavailable, cohorting patients with the same strain of multi-resistant organism in designated patient care areas; and ensuring consistent cleaning and disinfection of surfaces in close proximity to the patient and those likely to be touched by the patient and healthcare workers. Section B3.1.2 Page 91 Refer to: Section B2.4.3 Page 78
CONSULTATIONDRAFTJANUARY2010 Finding information Theserecommendationsprovidethebasisforappropriateinfectioncontrolpracticeinthehealthcaresetting. PracticalguidanceontheirimplementationisgiveninPartBoftheseguidelines.Thefollowingtable providesadirectoryforthisguidance.

Table 1: Directory of key information in these guidelines
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WHEN YOU NEED TO KNOW Infection control basics What are standard precautions and how are they applied How are transmission-based precautions applied How to help patients become involved in infection control
Basics p29 Basics p70 Section A3; Patient care tips also highlighted
How to apply the process of risk management
Section A2; Case studies pp35, 46, 50, 61, 73, 75, 79, 98, 105
Hand hygiene and cough etiquette When to perform hand hygiene What hand hygiene products to use and how What to do if there are cuts or abrasions on your hands About jewellery or artificial fingernails and infection How to care for your hands How to practice cough etiquette Personal protective equipment How to decide what PPE is needed for a particular situation What PPE to wear for routine clinical practice What PPE to wear when there is a risk of contamination with blood, body fluids, secretions, or excretions What PPE to wear when transmission-based precautions are implemented When to wear aprons and gowns When to wear face and eye protection When to wear gloves What is the correct procedure for putting on and removing PPE Handling and disposal of sharps How to avoid sharps injuries How to use needleless devices How to safely dispose of sharps What to do if a sharps injury is sustained Basics p47 ; Case study p50 Basics p49 Basics p48 Basics p48 Basics p36 Standard p71; Aprons and gowns p37, face and eye protection p38; gloves p40 Contact p71; Droplet p74; Airborne p77; MROs p91; Summary p81 Basics p37; Contact 71 Basics p38; Airborne 77 Basics p40; Contact 71; Case study p46 Basics p43 Basics p30; Contact 71; Droplet p74; MROs p90 Basics pp32 to 33; Case study p35; MROs p90 Basics p33 Basics p33 Basics pp33 to 34 Basics p32
Environmental cleaning What products and processes to use for routine environmental cleaning of surfaces When to use disinfectants How to minimise contamination of cleaning implements and solutions What products and processes to use when there is a spill of blood or body fluids Processing of instruments and equipment How to clean equipment and instruments How to disinfect equipment and instruments How to sterilise equipment and instruments How to decide which processing is required When there is a suspected or confirmed infection What transmission-based precautions are required for a specific infectious agent When to implement transmission-based precautions When to implement the use of single-use or dedicated patient care equipment What to consider when transporting patients Where to place patients to avoid cross-contamination Contact p73; Droplet p75; Airborne p78 Contact p72; Droplet p75; Airborne p78; MROs p91; Outbreak p103 General p82; Contact p71; Droplet p74; Airborne p77 Contact p72; MROs p91 Summary p81, p83 Methods p63; Agents 64 Methods p64 Methods p65 Basics p63; 66; Case study p68 Basics p54; Case study p61 Basics p52; MROs p91 Basics p53 Basics p51, p56
CONSULTATIONDRAFTJANUARY2010 INTRODUCTION Effectiveinfectioncontrolpreventingthetransmissionofinfectiousorganismsandmanaginginfectionsif theyoccuriscentraltoprovidinghighqualityhealthcareforpatientsandasafeworkingenvironmentfor thosethatworkinhealthcaresettings.

Healthcare-associated infection is preventable
Therearearound200,000healthcareassociatedinfections(HAIs)inAustralianacutehealthcarefacilities eachyear.ThismakesHAIsthemostcommoncomplicationaffectingpatientsinhospital.Aswellascausing unnecessarypainandsufferingforpatientsandtheirfamilies,theseadverseeventsprolonghospitalstays andarecostlytothehealthsystem.Theproblemdoesnotjustaffectpatientsandworkersinhospitals HAIscanoccurinanyhealthcaresetting,includingofficebasedpractices(e.g.generalpracticesurgeries, dentalclinics)andlongtermresidentialcarefacilities(seeGlossary).Anypersonworkinginorenteringa healthcarefacilityisatrisk.However,healthcareassociatedinfectionisapotentiallypreventableadverse eventratherthananunpredictablecomplication.ItispossibletosignificantlyreducetherateofHAIs througheffectiveinfectioncontrol.

Infection control is everybodys business
Understandingthemodesoftransmissionofinfectiousorganismsandknowinghowandwhentoapplythe basicprinciplesofinfectioncontroliscriticaltothesuccessofaninfectioncontrolprogram.This responsibilityappliestoeverybodyworkingandvisitingahealthcarefacility,includingadministrators, staff,patientsandcarers. SuccessfulapproachesforpreventingandreducingharmsarisingfromHAIsinvolveapplyingarisk managementframeworktomanagehumanandsystemfactorsassociatedwiththetransmissionof infectiousagents.Thisapproachensuresthatinfectiousagents,whethercommon(e.g.gastrointestinal viruses)orevolving(e.g.influenzaormultiresistantorganisms[MROs]),canbemanagedeffectively. Development of the guidelines AspartoftheAustralianCommissiononSafetyandQualityinHealthCares(ACSQHC)coordinated approachtothepreventionandcontrolofHAIs,theNationalHealthandMedicalResearchCouncil (NHMRC)wasaskedtodevelopguidelinestoprovidenationalguidanceforthecontrolofHAIsandalsoa foundationbywhichotherstrategiesaddressingthepriorityareaofHAIscanbeimplemented. TheNHMRCappointedanexpertgrouptoguidethedevelopmentprocess(SteeringCommittee membershipandtermsofreferencearegiveninAppendix1).Theguidelinesarebasedonthebestavailable evidence.Theybuildonexistingguidelinesandreviews,aswellassystematicreviewsoftheevidence. Aim Byassistinghealthcareworkerstoimprovethequalityofthecaretheydeliver,theseguidelinesaimto promoteandfacilitatetheoverallgoalofinfectioncontrol: Thecreationofsafehealthcareenvironmentsthroughtheimplementationofpracticesthatminimisetheriskof transmissionofinfectiousagents. Scope Thescopeoftheseguidelineswasestablishedatthestartoftheguidelinedevelopmentprocess,followinga periodofconsultationthatincludedforumsinvolvingawiderangeofstakeholders(seeAppendix2). Theguidelinesweredevelopedtoestablishanationallyacceptedapproachtoinfectioncontrol,focusingon coreprinciplesforinfectioncontrolandpriorityareasforaction.Theyprovideabasisforhealthcareworkers andhealthcarefacilitiestodevelopdetailedprotocolsandprocessesforinfectioncontrolthatapplytotheir specificsituation. Whiletheguidelinesfocusonacutecare,theriskapproachusedtoaddresstheprinciplesofinfectioncontrol meanstheyareapplicabletoawiderangeofhealthcaresettings,includingofficebasedpractice,residential
Introduction 13
CONSULTATIONDRAFTJANUARY2010 carefacilities,Aboriginalmedicalservices,homeandcommunitynursingandemergencyservices.Materials thatidentifyrelevantrisksandmakerecommendationsonorganisationalpoliciesandproceduresforother settingswillalsobedeveloped,basedontheprinciplesoutlinedintheseguidelines.Informationforpatients willalsobederivedfromtheseguidelines. Theguidelinesdonotincludedetailedinformationon: infectiousdiseases; pandemicplanning; thereprocessingofinstruments; occupationalhealthandsafety; hospitalhotelservicessuchasfoodservices,laundryservicesorwastedisposal;or engineering/healthfacilitydesign. TheguidelinesdonotduplicateinformationprovidedinexistingAustralianStandardsbutrefertospecific standardswhereverrelevant. Target audience Theguidelinesareforusebyallthoseworkinginhealthcarethisincludeshealthcareworkers, managementandsupportstaff. Evidence base Theseguidelinesarebasedonthebestavailableevidenceandknowledgeofthepracticalitiesofclinical procedures.Theydrawfromotherworkinthisarea,includingthetwopreviousnationalinfectioncontrol guidelines, 2internationalinfectioncontrolguidelines,systematicliteraturereviewsconductedtoinformthe developmentoftheseguidelines,workonHAIpreventionfromACSQHC,andAustralianStandards relevanttoinfectioncontrol.Australiandataareusedwhereveravailable.
Table 2: Sources of evidence to support recommendations
Systematically developed international guidelines 3 World Health Organization Guidelines on hand hygiene in health care (2009) United States Centers for Disease Control and Prevention Workbook for designing, implementing and evaluating a sharps injury prevention program (2009) Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings (2007) Management of multidrug-resistant organisms in healthcare settings (2006) Guidelines for infection control in the dental setting (2003) Guidelines for environmental infection control in health-care facilities (2003) United Kingdom National Institute for Health and Clinical Excellence Surgical site infection prevention and treatment of surgical site infection (2008) Prevention of healthcare-associated infection in primary and community care (2003) UK Department of Health Epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England (2007) British Society for Antimicrobial Chemotherapy Guidelines for UK practice for the diagnosis and management of methicillin-resistant Staphylococcus aureus (MRSA) infections presenting in the community Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy
CDNA(2004)InfectionControlGuidelinesforthePreventionofTransmissionofInfectiousDiseaseintheHealthCareSetting. CommunicableDiseasesNetworkofAustralia. NHMRC(1996)InfectionControlintheHealthcareSetting.GuidelinesforthePreventionofTransmissionofInfectious Diseases.NationalHealthandMedicalresearchCouncil.Rescinded. 3 TheseguidelineswereselectedbasedonanalysisusingtheAGREEtool,whichensuresthatguidelineshavebeen developedinarigorous,transparentandrobustmanner.ThisprocessisdiscussedindetailinAppendix2.

2
Introduction 14
Canadian Critical Care Trials Group Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: prevention (2008) European Association of Urology European and Asian guidelines on management and prevention of catheter-associated urinary tract infections Separate systematic reviews of published scientific and medical literature for areas of controversy and clinical variation 4 Alcohol products and other agents for hand hygiene Infection control measures related to the use of intravascular devices Positive pressure rooms in reducing risk for immunocompromised patients Staff exclusion policies relating to norovirus gastroenteritis Personal protective equipment in reducing the transmission of multi-resistant organisms Isolation measures for patients infected with vancomycin-resistant enterococci or multi-resistant Gram negative bacteria Education interventions for the prevention of HAIs
Limitations of the grading process as it applies to the practice of infection control TherecommendationsintheseguidelineswereformulatedbytheInfectionControlSteeringCommittee 5 throughaprocessofconsensus.Recommendationsaregivenwhenanactionisdeemedcriticaltopreventing ormanaginginfection.RecommendationsaregradedaccordingtotherevisedNHMRCgradingsfor assessingevidence,withtheadditionofgoodpracticepoints,whichoutlineactionsthatareessentialto infectionpreventionandcontrolbutwhereevidencegradescannotbeapplied. Inmanyareasofinfectioncontrol,theevidencemaybelimitedbytheinabilitytoconductcertainstudy designsthataredifficulttoimplementinrealpractice.Thishasimplicationsforthelevelofgradingthatis assignedtotherecommendations,sincegradingsystemswilltendtofavourstudydesignsthatare sometimesnotfeasibleorunethicaltoconductininfectioncontrolsettingssuchasrandomisedcontrolled trials.Forexample,itisunethicaltocomparetheincidenceofinfectionrelatedtosurgicalinstrumentsby allocatingonepatientgrouptohavesterilisedinstrumentsusedonthemandonepatientgrouptohavenon sterileinstrumentsusedonthem.Thismayresultinalowergradingduetotheavailableevidencebut sterilisationofsurgicalinstrumentsisuniversallydeemedcriticaltoinfectioncontrol. Giventhatthereislimitedevidenceavailabletosupportmanyroutinepracticesintendedtoreduceinfection risk,practiceisbasedondecisionsmadeonscientificprinciples.Someactivities,suchaspractisinghand hygienebetweenadministeringcaretosuccessivepatients,haveacrediblehistorytosupporttheirroutine applicationinpreventingcrossinfection.Others,suchassomeuniformandclothingrequirements,have moretodowiththeethosofqualitycareandworkplaceculturethanwithaprovenreductionofcross infection. Itisnotacceptabletodiscontinuepracticesforwhichthereisasolidscientificbasis,evenifthelevelof evidenceisnothigh.Rather,routinepracticesshouldcontinueunlessthereissufficientevidencetosupport alternativeprocedures.Continuingresearchisneededtokeepevaluatingpractice,toidentifyevidencegaps andpromoteresearchintheseareas,andensurethatpoorpracticesdonotcontinue.
Duetoapaucityofevidenceorlowqualityevidencesomesystematicreviewswerenotusedtodraft recommendations. MembershipoftheInfectionControlSteeringCommitteeisgiveninAppendix1.

Introduction 15
Table 3:
Grade A B C D
NHMRC grades of evidence

Description Body of evidence can be trusted to guide practice Body of evidence can be trusted to guide practice in most situations Body of evidence provides some support for recommendation(s) but care should be taken in its application Body of evidence is weak and recommendation must be applied with caution
TheICGSteeringCommitteealsoassignedanadditionalgradereferredtoasgoodpracticepoints(GPPs):
GPP Body of evidence is weak or non-existent. Recommendation for best practice based on clinical experience and expert opinion
Structure of the guidelines Theseguidelinesarebasedaroundthefollowingcoreprinciples: anunderstandingofthemodesoftransmissionofinfectiousagentsandanoverviewofriskmanagement; effectiveworkpracticesthatminimisetheriskofselectionandtransmissionofinfectiousagents; governancestructuresthatsupporttheimplementation,monitoringandreportingofinfectioncontrol workpractices;and compliancewithlegislation,regulationsandstandardsrelevanttoinfectioncontrol. ThePartsofthedocumentarebasedonthesecoreprinciplesandareorganisedaccordingtothelikely readership. PartApresentsbackgroundinformationthatshouldbereadbyeveryoneworkinginhealthcare(for exampleasorientationoraspartofannualreview)thisincludesimportantbasicsofinfectioncontrol, suchasthemainmodesoftransmissionofinfectiousagentsandtheapplicationofriskmanagement principles.Thispartoftheguidelinesdoesnotincluderecommendations. PartBisspecifictothepracticeofhealthcareworkersandsupportstaff,andoutlineseffectivework practicesthatminimisetheriskofselectionortransmissionofinfectiousagents.Recommendationsaregiven inSectionsB1toB3.Eachsectionincludesadviceonputtingtherecommendationsintopracticeandarisk managementcasestudy. SectionB1describesstandardprecautionsusedatalltimestominimisetheriskoftransmissionof infectiousagents; SectionB2outlinestransmissionbasedprecautionstoguidestaffinthepresenceofsuspectedorknown infectiousagentsthatrepresentanincreasedriskoftransmission; SectionB3outlinesapproachestothemanagementofmultiresistantorganisms(MROs)oroutbreak situations;and SectionB4outlinesprocessesforriskidentificationandtheapplicationofstandardandtransmission basedprecautionsforcertainprocedures. PartCdescribestheresponsibilitiesofmanagementofhealthcarefacilities,includinggovernance structuresthatsupporttheimplementation,monitoringandreportingofeffectiveworkpractices.The chaptersoutlinethemaincomponentsofasystemsapproachtofacilitywideinfectioncontrol,giving guidanceonmanagementandstaffresponsibilities,protectionofhealthcareworkers,requirementsfor educationandtrainingofallstaff,considerationsforfacilitydesignandrenovation,andotherimportant activitiessuchassurveillanceandantibioticstewardship. PartDprovidesexamplesofrelevantstandards,legislationandresources. Theappendicesprovideadditionalinformationontheguidelinedevelopmentprocess,andsometoolsto assistinapplyingtherecommendations. Keyinformationishighlightedintheguidelinesasfollows.
Introduction 16
Table 4: Key to types of information highlighted in the guidelines
Summaries provide key information from each section of the guidelines Recommendations (Sections B1, B2 and B3) outline the critical aspects of infection prevention and control Patient care tips highlight patient considerations in the application of infection control principles
Casestudiesillustratetheapplicationofriskmanagementprinciples(SectionsB1,B2andB3)andmeasuresto supportgoodpractice(PartC) Thefollowingtablesummarisesthekeytopicsdiscussedinthedocument.
Introduction 17
Table 5: Topics discussed in the guidelines
Effective work practices that minimise the risk of selection and transmission of infectious agents B1 STANDARD PRECAUTIONS B1.1 Hand hygiene 1.1.1 Risks 1.1.2 When to perform 1.1.3 Product choice 1.1.4 Cuts, abrasions, fingernails & jewellery 1.1.5 Hand care B1.2 PPE 1.2.1 Risks 1.2.2 Decision-making 1.2.3 Aprons and gowns 1.2.4 Face & eye wear 1.2.5 Gloves 1.2.6 Other items 1.2.7 Putting on & removing PPE B1.3 Sharps 1.3.1 Risks 1.3.2 Handling 1.3.3 Disposal 1.3.4 Safety devices B1.4 Routine environmental management 1.4.1 Risks 1.4.2 Routine cleaning 1.4.3 Spills B1.5 Processing of instruments and equipment 1.5.1 Risks 1.5.2 Assessing risk 1.5.3 Cleaning 1.5.4 Disinfection 1.5.5 Sterilisation 1.5.6 Storage & maintenance Introduction 18 B2 TRANSMISSIONBASED PRECAUTIONS B2.1 Application of transmission-based precautions 2.1.1 Risks B2.2 Contact precautions 2.2.1 Risks 2.2.2 Implementation 2.2.3 Application B2.3 Droplet precautions 2.3.1 Risks 2.3.2 Implementation 2.3.3 Application B2.4 Airborne precautions 2.4.1 Risks 2.4.2 Implementation 2.4.3 Application B2.5 Putting it into practice B3 B4 MANAGING RESISTANT APPLYING STANDARD ORGANISMS AND AND TRANSMISSIONOUTBREAKS BASED PRECAUTIONS TO PROCEDURES B3.1 Management of MROs B4.1 Taking a risk 3.1.1 Risks management approach to 3.1.2 Core strategies procedures 3.1.3 Organism-specific 4.1.1 Classifying approach procedures 3.1.4 Antibiotic 4.1.2 Appropriate use of stewardship devices 4.1.3 Care bundle approach B3.2 Outbreak investigation and B4.2 Therapeutic devices 4.2.1 Indwelling urinary management 3.2.1 Investigation and devices management 4.2.2 Intravascular access 3.2.2 Strategies to devices control/contain an outbreak 4.2.3 Ventilation 3.2.3 Applying 4.2.4 Enteral feeding tubes transmission-based B4.3 Surgical procedures precautions 4.3.1 Risks 4.3.2 Minimising risks B3.3 Putting it into 4.3.3 Pre-procedure practice 4.3.4 During a procedure 4.3.5 Post-procedure B4.4 Putting it into practice Governance structures that support implementation, monitoring and reporting of infection control practices C ORGANISATIONAL SUPPORT C1 Management and clinical governance 1.1 Clinical governance 1.2 Roles and responsibilities 1.3 Infection control programs 1.4 Systems approach C2 Staff health and safety 2.1 Roles and responsibilities 2.2 Screening & immunisation 2.3 Staff exclusion periods 2.4 Specific circumstances 2.5 Exposure-prone procedures 2.6 Occupational hazards C3 Education and training 3.1 Teaching facilities 3.2 Healthcare facilities 3.3 Education strategies 3.4 Education in practice 3.5 Accreditation 3.6 Patient engagement C4 Surveillance 4.1 Role of surveillance 4.2 Types of programs 4.3 Data management 4.4 Outbreaks 4.5 Office-based practice 4.6 Notifiable diseases C5 Antibiotic stewardship 5.1 Background 5.2 Programs 5.3 Surveillance C6 Facility design 6.1 Impact 6.2 Reducing HAIs 6.3 Single rooms 6.4 Construction & renovation 6.5 Guidance documents Legislation, regulations and standards relevant to infection control D STANDARDS, LEGISLATION AND OTHER RESOURCES D1 Risk management D2 Standard precautions D3 Transmissionbased precautions D4 MROs and outbreaks D5 Procedures
Modes of transmission of infectious agents and an overview of risk management A BASICS OF INFECTION CONTROL A1 Infection control in the healthcare setting 1.1 Risks of contracting a HAI 1.2 Standard and transmissionbased precautions A2 Overview of risk management in infection prevention and control 2.1 Risk management basics A3 A patient-centred approach 3.1 Patient-centred health care 3.2 How does patient-centred care relate to infection control?
PART A

BASICS OF INFECTION CONTROL
Healthcare-associated infections (HAIs) can occur in any healthcare setting. While the specific risks may differ, the basic principles of infection control apply regardless of the setting. In order to prevent HAIs, it is important to understand how infections occur in healthcare settings and then institute ways to prevent them. Risk management is integral to this approach. If effectively implemented, the two-tiered approach of standard and transmission-based precautions recommended in these guidelines provides high-level protection to patients, healthcare workers and other people in healthcare settings. Infection control is integral to clinical care and the way in which it is provided. It is not an additional set of practices. Involving patients is essential to successful clinical care. This includes ensuring that patients rights are respected at all times, that they are involved in decision-making about their care, and they are sufficiently informed to be able to participate in reducing the risk of transmission of infectious agents.
The information presented in this Part is relevant to everybody employed by a healthcare facility, including management, healthcare workers and support service staff.
CONSULTATIONDRAFTJANUARY2010 A1 INFECTION CONTROL IN THE HEALTHCARE SETTING
Summary Infectious agents (also called pathogens) are biological agents that cause disease or illness to their hosts. Many infectious agents are present in healthcare settings. Infection requires three main elements a source of the infectious agent, a mode of transmission and a susceptible host. Patients and healthcare workers are most likely to be sources of infectious agents and are also the most common susceptible hosts. Other people visiting and working in health care may also be at risk of both infection and transmission. In some cases, healthcare-associated infections are serious or even life threatening. In healthcare settings, the main modes for transmission of infectious agents are contact (including bloodborne), droplet and airborne.
A1.1
RISKS OF CONTRACTING A HEALTHCARE-ASSOCIATED INFECTION
Mostinfectiousagentsaremicroorganisms.Theseexistnaturallyeverywhereintheenvironment,andnotall causeinfection(e.g.goodbacteriapresentinthebodysnormalflora).Severalclassesofmicroorganism includingbacteria,viruses,fungi,parasitesandprionscanbeinvolvedineithercolonisationorinfection, dependingonthesusceptibilityofthehost: Withcolonisation,thereisasustainedpresenceofreplicatinginfectiousagentsonorinthebody,without theproductionofanimmuneresponseordisease. Withinfection,invasionofinfectiousagentsintothebodyresultsinanimmuneresponse,withor withoutsymptomaticdisease.
Transmissionofinfectiousagentswithinahealthcaresettingrequiresthefollowingelements: asourceorreservoirofinfectiousagents,includingaportalofexitfromthatsource; amodeoftransmission;and asusceptiblehost,includingaportalofentryintothathost. Infectiousagentstransmittedduringhealthcarecomeprimarilyfromhumansources,includingpatients, healthcareworkersandvisitors.Sourceindividualsmaybeactivelyill,mayhavenosymptomsbutbeinthe incubationperiodofadisease,ormaybetemporaryorchroniccarriersofaninfectiousagentwithor withoutsymptoms.Othersourcesoftransmissioninclude: endogenousfloraofpatients(e.g.bacteriaresidingintherespiratoryorgastrointestinaltract);and environmentalsourcessuchasair,water,medicationsormedicalequipmentanddevicesthathave becomecontaminated. Infectionistheresultofacomplexinterrelationshipbetweenahostandaninfectiousagentandpeoplevary intheirresponsetoexposuretoaninfectiousagent: somepeopleexposedtoinfectiousagentsneverdevelopsymptomaticdiseasewhileothersbecome severelyillandmaydie; someindividualsmaybecometemporarilyorpermanentlycolonisedbutremainasymptomatic;and othersprogressfromcolonisationtosymptomaticdiseaseeithersoonafterexposure,orfollowinga periodofasymptomaticcolonisation. Importantpredictorsofanindividualsoutcomeafterexposureincludehisorher: immunestatusatthetimeofexposure(includingwhetherimmunestatusiscompromisedbymedical treatmentsuchasimmunosuppressiveagentsorirradiation); age(e.g.neonatesandelderlypatientsaremoresusceptible); healthstatus(e.g.otherunderlyingdisease); thevirulenceoftheagent;and
Part A Basics of infection control 20
CONSULTATIONDRAFTJANUARY2010 otherfactorsthatincreasetheriskoftransmissionofinfection(e.g.undergoingsurgery,requiringan indwellingdevicesuchasacatheter,orremaininginhospitalforlengthyperiods). Inhealthcaresettings,themostcommonsusceptiblehostsarepatientsandhealthcareworkers: Patientsmaybeexposedtoinfectiousagentsfromthemselves(endogenousinfection)orfromother people,instrumentsandequipment,ortheenvironment(exogenousinfection).Thelevelofriskrelatesto thehealthcaresetting(specifically,thepresenceorabsenceofinfectiousagents),thetypeofhealthcare proceduresperformedandthesusceptibilityofthepatient. Healthcareworkersmaybeexposedtoinfectiousagentsfrominfectedorcolonisedpatients,instruments andequipment,ortheenvironment.Thelevelofriskrelatestothetypeofclinicalcontacthealthcare workershavewithpotentiallyinfectedorcolonisedpatientgroups,instrumentsorenvironments,andthe healthstatusofthehealthcareworker(e.g.immunisedorimmunocompromised). Inhealthcaresettings,themainmodesoftransmissionofinfectiousagentsarecontact(including bloodborne),dropletandairborne.Themodesoftransmissionvarybytypeoforganism.Insomecasesthe sameorganismmaybetransmittedbymorethanoneroute(e.g.norovirus,influenzaandrespiratory syncytialvirus[RSV]canbetransmittedbycontactanddropletroutes). A1.1.1 Routes of transmission
Contact transmission
Contactisthemostcommonmodeoftransmission,andusuallyinvolvestransmissionbyhandorviacontact withbloodorbodysubstances.Contactmaybedirectorindirect. Directtransmissionoccurswheninfectiousagentsaretransferredfromonepersontoanotherfor example,apatientsbloodenteringahealthcareworkersbodythroughanunprotectedcutintheskin. Indirecttransmissioninvolvesthetransferofaninfectiousagentthroughacontaminatedintermediate objectorpersonforexample,ahealthcareworkershandstransmittinginfectiousagentsaftertouching aninfectedbodysiteononepatientandnotperforminghandhygienebeforetouchinganotherpatient,or ahealthcareworkercomingintocontactwithfomites(e.g.bedding)orfaecesandthenwithapatient. Examplesofinfectiousagentstransmittedbycontactincludemultiresistantorganisms(MROs), Clostridiumdifficile,norovirusandhighlycontagiousskininfections/infestations(e.g.impetigo,scabies).
Droplet transmission
Droplettransmissioncanoccurwhenaninfectedpersoncoughs,sneezesortalks,andduringcertain proceduressuchassuctioning.Dropletsareinfectiousparticleslargerthan5micronsinsize.Respiratory dropletstransmitinfectionwhentheytraveldirectlyfromtherespiratorytractoftheinfectedpersonto susceptiblemucosalsurfaces(nasal,conjunctivaeororal)ofanotherperson,generallyovershortdistances. Dropletdistributionislimitedbytheforceofexpulsionandgravityandisusually1metreorless.However, dropletscanalsobetransmittedindirectlytomucosalsurfaces(e.g.viahands). Examplesofinfectiousagentsthataretransmittedviadropletsincludeinfluenzavirusandmeningococcus.

Airborne transmission
Airbornedisseminationmayoccurviaaerosols(smallairbornedropletslessthan5insize)containing infectiousagentsthatremaininfectiveovertimeanddistance.Aerosolscanbegeneratedbycoughingand sneezingandcertainprocedures,particularlythosethatinducecoughing,canpromoteairborne transmission.Theseincludeproceduressuchasdiagnosticsputuminduction,bronchoscopy,airway suctioning,endotrachealintubation,positivepressureventilationviafacemaskandhighfrequency oscillatoryventilation.Aerosolscontaininginfectiousagentscanbedispersedoverlongdistancesbyair currents(e.g.ventilationorairconditioningsystems)andinhaledbysusceptibleindividualswhohavenot hadanycontactwiththeinfectiousperson.Thesesmallparticlescantransmitinfectionintosmallairwaysof therespiratorytract. Examplesofinfectiousagentsthataretransmittedviatheairbornerouteincludemeasles(rubeola)virus, varicellavirusandM.tuberculosis.
Section A1 Infection control in the healthcare setting 21
Other modes of transmission
Transmissionofinfectioncanalsooccurviacommonsourcessuchascontaminatedfood,water, medications,devicesorequipment. A1.2 STANDARD AND TRANSMISSION-BASED PRECAUTIONS
Successfulinfectioncontrolinvolvesimplementingworkpracticesthatpreventthetransmissionof infectiousagentsthroughatwotieredapproachincluding: routinelyapplyingbasicinfectioncontrolstrategiestominimiserisktobothpatientsandhealthcare workers,suchashandhygiene,personalprotectiveequipment,cleaningandappropriatehandlingand disposalofsharps(standardprecautions);and effectivelymanaginginfectiousagentswherestandardprecautionsmaynotbesufficientontheirown. Thesespecificinterventionscontrolinfectionbyinterruptingthemodeoftransmission(transmissionbased precautions;formerlyreferredtoasadditionalprecautions). Ifsuccessfullyimplemented,standardandtransmissionbasedprecautionspreventanytypeofinfectious agentfrombeingtransmitted. A1.2.1 Standard precautions
Allpeoplepotentiallyharbourinfectiousagents.Workpracticestoensureabasiclevelofinfectioncontrol, coveredbythetermstandardprecautions,areappliedtoeveryone,regardlessoftheirperceivedor confirmedinfectiousstatus.Implementingstandardprecautionsasafirstlineapproachtoinfectioncontrol inthehealthcareenvironmentminimisestheriskoftransmissionofinfectiousagentsfrompersontoperson, eveninhighrisksituations. Standardprecautionsareusedbyhealthcareworkerstopreventorreducethelikelihoodoftransmissionof infectiousagentsfromonepersonorplacetoanother,andtorenderandmaintainobjectsandareasasfree aspossiblefrominfectiousagents. GuidanceonhowtoimplementstandardprecautionsisgiveninSectionB1.

Table A1.1: How standard precautions are implemented
Personal hygiene practices, particularly hand hygiene and cough etiquette, aim to reduce the risk of cross-transmission and cross-infection of infectious agents (see Section B1.1). The use of personal protective equipment, which may include gloves, gowns, plastic aprons, masks/face-shields and eye protection, aims to prevent exposure of the healthcare worker to infectious agents (see Section B1.2). Appropriate handling and disposal of sharps assist in preventing transmission of blood-borne diseases to healthcare workers (see Section B1.3). Environmental controls, including cleaning and spills management, assist in preventing transmission of infectious agents from the environment to patients (see Section B1.4). Appropriate reprocessing of reusable equipment and instruments, including appropriate use of disinfectants, aims to prevent patient-to-patient transmission of infectious agents (see Section B1.5). The appropriate use of aseptic and sterile techniques prevents contamination of wounds and other susceptible sites by infectious agents (see Glossary).
CONSULTATIONDRAFTJANUARY2010 A1.2.2 Transmission-based precautions
Anyinfectioncontrolstrategyshouldbebasedontheuseofstandardprecautionsasaminimumlevelof control.Transmissionbasedprecautionsarerecommendedasextraworkpracticesinsituationswhere standardprecautionsalonemaybeinsufficienttopreventtransmission.Transmissionbasedprecautionsare alsousedintheeventofanoutbreak(e.g.gastroenteritis),toassistincontainingtheoutbreakand preventingfurtherinfection. Transmissionbasedprecautionsshouldbetailoredtotheparticularinfectiousagentinvolvedanditsmode oftransmission.Thismayinvolveacombinationofpractices. GuidanceonwhenandhowtoimplementtransmissionbasedprecautionsisgiveninSectionsB2andB3 andAppendices3and4.

Table A1.2: Strategies for implementing transmission-based precautions
Transmission-based precautions may include one or any combination of the following: allocating a single room to an infected patient (isolation); placing patients colonised or infected with the same infectious agent in a room together (cohorting); wearing specific personal protective equipment; providing dedicated patient equipment; using disinfectants effective against the specific infectious agent; providing a dedicated toilet; use of specific air handling techniques; and restricting movement both of patients and healthcare workers.
Contact precautions are used when there is known or suspected risk of transmission of infectious agents by direct or indirect contact (see Section B2.2). Droplet precautions are used for patients known or suspected to be infected with agents transmitted by respiratory droplets (see Section B2.3). Airborne precautions are used for patients known or suspected to be infected with agents transmitted person-to-person by the airborne route (see Section B2.4).
Section A1 Infection control in the healthcare setting 23
CONSULTATIONDRAFTJANUARY2010 A2 OVERVIEW OF RISK MANAGEMENT IN INFECTION PREVENTION AND CONTROL
Summary Identifying and analysing risks associated with health care is an integral part of successful infection control. Adopting a risk management approach at all levels of the facility is necessary. This task requires the full support of the facilitys management as well as cooperation between management, healthcare workers and support staff.
A2.1
RISK MANAGEMENT BASICS
Inthecontextoftheseguidelines,riskisdefinedasthepossibilityofcolonisationorinfectionofpatientsor healthcareworkersarisingfromactivitieswithinahealthcarefacility.Riskmanagementisthebasisfor preventingandreducingharmsarisingfromhealthcareassociatedinfection.Asuccessfulapproachtorisk managementoccursonmanylevelswithinahealthcarefacility: facilitywideforexampleprovidingsupportforeffectiveriskmanagementthroughanorganisational riskmanagementpolicy,stafftrainingandmonitoringandreporting; wardordepartmentbasedforexampleembeddingriskmanagementintoallpoliciessothatrisksare consideredineverysituation; individualforexampleconsideringtherisksinvolvedincarryingoutaspecificprocedureand questioningthenecessityoftheprocedureaspartofclinicaldecisionmaking,attendingeducation sessions(e.g.handhygieneormaskfittraining). TheAustralian/NewZealandStandardonRiskManagementAS/NZS4360:2004outlinesastepwise approachtoriskmanagementthatallowscontinuousqualityimprovementandinvolves: establishingcontextidentifyingthebasicparametersinwhichriskmustbemanaged(e.g.thetypeof healthfacility,theextentofandsupportforthefacilitysinfectioncontrolprogram); avoidingriskestablishingwhetherthereisariskandwhetherpotentialriskcanbeaverted(e.g.by questioningwhetheraprocedureisnecessary); identifyingrisksasystematicandcomprehensiveprocessthatensuresthatnopotentialriskisexcluded fromfurtheranalysisandtreatment(e.g.usingrootcauseanalysis); analysingrisksconsideringthesourcesofrisk,theirconsequences,thelikelihoodthatthose consequencesmayoccur,andfactorsthataffectconsequencesandlikelihood(e.g.existingcontrols)(see riskanalysismatrixbelow); evaluatingriskscomparingthelevelofriskfoundduringtheanalysisprocesswithpreviously establishedriskcriteria,resultinginaprioritisedlistofrisksforfurtheraction;and treatingrisksselectingandimplementingappropriatemanagementoptionsfordealingwithidentified risk(e.g.modifyingprocedures,protocolsorworkpractices;providingeducation;andmonitoring compliancewithinfectioncontrolprocedures).
Table A2.1: Risk analysis matrix
Likelihood Rare Unlikely Possible Likely Almost certain Low risk Medium risk High risk Very high risk Consequences Negligible Low Low Low Medium Medium Minor Low Medium Medium High Very high Moderate Low Medium High Very high Very high Major Medium High Very high Very high Extreme Extreme High Very high Very high Extreme Extreme
Manage by routine procedures. Manage by specific monitoring or audit procedures. This is serious and must be addressed immediately. The magnitude of the consequences of an event, should it occur, and the likelihood of that event Part A Basics of infection control 24
Extreme risk occurring, are assessed in the context of the effectiveness of existing strategies and controls.
Monitoringandreviewisanessentialcomponentoftheriskmanagementprocess.Thisensuresthat: newrisksareidentified; analysisofriskisverifiedagainstrealdata,ifpossible;and risktreatmentisimplementedeffectively. Communicationandconsultationarealsokeyelementsofclinicalriskmanagement.Aninteractiveexchange ofinformationbetweenmanagement,healthcareworkers,patientsandotherstakeholdersprovidesthebasis forincreasedawarenessoftheimportanceofinfectionpreventionandcontrol,identificationofrisksbefore theyariseandpromptmanagementofrisksastheyoccur. Thefollowingflowchartoutlineskeyconsiderationsduringtheprocessofriskmanagementinthecontextof infectioncontrolinthehealthcaresetting.Casestudiesgivingexamplesofhowtousethisprocess,including relevantconsiderationsinspecificsituations,areincludedinPartB.
Figure A1.1: Risk management flowchart Avoid risk Are there alternative processes or procedures that would eliminate the risk? If a risk cannot be eliminated then it must be managed
Communicate and consult
Identify risks
Treat risks
What infectious agent is involved? How is it transmitted? Who is at risk (patient and/or healthcare worker)?
Monitor and review
What will be done to address risk? Who takes responsibility? How will change be monitored and reviewed? Evaluate risks
Analyse risks Why can it happen (activities, processes)? How often could it happen? What are likely consequences?
What can be done to reduce or eliminate the risk? How could this be applied in this situation (staff, resources)?
A2 Overview of risk management in infection prevention and control 25
CONSULTATIONDRAFTJANUARY2010 A3 A PATIENT-CENTRED APPROACH
Summary A patient-centred health system is known to be associated with safer and higher quality care. A two-way approach that encourages patient participation is essential to successful infection prevention and control.
A3.1
PATIENT-CENTRED HEALTH CARE
Peoplereceivinghealthcareincreasinglyexpecttobegiveninformationabouttheirconditionandtreatment optionsandthisextendstotheirrightsandresponsibilitiesasusersofhealthcareservices.Althoughpatient satisfactionwithhealthservicesinAustraliaisgenerallyhigh,patientsexperiencesarenotalwaysvalued andtheirexpectationsarenotalwaysmet.Whilethisdoesnotnecessarilyleadtopooroutcomesforthe individualsconcerned,thebestpossibleoutcomesaremorelikelywherepatientcentredhealthcareisa priorityofthehealthcarefacilityandastrongandconsistenteffortismadetorespectpatientsrightsand expectations. TheACSQHChasdevelopedanAustralianCharterofHealthcareRights, 6whichrecognisesthatpeople receivingcareandpeopleprovidingcareallhaveimportantpartstoplayinachievinghealthcarerights.The Charterallowspatients,families,carersandservicesprovidinghealthcaretoshareanunderstandingofthe rightsofpeoplereceivinghealthcare.TheCharterstipulatesthatallAustralianshavetherightto: accessservicesthataddresstheirhealthcareneeds; receivesafeandhighqualityhealthservices,providedwithprofessionalcare,skillandcompetence; receivecarethatshowsrespecttothemandtheirculture,beliefs,valuesandpersonalcharacteristics; receiveopen,timelyandappropriatecommunicationabouttheirhealthcareinawaytheycan understand; joininmakingdecisionsandchoicesabouttheircareandabouthealthserviceplanning; havetheirpersonalprivacyandpersonalhealthandotherinformationproperlyhandled;and commentonorcomplainabouttheircareandhavetheirconcernsdealtwithproperlyandpromptly. Patientcentredcarecannotjustbeaddedontousualcare.Therights,experiencesandviewsofpatients shouldbeatthecentreofthecareprocessanddrivethewayinwhichcareisdelivered.Inmosthealthcare facilities,asignificantculturechangeisnecessarytoembedpatientcentredcareprinciplesintothe philosophyandpracticesoftheorganisation.Healthcareworkersandorganisationsneedtoacknowledge andunderstandtheCharterofHealthcareRightsandworktoensurethatpatientsrightsareintegraltothe careprocess. A3.2 HOW DOES PATIENT-CENTRED CARE RELATE TO INFECTION CONTROL?
Infectioncontrolisultimatelyaboutpeople.Effectiveinfectioncontroliscentraltoprovidinghighquality, patientcentredhealthcare. Puttingpatientsatthecentreofinfectioncontrolandenablingthemtoparticipateinthecareprocessisnot justaboutexplainingtherisksoftreatments,butinvolvesconsideringpatientsneedsateverylevel.This rangesfromdesigningthefacilitytomaximisepatientcomfortandsafetytohavingarangeofprocessesto engagepatientsintheircareandlistenandactontheirfeedbackaswellasprovidingthepatientwith educationandsupportsothattheycanbeinvolvedinlookingafterthemselves.
Availableat:http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/compubs_ACHR roles/$File/17537charter.pdf
CONSULTATIONDRAFTJANUARY2010 Tosupportatwowayapproachtoinfectionpreventionandcontrolandencouragethepatientparticipation requiredtopreventinfectionandminimisecrossinfection,itisimportantto: takepatientsperspectivesintoaccountwhendevelopingpoliciesandprograms; familiarisepatientswiththeinfectionpreventionandcontrolstrategiesthatareemployedinhealthcare facilitiestoprotectthem,thepeoplecaringforthemandthehealthcareenvironment,andproceduresfor dealingwithinfectioncontrolbreaches; discusswithpatientsthespecificrisksassociatedwiththeirmedicaland/orsurgicaltreatment; encouragepatientstodisclosetheirhealthorriskstatusifthereisapotentialriskorsourceofinfectionto healthcareworkersorotherswithinthehealthcarefacility; provideopportunitiesforpatientstoidentifyandcommunicaterisksandencouragethemtouse feedbackproceduresforanyconcernsthattheyhaveaboutinfectionpreventionandcontrolprocedures; provideeducationalmaterialsaboutinfectionpreventionandcontrolusingavarietyofmedia,including postersinwaitingrooms,printedmaterialandeducationalvideos;and informpatientsabouttheprotocolsforprotectingtheirprivacyandconfidentiality. Specificguidanceonprovidingpatientcentredcareishighlightedthroughouttheguidelines,intextboxes, inthePuttingitintopracticesectionattheendofeachchapterinPartB,andineachchapterofPartC. Resourcesonhealthcarerights,culturalcompetence,andlinkstotoolsthataimtoassistdeliveryofpatient centredcare,arelistedinPartD.
A3 A patient-centred approach 27
PART B STANDARD AND TRANSMISSION-BASED PRECAUTIONS

The use of standard precautions is the primary strategy for minimising the transmission of healthcareassociated infections. Transmission-based precautions are used in addition to standard precautions, where the suspected or known presence of infectious agents represents an increased risk of transmission. The application of transmission-based precautions is particularly important in containing multi-resistant organisms (MROs) and in outbreak management. Medical and dental procedures increase the risk of transmission of infectious agents. Effective work practices to minimise risk of transmission of infection related to procedures require consideration of the specific situation, as well as appropriate use of standard and transmission-based precautions. Appropriate use of aseptic technique also lowers the risk of infection risk by minimising the number of infectious agents to which patients are exposed. This comprises clean technique (standard precautions such as hand hygiene, reprocessing of equipment between patients, environmental cleaning) as a minimum, as well as sterile technique to prevent infectious agents from entering a patients bloodstream (e.g. use of sterile instruments, dressing materials and gloves, skin antisepsis, and creation of a sterile field within which to operate).
The information presented in this Part is particularly relevant to healthcare workers and support staff. It outlines effective work practices that minimise the risk of transmission of infectious agents.
In applying standard and transmission-based infection controls as part of day-to-day practice, healthcare workers should ensure that their patients understand why certain practices are being undertaken, and that these practices are in place to protect everyone from infection. In this way, patients can take part in minimising risks and question aspects of their care if necessary.
CONSULTATIONDRAFTJANUARY2010 B1 STANDARD PRECAUTIONS
Summary It is essential that standard precautions are applied at all times. This is because: people may be placed at risk of infection from others who carry infectious agents; people may be infectious before signs or symptoms of disease are recognised or detected, or before laboratory tests are confirmed in time to contribute to care; people may be at risk from infectious agents present in the surrounding environment including environmental surfaces or from equipment; and there may be an increased risk of transmission associated with specific procedures and practices. hand hygiene and cough etiquette; the use of personal protective equipment; the safe use and disposal of sharps; and routine environmental cleaning.
Standard precautions consist of the appropriate use of four distinct interventions:
Hand hygiene practices are recommended before and after every episode of patient contact. Standard precautions should be used in the handling of: blood (including dried blood); all other body fluids, secretions and excretions (excluding sweat), regardless of whether they contain visible blood; non-intact skin; and mucous membranes.
Appropriate disposal of hazardous materials (i.e. waste and linen) is a further important aspect of infection control. This is outside the scope of these guidelines and practice in these areas should adhere to relevant Australian standards.
Evidence supporting practice
Themajorityoftherecommendationsinthissectionhavebeenadaptedfrom: 7 GraysonL,RussoP,RyanKetal(2009)HandHygieneAustraliaManual.AustralianCommissionforSafety andQualityinHealthcareandWorldHealthOrganization; UnitedStatesCentersforDiseaseControlandPrevention(CDC)GuidelineforIsolationPrecautions: PreventingTransmissionofInfectiousAgentsinHealthcareSettings(2007); Prattetal(2007)Epic2:NationalEvidenceBasedGuidelinesforPreventingHealthcareAssociatedInfectionsin NHSHospitalsinEngland;and WorldHealthOrganization(2009)GuidelinesonHandHygieneinHealth. Furtherreviewoftheevidenceelicitedgoodqualityevidenceontheuseofalcoholbasedhandrubsin reducingtransmissionofinfectiousagents.8
TheseguidelineswereselectedbasedonanalysisusingtheAGREEtool,whichensuresthatguidelineshavebeen developedinarigorous,transparentandrobustmanner.ThisprocessisdiscussedindetailinAppendix2.
B1.1 Hand hygiene 29
ThereportofthisreviewisavailablefromtheNHMRCuponrequest.
CONSULTATIONDRAFTJANUARY2010 B1.1 B1.1.1 HAND HYGIENE AND COUGH ETIQUETTE What are the risks?
Anyinfectiousagenttransmittedbythecontactordropletroutecanpotentiallybetransmittedbytouch. Microorganismsareeitherpresentonthehandsmostofthetime(residentflora)oracquiredduring activitiessuchashealthcare(transientflora).Handscanalsobecomecontaminatedthroughcontactwith respiratorysecretionswhencoughingorsneezing.Contaminatedhandscanleadtocrosstransmissionof infectiousagentsinnonoutbreaksituations(Prattetal2001;CDC2002;Prattetal2007)andcontributeto outbreaksinvolvingorganismssuchasmethicillinresistantStaphylococcusaureus(MRSA),vancomycin resistantenterococci(VRE)andmultiresistantGramnegative(MRGN)microorganisms,suchas Acinetobacterspp(Prattetal2001).

Figure B1.1: Importance of hand hygiene
Theseimagesillustratethecriticalimportanceofhandhygieneincaringforpatients,includingthosenotknownto carryantibioticresistantorganisms.Animprintofahealthcareworkersunglovedhandwasobtainedafterroutine abdominalexaminationofapatientwithnohistoryofMRSAinfectionbutfoundonroutinesurveillancetohave MRSAcolonisation.TheresultantcultureshowsMRSAcolonies(imageonleft).Anotherhandimprintobtainedafter theworkershandhadbeencleanedwithalcoholbasedhandrubwasnegativeforMRSA(imageonright).

Source: DonskeyCJ&EcksteinBC(2009)Imagesinclinicalmedicine.Thehandsgiveitaway.NEnglJMed360(3):e3.
Improvedhandhygienepracticeshavebeenassociatedwith: sustaineddecreasesintheincidenceofinfectionscausedbyMRSAandVRE(Websteretal1994;Zafaret al1995;Maliketal1999;Larsonetal2000a;Pittetetal2000;Pittet&Boyce2001); reductionsinhealthcareassociatedinfectionsofupto45%inarangeofhealthcaresettings(Fendleretal 2002;Pittetetal2000;Ryanetal2001);and greaterthan50%reductionintheratesofnosocomialdiseaseassociatedwithMRSAandothermulti resistantorganisms,after12years(Graysonetal2008;Johnsonetal2005).
Handhygienepracticesalonearenotsufficienttopreventandcontrolinfectionandneedtobeusedaspart ofamultifactorialapproachtoinfectioncontrol. B1.1.2 When should hand hygiene be performed?
Handscanbecomecontaminatedwithinfectiousagentsthroughcontactwithapatient,patient surroundings,theenvironment,orotherhealthcareworkers.Crosscontaminationcanoccurfromonesiteto anotherinthesamepatient,betweenhealthcareworkerandpatient,betweenpatientorhealthcareworker andtheenvironment,orbetweenhealthcareworkers.Practicinghandhygienebeforeeveryepisodeofpatient

B1 Standard precautions 30
CONSULTATIONDRAFTJANUARY2010 contact(includingbetweencaringfordifferentpatientsandbetweendifferentcareactivitiesforthesame patient)andafteranyactivityorcontactthatpotentiallyresultsinhandsbecomingcontaminated(including removalofgloves)reducestheriskofcrosscontamination.

The 5 moments of hand hygiene
The5momentsofhandhygienedevelopedbytheWorldHealthOrganizationandadoptedbyHand HygieneAustralia(Graysonetal2009): protectpatientsagainstacquiringinfectiousagentsfromthehandsofthehealthcareworker; helptoprotectpatientsfrominfectiousagents(includingtheirown)enteringtheirbodiesduring procedures;and protecthealthcareworkersandthehealthcaresurroundingsfromacquiringpatientsinfectiousagents.
Figure B1.2: The 5 moments of hand hygiene
Note: Handhygieneisalsoperformedaftertheremovalofgloves. Source: Graysonetal2009.
RECOMMENDATION
1 Routine hand hygiene Grade B
Hand hygiene must be performed before and after every episode of patient contact. This includes: before touching a patient; before a procedure; after a procedure or body fluid exposure risk; after touching a patient; and after touching a patients surroundings.
Hand hygiene is also performed after the removal of gloves. Cough etiquette
Coveringsneezesandcoughspreventsinfectedpersonsfromdispersingrespiratorysecretionsintotheair. Practisinghandhygieneaftercontactwithrespiratorysecretionsandcontaminatedobjectsormaterialsisan essentialelementofcoughetiquette.

CONSULTATIONDRAFTJANUARY2010 Coughetiquetteisparticularlyimportantforpatientsondropletprecautions(seeSectionB2.3).
Table B1.1: Steps in cough etiquette
Anyone with signs and symptoms of a respiratory infection, regardless of the cause, should follow or be instructed to follow cough etiquette as follows: Cover the nose/mouth when coughing or sneezing Use tissues to contain respiratory secretions Dispose of tissues in the nearest waste receptacle after use If no tissues are available, cough or sneeze into the inner elbow rather than the hand Practice hand hygiene after contact with respiratory secretions and contaminated objects/materials
B1.1.3
What product should be used?
Recentsystematicreviewsandexistingguidelines(Boyce&Pittet2002;Picheansathian2004;Prattetal2007; CanadaStandardsandGuidelineCoreCommittee2008;Larmeretal2008;PIDAC2008;Graysonetal2009) andotheravailablereviewarticles(Pittet&Boyce2001;Rotter2004;Nicolay2006)agreethathandhygiene usingalcoholbasedhandrubsismoreeffectiveagainstthemajorityofcommoninfectiousagentsonhands thanhandhygienewithplainorantisepticsoapandwater. Alcoholbasedhandrubs(liquidorgel)areeasilyaccessibleatpointofcareandhave(Graysonetal2009): excellentantimicrobialactivityagainstGrampositiveandGramnegativevegetativebacteria, Mycobacteriumtuberculosisandawiderangeoffungi; generallygoodantimicrobialactivityagainstenvelopedviruses; lesserand/orvariableantimicrobialactivityagainstnonenvelopedviruses(suchasnorovirus);and noactivityagainstprotozoanoocystsandbacterialspores(suchasC.difficile)(seeSectionB2.2).
Therangeofantimicrobialactivityinalcoholbasedhandrubsvarieswiththealcoholcompound(ethanol, isopropanolornpropanol)used.Alcoholbasedhandrubsthathave70%byvolume(v/v)ethanolor equivalenthavesignificantlygreaterantimicrobialactivityagainstcommoninfectiousagentsthanthose below70%v/vethanol(Picheansathian2004;CanadaStandardsandGuidelineCoreCommittee2008; PIDAC2008).Theadditionofalowconcentrationofchlorhexidinetoanalcoholbasedhandrubenhances residualactivity(Rotter2004;Graysonetal2009)buthasbeenassociatedwithskinsensitivity. Alcoholbasedhandrubsdonotremovedirtorotherorganicmaterial,andcontinuedusemayleadto productbuildupthatleavesaresidue,requiringhandhygienewithliquidsoapandwater. Plainsoapsactbymechanicalremovalofmicroorganismsandhavenoantimicrobialactivity.Theyare sufficientforgeneralsocialcontactandforcleansingofvisiblysoiledhands.Thereisatendencyfor antimicrobialsoapstobemoreeffectivethanplainsoaps,althoughtheevidencearoundthisisinconsistent. Antimicrobialsoapisassociatedwithskincareissuesanditisnotnecessaryforuseineverydayclinical practice(Prattetal2001;CDC2002;Prattetal2007.) RECOMMENDATIONS
2 Choice of product for routine hand hygiene practices Alcohol-based hand rubs containing at least 70% v/v ethanol or equivalent should be used for all routine hand hygiene practices in the healthcare environment. 3 Choice of hand hygiene product when hands are visibly soiled If hands are visibly soiled, hand hygiene should be performed using soap and water. B Grade B
Technique
Effectivehandhygienereliesonappropriatetechniqueasmuchasonselectionofthecorrectproduct.Key factorsineffectivehandhygieneandmaintainingskinintegrityinclude(CDC2002): thedurationofhandhygienemeasures; theexposureofallsurfacesofhandsandwriststothepreparationused(Widmer&Dangel2004); theuseofvigorousrubbingtocreatefriction;and ensuringthathandsarecompletelydry.
Table B1.2: Use of alcohol-based hand rub

Apply the amount of alcohol-based hand rub recommended by the manufacturer to dry hands. Rub hands vigorously together so that the solution comes into contact with all surfaces of the hand, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Continue rubbing until the solution has evaporated and the hands are dry.
Table B1.3: Using soap (including antimicrobial soap) and water

Wet hands under tepid running water and apply the recommended amount of liquid soap. Rub hands vigorously together for a minimum of 15 seconds so that the solution comes into contact with all surfaces of the hand, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Rinse hands thoroughly under running water, then pat dry with single-use towels.
B1.1.4
Other aspects of hand hygiene
Asintactskinisanaturaldefenceagainstinfection,cutsandabrasionsreducetheeffectivenessofhand hygienepractices.Breaksorlesionsoftheskinarepossiblesourcesofentryforinfectiousagents(Larson 1996)andmayalsobeasourceofthem.Toreducetheriskofcrosstransmissionofinfectiousagents,cuts andabrasionsshouldbecoveredwithwaterproofdressings. Thetypeandlengthoffingernailscanhaveanimpactontheeffectivenessofhandhygiene(CDC2002;Lin etal2003).Artificialnailshavebeenassociatedwithhigherlevelsofinfectiousagents,especiallyGram negativebacilliandyeasts,thannaturalnails(Pottingeretal1989;Passaroetal1997;Focaetal2000; Hedderwicketal2000;Moolenaaretal2000;Parryetal2001;CDC2002;Guptaetal2004;Boszczowskietal 2005).Fingernailsshouldthereforebekeptshortandcleanandartificialfingernailsshouldnotbeworn. Althoughthereislessevidenceconcerningtheimpactofjewelleryontheeffectivenessofhandhygiene, ringscaninterferewiththetechniqueusedtoperformhandhygieneresultinginhighertotalbacterialcounts (CDC2002).Handcontaminationwithinfectiousagentsisincreasedwithringwearing(CDC2002;Tricket al2003),althoughnostudieshaverelatedthispracticetohealthcareworkertopatienttransmission. Wearingofjewelleryinclinicalareasshouldthereforebelimitedtoaplainband(e.g.weddingring)andthis shouldbemovedaboutonthefingerduringhandhygienepractices.Inhighrisksettingssuchasoperating suites/roomsthewearingofanyjewellery,evenaplainband,isnotrecommended. B1.1.5 Hand care
Themaintypeofskinreactionassociatedwithhandhygiene,irritantcontactdermatitis,includessymptoms suchasdryness,irritation,itchingandsometimescrackingandbleeding.Allergiccontactdermatitisisrare andrepresentsanallergy,whichmaybetosomeingredientinahandhygieneproduct. Generally,alcoholbasedhandrubscausesignificantlylessskindamagethanhandhygienewithplainor antisepticsoaps(Pittet&Boyce2001).
CONSULTATIONDRAFTJANUARY2010 Expertopinionconcludesthat(Prattetal2001;CDC2002;Graysonetal2009): skindamageisgenerallyassociatedwiththedetergentbaseofthepreparation,poorhandhygiene techniqueand/orfrequentuseofalcoholbasedhandrubimmediatelybeforeorafterperforminghand hygienewithsoap; frequentuseofhandhygieneagentsmaycausedamagetotheskinandalternormalhandflora; excoriatedhandsareassociatedwithincreasedcolonisationbypotentiallyinfectiousagents; theirritantanddryingeffectsofhandpreparationsareonereasonwhyhealthcareworkersfailtoadhere tohandhygieneguidelines;and appropriateuseofhandlotionormoisturisersaddedtohandhygienepreparationsisanimportant factorinmaintainingskinintegrity,encouragingadherencetohandhygienepracticesandassuringthe healthandsafetyofhealthcareworkers.
Use of hand cream
Anemollienthandcreamshouldbeappliedregularly,suchasafterperforminghandhygienebeforeabreak orgoingoffduty,orwhenoffduty.Handhygienetechniqueshouldbereviewedifskinirritationoccurs.If theirritationpersistsorifitcausedbyaparticularsoap,antisepticagentoralcoholbasedproduct,the personwithdesignatedresponsibilityforinfectioncontroloroccupationalhealthshouldbeconsulted. Itisimportanttoensurethattheselectedalcoholbasedhandrubs,soapsandmoisturisinglotionsare chemicallycompatible,tominimiseskinreactionsandensurethatthedecontaminatingpropertiesofthe handhygieneproductarenotdeactivated.Often,healthcarefacilitiespurchasehandhygieneandhandcare productsfromarangemadebyasinglemanufacturer,asthishelpstoensurecompatibilitybetweenthe products(seealsoSectionC6). B1.1.6 Putting it into practice
Individual actions for reducing the risk

Follow the 5 moments of hand hygiene, even when it seems that there is insufficient time Follow cough etiquette Become familiar with your facility policy on hand hygiene and follow it Use the appropriate product for the situation and use it as directed Follow facility policy on cuts and abrasions, fingernails and jewellery Use hand care products provided by your organisation; your own products may not be compatible with the hand hygiene products provided Minimise physical contact with patient surroundings Lead by example and champion hand hygiene in your setting Attend hand hygiene education sessions regularly to refresh your knowledge and skills Contact the person with designated responsibility for occupational health or infection control if you have a reaction to hand hygiene and hand care products used in your setting If alcohol-based hand rub is not readily accessible at key points of care in a patient care area, consider approaching management
Involving patients in hand hygiene
Thefollowinginformationmaybeprovidedtopatientstoassisttheminbecominginvolvedinidentifying andreducingrisksrelatedtopoorhandhygiene.
Hand hygiene is the most important aspect of reducing the risk of infection this applies to everyone including healthcare workers, patients and visitors The 5 moments of hand hygiene tell healthcare workers, patients and visitors when hand hygiene should be performed to reduce the risk of infection Cough etiquette is an important part of reducing the risk of infection to others. This includes covering the mouth with a tissue when coughing or sneezing, disposing of the tissue in the nearest waste receptacle and performing hand hygiene Healthcare workers generally use alcohol-based hand rub as it is effective and easy to use but, if their hands are visibly dirty, they need to use soap and water first Performing hand hygiene regularly reduces the risk of infection to you and others. If in hospital, remind your visitors to use alcohol-based hand rub when they come into the ward and before they leave No matter what product you use to clean your hands, the solution should come into contact with all surfaces After hand hygiene, the hands should be dry. If alcohol-based hand rub is used, the solution will dry on the hands. After hand hygiene with soap and water, hands should be patted dry Healthcare workers should have short, clean fingernails and not wear artificial fingernails Its okay to question healthcare workers about their hand hygiene practices
Risk management case study

Hand hygiene in a neonatal intensive care unit
TheneonatalintensivecareunitinalargeregionalhospitalidentifiescolonisationorinfectionwithPseudomonas aeruginosainanumberofinfants.Surveillanceculturesfromotherinfantsintheunit,fromthehandsofstaffonthe unitandfrompossibleenvironmentalreservoirsareassessed.Theculturesshowthatanadditionalthreeinfantsare colonised.Culturesofenvironmentalspecimensarenegativebutculturesofthreeoftwentyfourhealthcareworkersare positive.Ofthese,twohaverecentlyjoinedtheunitandreceivednoeducationonhandhygieneinorientationandthe thirdhasartificialfingernails.

Eliminating risks Identifying risks In this situation, it is not possible to eliminate risk, so it must be managed. In this case, the risk has been identified as cross-transmission of Pseudomonas aeruginosa. Ongoing surveillance would assist in identifying other infectious agents that may be present in the neonatal intensive care unit. Analysing risks One source of the risk is the lack of appropriate hand hygiene practices by some staff members. Each time these staff members are involved in the care of an infected or colonised infant, there is potential for spread of the infectious agent (to other infants and to staff members), with the risk continuing until appropriate hand hygiene practices are performed. There is no mention in the case study of existing controls to counter the risk (e.g. use of gloves) but these would need to be included in the analysis, as would other possible causes of the risk (e.g. line setup, reprocessing of equipment). Evaluating risks The balance of likelihood and consequences identify this as a very high risk situation requiring immediate response. Treating risks Immediate measures may include providing alcohol-based hand rub by each incubator, introducing clustering of patient care activities to reduce contact, providing staff education sessions. In the longer term, improvements could be made to facility orientation processes. Banning the use of artificial fingernails in the unit might also be considered. Monitoring Hand hygiene compliance could be audited through direct observation by trained observers. B1.1 Hand hygiene 35
CONSULTATIONDRAFTJANUARY2010 B1.2 B1.2.1 PERSONAL PROTECTIVE EQUIPMENT What are the risks?
Anyinfectiousagenttransmittedbythecontactordropletroutecanpotentiallybetransmittedby contaminationofhealthcareworkershands,skinorclothing.Crosscontaminationcanthenoccurbetween thehealthcareworkerandotherpatientsorhealthcareworkers,orbetweenthehealthcareworkerandthe environment.Infectiousagentstransmittedthroughdropletscanalsocomeintocontactwiththemucous membranesofthehealthcareworker. Personalprotectiveequipment(PPE)referstoavarietyofbarriers,usedaloneorincombination,toprotect mucousmembranes,airways,skinandclothingfromcontactwithinfectiousagents.PPEusedaspartof standardprecautionsincludesaprons,gowns,gloves,surgicalmasks,eyeprotectionandfaceshields. SelectionofPPEisbasedonthetypeofpatientinteraction,knownorpossibleinfectiousagents,and/orthe likelymode(s)oftransmission. TherehavebeenfewcontrolledclinicalstudiesevaluatingtherelationshipbetweentheuseofPPEandrisk ofhealthcareassociatedinfections.However,theuseofbarriersreducesopportunitiesfortransmissionof infectiousagents(CDC1999;Prattetal2001;Clarketal2002).PPEalsoprotectspatientsfromexposureto infectiousagentscarriedbyhealthcareworkers. This section discusses the routine use of PPE as part of standard precautions. Specific PPE used when transmission-based precautions are applied is discussed in Section B2.1. The use of PPE during specific procedures is discussed in Section B4. B1.2.2 Decision-making about personal protective equipment
ThedecisiontousePPEisbasedonanassessmentofthelevelofriskassociatedwithaspecificpatientcare activityorinterventionandshouldtakeaccountoflocalpoliciesandcurrenthealthandsafetylegislation (Clarketal2002). Selectionofprotectiveequipmentmustbebasedonassessmentoftheriskoftransmissionofinfectious agentstothepatientorcarer,andtheriskofcontaminationoftheclothingorskinofhealthcareworkersor otherstaffbypatientsblood,bodyfluids,secretionsorexcretions. Factorstobeconsideredare: probabilityofexposuretobloodandbodyfluids; typeofbodyfluidinvolved;and probabletypeandprobablerouteoftransmissionofinfectiousagents. AppropriatesequencesandproceduresforputtingonandremovingPPE 9areshowninSectionB1.2.7. RelevantAustralianStandardsarelistedinPartD.
Where to wear PPE
PPEisdesignedandissuedforaparticularpurposeinaprotectedenvironmentandshouldnotbeworn outsidethatarea.Protectiveclothingprovidedforstaffinareaswherethereishighriskofcontamination (e.g.operatingsuite/room)mustberemovedbeforeleavingthearea.Evenwherethereisalowerriskof contamination,clothingthathasbeenincontactwithpatientsshouldnotbewornoutsidethepatientcare area.InappropriatewearingofPPE(e.g.wearingoperatingsuite/roomattireinthepublicareasofahospital orwearingsuchattireoutsidethefacility)mayalsoleadtoapublicperceptionofpoorpracticewithinthe facility.
WhileitisacknowledgedthatdonninganddoffingareacceptedtermsforputtingonandremovingPPE,in theseguidelinesplainEnglishtermsareusedforsimplicityandclarity.
CONSULTATIONDRAFTJANUARY2010 B1.2.3 Aprons and gowns
Internationalguidelinesrecommendthatprotectiveclothingbewornbyallhealthcareworkerswhen (Garner1996;Prattetal2001;Clarketal2002;Prattetal2007): closecontactwiththepatient,materialsorequipmentmayleadtocontaminationofskin,uniformsor otherclothingwithinfectiousagents;or thereisariskofcontaminationwithblood,bodyfluids,secretions,orexcretions(exceptsweat). Clinicalandlaboratorycoatsorjacketswornoverpersonalclothingforcomfortand/orpurposesofidentity arenotconsideredtobePPE.

Plastic aprons
Singleuseplasticapronsarerecommendedforgeneralusewhenthereisthepossibilityofspraysorspills, toprotectclothesthatcannotbetakenoff(Garner1996;Prattetal2001;Clarketal2002;Prattetal2007). Unusedapronsshouldbestoredinanappropriateareaawayfrompotentialcontamination(Callaghan 1998).

Full body gowns
Fullbodygownsareusedtoprotectthehealthcareworkersarmsandexposedbodyareasandprevent contaminationofclothingwithblood,bodyfluids,andotherpotentiallyinfectiousmaterial(Boyceetal1994; Boyceetal1995;Gerdingetal1995;Boyceetal1997;Hall2000;CDC2003).Theneedforandtypeoffull bodygownselectedisbasedon: thenatureofthepatientinteraction,includingtheanticipateddegreeofcontactwithinfectiousmaterial; and thepotentialforbloodandbodyfluidstopenetratethroughtoclothesorskin. Fullbodygownsarealwayswornincombinationwithgloves,andwithotherPPEwhenindicated.Full coverageofthearmsandbodyfront,fromnecktothemidthighorbelowensuresthatclothingandexposed upperbodyareasareprotected. Fluidresistantaprons/gownsshouldbewornwhenthereisariskthatclothingmaybecomecontaminated withblood,bodyfluids,secretionsorexcretions(exceptsweat).
Table B1.4: Characteristics of aprons/gowns
Plastic apron Single use Recommended for general use (when helping patients to shower or eat), to protect the healthcare workers skin and clothes from being sprayed with fluids Full body gown Fully covers arms, exposed body areas and protects clothes from contamination Used when there is a possibility of splashing of blood, body fluids, secretions or excretions (except sweat) Should be fluid repellent Recommended for use in situations where a high degree of environmental exposure (e.g. to unprotected arms or sleeves) or close care (e.g. in paediatrics) is anticipated
Removing aprons and gowns
Removalofapronsandgownsbeforeleavingthepatientcarearea(e.g.intheroomoranteroom)prevents possiblecontaminationoftheenvironmentoutsidethepatientsroom.Apronsandgownsshouldbe removedinamannerthatpreventscontaminationofclothingorskin.Theouter,contaminated,sideofthe gownisturnedinwardandrolledintoabundle,andthendiscardedintoadesignatedcontainerforwasteor linentocontaincontamination(seeSectionB1.2.7). Aprons/gownsareroutinelyuseduponenteringtheroomofapatientrequiringcontactprecautions.Thisis discussedinSectionB2.2.3.
B1.2 Personal protective equipment 37
CONSULTATIONDRAFTJANUARY2010 RECOMMENDATIONS
4 Wearing of aprons/gowns Aprons or gowns should be appropriate to the task being undertaken. They should be worn for a single procedure or episode of patient care and removed in the area where the episode of care takes place. Grade C
B1.2.4
Face and eye protection
Themucousmembranesofthemouth,noseandeyesareportalsofentryforinfectiousagents,asareother skinsurfacesifskinintegrityiscompromised(e.g.byacne,dermatitis)(Sartorietal1993;Rosen1997; Keijmanetal2001;Hosogluetal2003). Faceandeyeprotectionreducestheriskofexposureofhealthcareworkerstosplashesorspraysofblood, bodyfluids,secretionsorexcretions(Dancer1999;Prattetal2001;Clarketal2002)andisanimportantpart ofstandardprecautions.Proceduresthatgeneratesplashesorspraysofblood,bodyfluids,secretionsor excretionsrequireeitherafaceshieldoramaskwornwithgoggles(CDC1978;Davidsonetal1995; Gehannoetal1999;Scalesetal2003;Setoetal2003;Fowleretal2004;Loebetal2004).

Table B1.5: Use of face and eye protection as part of standard precautions
Type of care Routine care Examples General medical examination Routine observations Procedures that generate splashes or sprays Dental procedures Nasopharyngeal aspiration Emptying wound or catheter bag Procedures involving the respiratory tract (including the mouth) Routine dental practices/dental surgery Respiratory procedure Face shield that fully covers the front and sides of the face OR Mask with attached shield OR Mask and goggles/safety glasses Face and eye protection required Not required unless caring for patients on droplet precautions (surgical mask) or on airborne precautions (P2 [N95] respirator) Mask and goggles
Surgical masks
Surgicalmasksareloosefitting,singleuseitemsthatcoverthenoseandmouth.Theyareusedaspartof standardprecautionstokeepsplashesorspraysfromreachingthemouthandnoseofthepersonwearing them.Theyalsoprovidesomeprotectionfromrespiratorysecretionsandarewornwhencaringforpatients ondropletprecautions(seeSectionB2.3.3).SurgicalmasksdifferfromP2(N95)respirators,asoutlinedin thetablebelow.

Table B1.6: Properties of different types of mask
Properties Other names Surgical masks Single-use face mask, medical mask, patient care mask, general purpose mask Characteristics Sealing Pleated face 23 polypropylene layers Filtration through mechanical impaction Fluid resistant Elasticised ties at crown and bottom of head P2 (N95) respirator (see Section 2.4.3) N95 respirator, P2 respirator, respiratory protection device, particulate respirator Raised dome or duckbill 45 layers (outer polypropylene, central layers electret [charged polypropylene]) Filtration through mechanical impaction and electrostatic capture Elasticised ties at crown and bottom of head, pliable metal nose bridge B1 Standard precautions 38
Properties Australian standards Intended use Procedures that generate splashes or sprays of large droplets of blood, body fluids, secretions and excretions Procedures requiring sterile technique (to protect patients from exposure to infectious agents carried in a healthcare workers mouth or nose) Routine care of patients on droplet precautions Routine and other care if the healthcare worker has a respiratory infection Routine care of patients on airborne precautions High risk procedures such as bronchoscopy when the patients infectious status is unknown Procedures that involve aerosolisation of particles that may contain biological material (e.g. mould, Bacillus, anthracis, M. tuberculosis, SARS virus) Surgical masks AS4381:2002 P2 (N95) respirator (see Section 2.4.3) AS1719:2009
Masksorrespiratorscanalsobeplacedoncoughingpatientstolimitpotentialdisseminationofinfectious respiratorysecretionsfromthepatienttoothers(seeSectionB2.3.3). Considerationswhenusingasurgicalmaskinclude: masksshouldbechangedwhentheybecomesoiledorwet; masksshouldneverbereappliedaftertheyhavebeenremoved; masksshouldnotbeleftdanglingaroundtheneck; touchingthefrontofthemaskwhilewearingitshouldbeavoided;and handhygieneshouldbeperformedupontouchingordiscardingausedmask.

Eye protection
Indirectlyventedgoggleswithamanufacturersantifogcoatingmayprovidethemostreliablepracticaleye protectionfromsplashes,sprays,andrespiratorydropletsfrommultipleangles.Newerstylesofgogglesfit adequatelyoverprescriptionglasseswithminimalgaps(tobeefficacious,gogglesmustfitsnugly, particularlyfromthecornersoftheeyeacrossthebrow).Whileeffectiveaseyeprotection,gogglesdonot providesplashorsprayprotectiontootherpartsoftheface. Safetyglassesprovideimpactprotectionandaresuitableforgeneralworkshoporlaboratoryuse.Theydo notprovidethesamelevelofsplashordropletprotectionasgoggles. Personaleyeglassesandcontactlensesarenotconsideredadequateeyeprotection.

Face shields
Singleuseorreusablefaceshieldsmaybeusedasanalternativetomaskandgoggles.Comparedwith goggles,afaceshieldcanprovideprotectiontootherpartsofthefaceaswellastheeyes.Faceshields extendingfromchintocrownprovidebetterfaceandeyeprotectionfromsplashesandsprays;faceshields thatwraparoundthesidesmayreducesplashesaroundtheedgeoftheshield.

Removing face and eye protection
Removalofafaceshield,protectiveeyewearandmaskcanbeperformedsafelyaftergloveshavebeen removedandhandhygieneperformed.Theties,earpiecesand/orheadbandusedtosecuretheequipmentto theheadareconsideredcleanandthereforesafetotouchwithbarehands.Thefrontofamask,gogglesor faceshieldisconsideredcontaminated.

Cleaning reusable face and eye protection
Reusablefaceshieldsandgogglesshouldbecleanedaccordingtothemanufacturersinstructions,generally withdetergentsolution,andbecompletelydrybeforebeingstored.
CONSULTATIONDRAFTJANUARY2010 RECOMMENDATION
5 Use of face and eye protection for procedures A surgical mask and goggles must be worn during procedures that generate aerosols, splashes or sprays of blood, body fluids, secretions or excretions into the face and eyes. Grade C
B1.2.5
Gloves
Glovescanprotectbothpatientsandhealthcareworkersfromexposuretoinfectiousagentsthatmaybe carriedonhands(Duckroetal2005).Aspartofstandardprecautions,theyareusedtoprevent contaminationofhealthcareworkershandswhen(Siegeletal2007): anticipatingdirectcontactwithbloodorbodyfluids,mucousmembranes,nonintactskinandother potentiallyinfectiousmaterial;and handlingortouchingvisiblyorpotentiallycontaminatedpatientcareequipmentandenvironmental surfaces(CDC2002;Bhallaetal2004;Duckroetal2005). Glovesareanessentialcomponentofcontactprecautions(inparticularforpatientswithMROs)(see SectionsB2.2.3andB3.1.2)andmayalsobeusedaspartofdropletprecautions,topreventindirect transmissionofinfectiousagentsbythehands(seeSectionB2.3.3). Thecapacityofglovestoprotecthealthcareworkersfromtransmissionofbloodborneinfectiousagents followinganeedlestickorotherpuncturethatpenetratestheglovebarrierhasnotbeendetermined(Siegelet al2007)(seeSectionB1.3).
When should gloves be worn?
AswithallPPE,theneedforglovesisbasedoncarefulassessmentofthetasktobecarriedoutandits relatedriskstopatientsandhealthcareworkers(Prattetal2001;Clarketal2002).Riskassessmentincludes considerationof: whoisatrisk(whetheritisthepatientorthehealthcareworker)andwhethersterileornonsterilegloves arerequired; thepotentialforexposuretoblood,bodyfluids,secretionsandexcretions; contactwithnonintactskinormucousmembranesduringgeneralcareandinvasiveprocedures;and whethercontaminatedinstrumentswillbehandled. WhenglovesarewornincombinationwithotherPPE,theyareputonlast(seeSectionB1.2.7).

When should gloves be changed?
Internationalguidancesuggeststhatchangingofglovesisnecessary: betweenepisodesofcarefordifferentpatients,topreventtransmissionofinfectiousmaterial(Prattetal 2001;Siegeletal2007); duringthecareofasinglepatient,topreventcrosscontaminationofbodysites(CDC1995;CDC2002); and ifthepatientinteractioninvolvestouchingportablecomputerkeyboardsorothermobileequipmentthat istransportedfromroomtoroom(Siegeletal2007). Prolongedandindiscriminateuseofglovesshouldbeavoidedasitmaycauseadversereactionsandskin sensitivity(Prattetal2001;Clarketal2002).
CONSULTATIONDRAFTJANUARY2010 RECOMMENDATIONS
6 Wearing of gloves Gloves must be worn as a single-use item for: invasive procedures; contact with sterile sites and non-intact skin or mucous membranes; and activity that has been assessed as carrying a risk of exposure to blood, body fluids, secretions and excretions. Grade GPP
Gloves must be changed between patients and after every episode of individual patient care. 7 Sterile gloves Sterile gloves must be used for aseptic procedures and contact with sterile sites. What type of gloves should be worn? Grade GPP
Nonsterilesingleusemedicalglovesareavailableinavarietyofmaterials,themostcommonbeingnatural rubberlatex(NRL)andsyntheticmaterials(e.g.nitrile,vinyl).NRLremainsthematerialofchoiceduetoits efficacyinprotectingagainstbloodbornevirusesandpropertiesthatenablethewearertomaintaindexterity (Prattetal2001;Clarketal2002).However,sensitivitytoNRLinpatients,carersandhealthcareworkers mustbedocumentedandalternativesprovided. Theselectionofglovetypefornonsurgicaluseisbasedonanumberoffactors(Korniewiczetal1994; Bolyardetal1998;Korniewicz&McLeskey1998;Ranta&Ownby2004): thetasktobeperformed; anticipatedcontactwithchemicalsandchemotherapeuticagents;and personalfactors,suchaslatexsensitivityandsize.
Table B1.7: Selection of glove type
Glove Non-sterile gloves Use Procedures/activities that do not require a sterile technique. Examples Emptying a urinary catheter bag Naso-gastric aspiration Tracheal suctioning Sterile gloves Sterile procedures Urinary catheter insertion Complex dressings Central venous line insertion site dressing Utility gloves Cleaning General cleaning duties Instrument cleaning in sterilising services unit Gloves suitable for clinical use NRL (latex) gloves Nitrile gloves Vinyl gloves Preferable for clinical procedures that require manual dexterity and/or will involve more than brief patient contact Latex sensitivity may be an issue Suitable alternative to latex, provided there are no sensitivity issues Have a higher failure rates than latex or nitrile gloves when tested under simulated and actual clinical conditions
Gloves not suitable for clinical use Re-usable utility gloves Polythene gloves Powdered gloves Indicated for non-patient care activities, such as handling or cleaning contaminated equipment, instruments or surfaces Permeable, tend to damage easily Cause inflammation and granuloma formation Promote latex allergy
Sources: DerivedfromKotilainenetal1989;Korniewiczetal1989;Korniewiczetal1993;Rego&Roley1999;Prattetal 2001;Korniewiczetal2002;CDC2003;Siegeletal2007. Removing and disposing of gloves
Gloves(otherthanutilitygloves)shouldbetreatedassingleuseitems.Theyshouldbeputonimmediately beforeaprocedureandremovedassoonastheprocedureiscompleted. Whenremovinggloves,careshouldbetakennottocontaminatethehands.Aftergloveshavebeenremoved, handhygieneshouldbeperformedincaseinfectiousagentshavepenetratedthroughunrecognisedtearsor havecontaminatedthehandsduringgloveremoval(Olsenetal1993;Tenorioetal2001;CDC2002). Glovesmustnotbewashedforsubsequentreuseinfectiousagentscannotberemovedreliablyfrom glovesurfacesandcontinuedgloveintegritycannotbeensured.Glovereusehasbeenassociatedwith transmissionofMRSAandGramnegativebacilli(Doebbelingetal1988;Makietal1990;Olsenetal1993). Glovesshouldbedisposedofassoonastheyareremoved,withdisposalcomplyingwithlocalpoliciesand standards. B1.2.6
Footwear
Other items of clothing
Footwearsuitableforthedutiesbeingundertakenmustbeworn.Footwearshouldminimisetheriskof sharpsinjury.
Uniforms
Inareasofclinicalpracticewherethereisahighriskofrepeatedexposuretobloodandotherbodyfluidsit isrecommendedthatuniformsbewornaswellastheappropriatePPE. Whilesomestudiesshowthatuniformsandwhitecoatsbecomeprogressivelycontaminatedduringclinical care,nostudieshavedemonstratedthatuniformstransmitinfectiousagentsorleadtoHAI(Lovedayetal 2007). Uniformsshouldbewasheddaily.Thereisnoevidencetosuggestthathomelaunderingisinferiorto commercialprocessingofuniforms(Lovedayetal2007).
CONSULTATIONDRAFTJANUARY2010 B1.2.7 Sequence for putting on and removing PPE
Toreducetheriskoftransmissionofinfectiousagents,PPEmustbeusedappropriately.Thefollowingtable outlinessequencesandproceduresforputtingonandremovingPPE.Steps2and3ofremovingare interchangeableaslongasgeneralprinciplesareapplied. HandhygienemustbeperformedbetweeneachstepandimmediatelyafterremovingallPPE.

Table B1.8: Putting on and removing PPE
SEQUENCE FOR PUTTING ON PPE 1. GOWN Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back Fasten in back of neck and waist
2. MASK Secure ties or elastic bands at middle of head and neck
3. GOGGLES OR FACE SHIELD Place over face and eyes and adjust to fit
4. GLOVES Extend to cover wrist of isolation gown
SEQUENCE FOR REMOVING PPE 1. GOWN Gown front and sleeves are contaminated! Unfasten ties Pull away from neck and shoulders, touching inside of gown only Turn gown inside out Fold or roll into a bundle and discard
Remove PPE at doorway or in anteroom.
2. GLOVES Outside of gloves is contaminated! Grasp outside of glove with opposite gloved hand; peel off Hold removed glove in gloved hand Slide fingers of ungloved hand under remaining glove at wrist Peel glove off over first glove Discard gloves in waste container
3. GOGGLES OR FACE SHIELD Outside of goggles or face shield is contaminated! To remove, handle by head band or ear pieces Place in designated receptacle for reprocessing or in waste container 4. MASK Front of mask is contaminated DO NOT TOUCH! Grasp bottom, then top ties or elastics and remove Discard in waste container PERFORM HAND HYGIENE IMMEDIATELY AFTER REMOVING ALL PPE
Source:
Adaptedfromwww.cdc.gov.
CONSULTATIONDRAFTJANUARY2010 B1.2.8 Putting it into practice

Before putting on PPE explain to the patient that it is a routine part of infection prevention and control Assess the risk of spraying or splashing in the specific situation and choose PPE accordingly If you have an infection, or you might have one, think about whether you should be at work and wear a mask to protect your patients Follow appropriate sequence and procedure for putting on and removing PPE as outlined above Remove PPE before leaving the patient care area and following the sequence and procedure outlined above Lead by example and champion the appropriate use of PPE in your setting
Involving patients in their care
Thefollowinginformationmaybeprovidedtopatientstoassisttheminbecominginvolvedinidentifying andreducingrisksrelatedtotheuseofPPE.
The wearing of PPE such as gowns, masks and gloves is a routine part of infection prevention and control in healthcare it is used for everybodys safety The use of PPE alone is not enough healthcare workers should perform hand hygiene after removing the protective items PPE is used in the patient care area only healthcare workers remove the equipment before they leave the area to reduce the risk of spreading infection Gowns or aprons are used so that the healthcare workers clothing or skin does not become contaminated Healthcare workers wear a mask if there is risk of them inhaling an infectious agent For some infections, the patient also needs to wear a mask so that they do not infect others (for example when they are sneezing or coughing), especially if they are moving between patient care areas. Goggles or faceshields are worn by a healthcare worker in situations where the patients body fluids may splash onto his or her face Healthcare workers wear gloves when they will have direct hand contact with blood or body fluids, mucous membranes or wounds or if there is a chance that touching the patient could transmit infection. Its okay to question a healthcare worker about whether they should be using protective personal equipment or whether they are using it properly
CONSULTATIONDRAFTJANUARY2010 Risk management case study

Glove use and hand hygiene in office-based practice Following audit of healthcare-associated infection in the practice and comparison of the results with Division benchmarks, a GP identifies a higher than usual rate of Staphylococcus aureus cross-transmission in her practice. The practice comprises three GPs and a part-time practice nurse. Practice policy is that staff members use gloves for patient contact, changing gloves between patients. There is no recommendation in the policy for hand hygiene between different care activities for the same patient or after removing gloves.
Eliminating risks As patients may present with Staphylococcus infections or asymptomatic colonisation, in this situation it is not possible to eliminate risk, so it must be managed. Identifying risks The risk has been identified as cross-transmission of Staphylococcus aureus, with higher than usual rates occurring. Audit of cases of other infections that may be transmitted in the healthcare environment would assist in identifying other infectious agents that may occur at high rates in the practice. Analysing risks One source of the risk has been identified as the lack of hand hygiene before and after use of gloves. Each time a patient carrying Staphylococcus aureus is examined, there is potential for the spread of the infectious agent from the glove to the healthcare workers hand and then to the gloves worn for subsequent patients. The same applies for other infectious agents spread by contact. Existing controls and other sources of risk (e.g. low availability of alcohol-based hand rub) would also need investigation. Evaluating risks The balance of likelihood and consequences identify this as a very high risk situation requiring immediate response. Treating risks Immediate measures may include provision of alcohol-based hand rub at all points of care and staff education in hand hygiene and PPE. Long-term measures would include revision and implementation of PPE and hand hygiene policies. This could be carried out by the GP as practice leader in consultation with other staff. Monitoring Changes in practice could be monitored through audit of amounts of gloves and alcohol-based hand rub used. Repeating the audit of patient infections at regular intervals would assist in monitoring improvements.
CONSULTATIONDRAFTJANUARY2010 B1.3 B1.3.1 HANDLING AND DISPOSING OF SHARPS What are the risks?
Theuseofsharpdevicesexposeshealthcareworkerstotheriskofinjuryandpotentialexposureto bloodborneinfectiousagents,includinghepatitisBvirus(HBV),hepatitisCvirus(HCV)andhuman immunodeficiencyvirus(HIV)(CDC2001;Doetal2003). Sharpsinjuriescanoccurinanyhealthcaresetting,includingnonhospitalsettingssuchasinofficebased practices,homehealthcareandlongtermcarefacilities.Injuriesmostoftenoccurafteruseandbefore disposalofasharpdevice(40%),duringuseofasharpdeviceonapatient(41%),andduringorafter disposal(15%)(CDCunpublisheddata).Therearemanypossiblemechanismsofinjuryduringeachofthese periods. Hollowboreneedlesareofparticularconcern,especiallythoseusedforbloodcollectionorintravascular catheterinsertion,astheyarelikelytocontainresidualbloodandareassociatedwithanincreasedriskfor bloodbornevirustransmission.Glassvialsandbutterflyneedleshavealsobeeninvolvedinsharpsincidents (ASCC2008). Despitesystemsapproachestoimprovingsafetyandthegrowingavailabilityofsafetydevices,healthcare workersarestillexposedtobloodbornevirusinfections(Prattetal2007).Forexample,asurveyof occupationalexposuresinAustraliannurses(ASCC2008)foundthatinthe12monthspriortothesurvey, 11.2%ofnurseshadsustainedatleastoneneedlestickorothersharpsinjury. Assessingandmanagingtherisksassociatedwiththeuseofsharpsisparamount.Aswellasindividual actions,safesystemsofworkandengineeringcontrolsmustbeinplacetominimiseanyidentifiedrisks (Prattetal2007).Facilitywidesharpspreventionstrategiesandpostexposureprophylaxis(PEP)are discussedinPartC2. B1.3.2 Handling of sharps
Allhealthcareworkersshouldtakeprecautionstopreventinjuriescausedbyneedles,scalpelsandother sharpinstrumentsordevicesduringprocedures;whencleaningusedinstruments;duringdisposalofused needles;andwhenhandlingsharpinstrumentsafterprocedures. Standardmeasurestoavoidsharpsinjuriesincludehandlingsharpdevicesinawaythatpreventsinjuryto theuserandtootherswhomayencounterthedeviceduringorafteraprocedure.Examplesinclude(CDC): usinginstruments,ratherthanfingers,tograspneedles,retracttissue,andload/unloadneedlesand scalpels; givingverbalannouncementswhenpassingsharps; avoidinghandtohandpassageofsharpinstrumentsbyusingabasinorneutralzone; usingalternativecuttingmethodssuchasbluntelectrocauteryandlaserdeviceswhenappropriate; substitutingendoscopicsurgeryforopensurgerywhenpossible; usingroundtippedscalpelbladesinsteadofpointedsharptippedblades;and doublegloving. Theextenttowhichglovesprotecthealthcareworkersfromtransmissionofbloodborneinfectiousagents followinganeedlestickorotherpuncturethatpenetratestheglovehasnotbeendetermined(Siegeletal 2007).Althoughglovesmayreducethevolumeofbloodontheexternalsurfaceofasharp(Mastetal1993), theresidualbloodinthelumenofahollowboreneedlewouldnotbeaffected;therefore,theeffecton reductionoftransmissionriskisnotquantifiable(Siegeletal2007). RECOMMENDATION
8 Safe handling of sharps Grade
B1.3 Handling and disposal of sharps 47
Sharps must not be passed directly from hand to hand and handling should be kept to a minimum. Needles must not be recapped, bent, broken or disassembled after use. Table B1.9: Reducing risks if a sharps injury is sustained
Seek care immediately if you sustain a sharps injury If skin is penetrated, wash the affected area immediately with soap and water. Report the incident immediately to your supervisor. Ask about follow-up care, including post-exposure prophylaxis, which is most effective if implemented soon after the incident. Complete an accident / incident report form, including the date and time of the exposure, how it happened, and name of the source individual (if known). If a sharps injury happens to you, you can be reassured that only a small proportion of accidental exposures result in infection. Taking immediate action will lower the risk even further.
B1.3.3
Disposal of sharps
Aftertheyareused,singleusesyringesandneedles,scalpelblades,andothersharpitemsshouldbeplaced incontainersapprovedbyanappropriateregulatoryauthorityfordisposalofsharps.Thecontainersshould belocatedatthepointofuseor,ifthisisnotpossible,ascloseaspracticaltotheusearea.Approved containersaregenerallyspecificallylabelled,punctureresistantandtamperproof. RECOMMENDATION

9 Disposal of sharps The person who has used the sharp must be responsible for its immediate safe disposal. Used sharps must be discarded into an approved sharps container at the point-of-use. These must not be filled above the mark that indicates the bin is threequarters full. Grade D
B1.3.4
Safety devices
Arangeofdeviceshasbeendesignedwithbuiltinsafetyfeaturesthatreducetheriskofinjuryinvolvinga sharp.Theseinclude:syringeswithguardsthatshieldtheattachedneedleafteruse;needlesthatretractinto asyringeafteruseandshieldedorretractingneedlesusedforintravenouscannulation. Theuseofdeviceswithsafetyengineeredprotectivefeatures(e.g.safetyorretractabledevices)was mandatedintheUSin2000andisthoughttohavereducedtheratesofincidenceofneedlestickinjuries (Jaggeretal2008).TheirusehasrecentlybeenmandatedintheUKandEurope,butnotyetinAustralia. However,safetydevicesarebeingactivelypromotedinAustraliabyindustry.Theirintroductionneedsto beaccompaniedbyeducationofhealthcareworkerssothattheyareusedproperlyandanyrisktopatientsis minimised.

Needleless devices
Needlelessdevicesdonotuseneedlesforproceduressuchasthecollectionorwithdrawalofbodyfluids afterinitialvenousorarterialaccessisestablished,oradministeringmedicationorfluids. Sincetheiradoptioninhealthcarefacilities,needlelessdeviceshavecontributedtoadecreasein percutaneousinjuriesamonghealthcareworkers.However,theremaybeimplicationsforpatientsafety. Whileitisdifficulttoassesstheoveralleffectofneedlessdevicesbecauseofthewidevarietyofdevicesand systemsthatareinuse,somestudieshaveshownanincreasedriskofbloodstreaminfections(BSI)among patients(Ruppetal2007;Salgadoetal2007).

CONSULTATIONDRAFTJANUARY2010 Unfamiliaritywiththeuseofthesecomplexdevices,togetherwithinadequatedisinfectionprocedures,may contributetoincreasedBSIrates.UnitedStatesCentersforDiseaseControlrecommendationsforuseof needlelessdevicesareto(OGradyetal2002): changetheneedlelesscomponentsatleastasfrequentlyastheadministrationset; changecapsnomorefrequentlythanevery3daysoraccordingtomanufacturersrecommendations; ensurethatallcomponentsofthesystemarecompatibletominimiseleaksandbreaks;and
minimisecontaminationriskbywipingtheaccessportwithanappropriateantisepticandaccessingthe
portonlywithsteriledevices. Disinfectionofneedlelessconnectorswitheitherchlorhexidinewithalcoholorpovidoneiodinehasbeen showntosignificantlyreduceexternalcontamination(Caseyetal2003).
Retractable devices
Theuseofretractablesafetydevicesonsharpshasbeenassociatedwithasignificantreductioninneedlestick injuryinhealthcaresettings(Tuma&Sepkowitz2006;Rogues2004),althoughtheirdirectimpactisdifficult todeterminebecausetheirintroductionisoftenaccompaniedbyotherinterventions(e.g.trainingand education,overarchinghospitalpoliciesandothertechnologies)thatinisolationcouldalsocausea reductioninneedlestickinjuries(Whitby2008). B1.3.5 Putting it into practice

Explain to patients the risks to healthcare workers and others involved in the use and disposal of sharps and the measures taken to reduce these Become familiar with facility protocols on handling and disposal of sharps Use the appropriate product for the situation and use it as directed Avoid using needles where safe and effective alternatives are available If using needles, plan for their safe handling and disposal before using them Make sure every used needle is disposed of properly in puncture-resistant sharps containers Report any needlestick or sharps-related injuries promptly as relevant (e.g. to infection control or occupational health and safety professional, management, insurer) and ensure that you receive appropriate follow-up care. Ensure you are vaccinated for hepatitis B Participate in education sessions and professional development sessions on handling sharps, as well as those on new safety devices and how to use them
Thefollowinginformationmaybeprovidedtopatientstoassisttheminbecominginvolvedinidentifying andreducingrisksrelatedtothehandlinganddisposalofsharps.
Healthcare workers are at risk of injury and infection when using sharp equipment such as needles and scalpels Healthcare workers take measures to handle sharp devices in a way that prevents injury to the user and to others who may encounter the device during or after a procedure Special containers are used for the disposal of sharp devices Its okay to question a healthcare worker about the way in which they are handling or disposing of sharp devices
B1.3 Handling and disposal of sharps 49

Prevention of stick injury during surgery at a university hospital
Aspartoftherevisionofinfectioncontrolpoliciesatauniversityhospital,ananalysisoftheriskofpercutaneousblood andbodyfluidexposureduringsurgicalprocedureswasundertaken.Separateanalyseswereconductedfordifferent devicetypesandfordifferentmembersofthesurgicalteam.Surgeonsandfirstassistantswereathighestriskforinjury, sufferingmorethanhalfofinjuriesintheoperatingroom,followedbyscrubnursesandtechnicians,anaesthetistsand circulatingnurses.Ratesofstickinjuryincreasedwithestimatedbloodlossandsurgeryduration.Sutureneedle injurieswerethemostcommonandmostlyoccurredduringwoundclosure.Aconsiderablenumberofinjuriesalso occurredwhilepassingsharpinstrumentshandtohand.Asmanyasonethirdofdevicesthatcausedinjuriescamein contactwiththepatientaftertheinjurytothehealthcareworker.However,onlyasmallproportionofinjuriesto surgeons(0.5%)involvedhollowborevascularaccessneedles,whicharedefinedashighrisk. Source:BasedonMyersetal(2008)andBergauer&Heller(2005).
Eliminating risks Although the risk of injury varies for different healthcare team members, it is never zero and must be managed. Identifying risks In this case, the risk has been identified as exposure of healthcare workers to blood and body fluids (and potential infection) through suture needle injury. As a high proportion of devices causing injury came into contact with the patient after injury to the healthcare worker, there could also be a risk of transmission of bloodborne infection to the patient. Analysing risks The fundamental source of risk is the need to use sharps coupled with the potential for a patient to be a source of infection. The level of risk increases with duration of procedure and amount of blood lost. Other factors that may contribute to the risk are levels of staff training and experience, staffing levels, the existence of a hospital policy for safe use of sharps and compliance with the policy. Other factors that would need to be included in the analysis are existing controls to mitigate risk (e.g. double gloving) and other possible causes (e.g. poor surgical technique increasing blood loss and procedure duration). Evaluating risks The balance of likelihood and consequences identify this as a very high risk situation requiring immediate response. Treating risks Immediate measures may include providing staff education, use of blunt suture needles and a neutral zone for passing surgical equipment, and double gloving during long surgery. In the longer term, reviewing local policy on the prevention of needlestick injury and raising awareness of measures to reduce injury among staff members might also be considered. Monitoring Changes in adverse events could be evaluated by repeating the analysis after implementation of changes.
CONSULTATIONDRAFTJANUARY2010 B1.4 B1.4.1 ROUTINE MANAGEMENT OF THE PHYSICAL ENVIRONMENT What are the risks?
Infectiousagentscanbewidelyfoundinhealthcaresettingsandthereisabodyofclinicalevidence,derived fromcasereportsandoutbreakinvestigations,suggestinganassociationbetweenpoorenvironmental hygieneandthetransmissionofinfectiousagentsinhealthcaresettings(Dancer1999;Garner&Favero 1986).Transmissionofinfectiousagentsfromtheenvironmenttopatientsmayoccurthroughdirectcontact withcontaminatedequipment,orindirectly,forexample,viahandsthathavetouchedcontaminated equipmentortheenvironmentandthentouchapatient(Dancer2008). Environmentalsurfacescanbesafelydecontaminatedusinglessrigorousmethodsthanthoseusedon medicalinstrumentsanddevices.Thelevelofcleaningrequireddependsontheobjectsinvolvedandthe riskofcontaminationforexample,surfacesthatarelikelytobecontaminatedwithinfectiousagents (e.g.sharedclinicalequipment)requirecleaningbetweenpatientuses,whichismoreoftenthangeneral surfacesandfittings.However,allsurfacesrequireregularcleaning.Thoroughcleaningofallsurfacesis necessaryafterspillsandbetweenpatientusesofaroomorpatientcarearea. Intensivecareunitsandisolationareasrequireadditionallevelsofcleaning,especiallywherethereisarisk ofMROtransmission(seeSectionB2.2). B1.4.2 Routine environmental cleaning
Generalsurfacescanbedividedintotwogroupsthosewithminimalhandcontact(e.g.floorsand ceilings)andthosewithfrequentskincontact(frequentlytouchedorhighrisksurfaces).Themethods, thoroughnessandfrequencyofcleaningandtheproductsusedaredeterminedbyhealthcarefacilitypolicy. Frequentlytouchedsurfacesinpatientcareareasshouldbecleanedusingadetergentsolutionandmore frequentlythansurfaceswithminimalhandcontact.Infectioncontrolpractitionerstypicallyusearisk assessmentapproachtoidentifyfrequentlytouchedsurfacesandthencoordinateanappropriatelythorough cleaningstrategyandschedulewiththehousekeepingstaff.WhenMROsmaybepresent,routinecleaningis intensifiedtheuseofadetergentsolutionisfollowedbytheuseofadisinfectantsothatsurfacesare cleanedtwice.

Figure B1.3: Processes for routine cleaning
Minimally touched surfaces Frequently touched/ high risk surfaces
MRO or other infectious agent requiring transmission-based precautions
No
Yes
Non-acute setting
Acute setting
Detergent solution
Consider detergent solution followed by disinfectant
Use detergent solution followed by disinfectant
TableB1.11(seepage56)outlinestherecommendedfrequenciesforminimumroutinecleaningofvarious itemsinhealthcarefacilities.Theappendixprovidesguidancespecifictovariouslevelsofrisk(e.g.forhigh riskareassuchasintensivecareandforlowerriskareassuchasofficebasedpractice).
B1.4 Routine management of the physical environment 51
Minimal touch surfaces
Adetergentsolution(dilutedaspermanufacturersinstructions)isadequateforcleaninggeneralsurfaces (e.g.floors,tabletops),aswellasnonpatientcareareas(e.g.administrativeoffices).Dampmoppingis preferabletodrymoppingforroutinecleaning(Andersenetal2009). Wallsandblindsinpatientcareareasshouldbecleanedwhentheyarevisiblydustyorsoiled,with detergentsolution.Windowcurtainsshouldberegularlychangedinadditiontobeingcleanedwhensoiled orexposedtoMROs.Sinksandwashbasinsshouldbecleanedwithadetergentsolutiononaregularbasisas setbyfacilitypolicy.

Frequently touched surfaces
Surfacesthatareincloseproximitytothepatientandfrequentlytouchedsurfacesinthepatientcareareas shouldbecleanedmorefrequentlythanminimaltouchsurfaces.Examplesincludedoorknobs,bedrails, overbedtables,lightswitches,andwallareasaroundthetoiletinthepatientsroom. Frequentlytouchedsurfacescanbecleanedwithadetergentsolutiondesignedforgeneralpurposecleaning. Theexactchoiceofdetergentwilldependonthenatureofthesurfaceandthelikelydegreeof contamination.Detergentimpregnatedwipesmaybeusedtocleansinglepiecesofequipmentandsmall surfaceareas.Thismethodisnotnormallyusedforgeneralwardcleaningandshouldnotbeconsidereda replacementforcleancloths,wateranddetergent. RECOMMENDATION

10 Routine cleaning of surfaces Clean frequently touched surfaces with detergent solution at least daily, and when visibly soiled and after every known contamination. Clean general surfaces and fittings when visibly soiled and immediately after spillage. Use of disinfectants Grade GPP
Inacutepatientcareareaswherethereisuncertaintyaboutthenatureofsoilingonthesurface(e.g.bloodor bodyfluidcontaminationversusroutinedustordirt)orthepresenceofMROs(includingC.difficile)orother infectiousagentsrequiringtransmissionbasedprecautions(e.g.pulmonarytuberculosis)issuspected, surfacesshouldbecleanedwithadetergentsolution,thenadisinfectant.Inofficebasedpracticeandless acutepatientcareareas(e.g.longtermcarefacilities),theriskofcontamination,modeoftransmissionand risktoothersshouldbeusedtodeterminewhetherdisinfectantsarerequired. Highleveldisinfectantsorliquidchemicalsterilantsarenotappropriateforgeneralcleaning;suchuseis countertomanufacturersinstructionsforthesetoxicchemicals.Alcoholshouldnotbeusedtodisinfect largeenvironmentalsurfaces.

Table B1.10: Characteristics of disinfectants
Hypochlorite (chlorine) Hydrogen peroxide Alcohol Effective at a range from 100ppm (0.01%) to 52,000ppm (or 5.25%), depending of the organism and exposure time 1000ppm is a recommended concentration based on practical application Can be utilised in both liquid and mist form Ethanol and isopropyl alcohol have some antibacterial and antiviral effects A concentration of 70% isopropyl (or equivalent) alcohol is recommended
Source: AdaptedfromGrampiansRegionInfectionControlGroup(2006)TheLittleYellowInfectionControlBook. http://www.health.vic.gov.au/__data/assets/pdf_file/0018/37350/lyicb_original.pdf
Shared clinical equipment
Whilesharedclinicalequipmentcomesintocontactwithintactskinonlyandisthereforeunlikelyto introduceinfection,itcanactasavehiclebywhichinfectiousagentsaretransferredbetweenpatients (MicrobiologicalAdvisoryCommitteetotheDepartmentofHealth2006).Examplesofpossible contaminatedsurfacesonsharedmedicalequipmentincludeknobsorhandlesonhaemodialysismachines, xraymachines,instrumenttrolleysanddentalunits(CDC2003). Surfacebarriers(e.g.clearplasticwrap,bags,sheets,tubingorothermaterialsimpervioustomoisture)help preventcontaminationofsurfacesandequipment.Surfacebarriersonequipment(e.g.airwatersyringes, bedboards,computerkeyboards)needtobeplacedcarefullytoensurethattheyprotectthesurfaces underneathandshouldbechangedbetweenpatients. RECOMMENDATIONS
11 Cleaning of shared clinical equipment Clean touched surfaces of shared clinical equipment between patient uses, with detergent solution. Exceptions to this should be justified by risk assessment. 12 Surface barriers Use surface barriers to protect clinical surfaces (including equipment) that are: touched frequently with gloved hands during the delivery of patient care; likely to become contaminated with blood or body substances; or difficult to clean (e.g. computer keyboards). Grade GPP Grade GPP
Exceptions to this should be justified by risk assessment. Cleaning implements and solutions
Partofthecleaningstrategyistominimisecontaminationofcleaningsolutionsandcleaningtools.Proper proceduresforeffectiveuseofmops,cloths,andsolutionsshouldbefollowed: preparecleaningsolutionsdailyorasneeded,andreplacewithfreshsolutionfrequentlyaccordingto facilitypolicy; changethemopheadatthebeginningofeachdayandalsoasrequiredbyfacilitypolicy,orafter cleaninguplargespillsofbloodorotherbodysubstances;and cleanmopsandclothsafteruseandallowtodrybeforereuse,orusesingleusemopheadsandcloths.
Carpet
Carpetsinpublicareasandingeneralpatientcareareasshouldbevacuumeddailywithwellmaintained equipmentfittedwithhighefficiencyparticulateair(HEPA)filterstominimisedustdispersion(seeSection C6.2.3).Afteraspillhasbeenremovedasmuchaspossible(seeSection1.4.2),thecarpetshouldbesteam cleaned. Carpetsshouldundergothoroughsteamcleaningonaregularbasisassetbyfacilitypolicy,usingamethod thatminimisestheproductionofaerosolsandleaveslittleornoresidue.

Checking, auditing and environmental sampling
Healthcarefacilitiesuseavarietyofsystemstoensurethatcleaningstandardsaremet.Theseinclude checklists,colourcodingtoreducethechanceofcrossinfection,cleaningmanuals,modelcleaningcontracts, infectioncontrolguidance,andmonitoringstrategies.Somestatesandterritorieshavecleaningstandards thatareappliedtohealthcarefacilitiesregardlessofwhethercleaningservicesarecontractedorperformed inhouse.
CONSULTATIONDRAFTJANUARY2010 Auditingofcleaningismostlydonethroughvisualchecking;however,thisdoesnotrecognisethat microorganismsareinvisibletothenakedeye(Dancer2008).Moreobjectivemethodsofassessingsurface cleanlinessandbenchmarkingarebeinginvestigated. Routinemicrobiologicalsamplingoftheenvironmenttodeterminetheeffectivenessofcleaninghas considerablelimitations,includingdetectionofspecificclassesoforganisms(withexclusionofothers), inconsistencyandunpredictabilityofpatientsheddingandothercausesofenvironmentalcontamination, variationofeffectsofresidualdetergent/disinfectants,andvariationsinsamplingtechniquesandtesting. Theselimitationsmakeinterpretingtheresultsverydifficult(Button2006;Muttersetal2009;Rohretal 2009)androutineenvironmentalsamplingisthereforenotrecommended.However,theremaybearolefor environmentalsamplinginthemanagementofspecificsituationsandaspartofaholisticriskmanagement approach(e.g.anoutbreaksituationorunidentifiedcauseofinfections). B1.4.3 Management of blood and body substance spills
Promptremovalofspotsandspillsandcleaninganddisinfectionoftheareacontaminatedbybloodorbody substancesaresoundinfectioncontrolpracticesandoccupationalhealthandsafetyrequirements(CDC 2003).

Process of spills management
Strategiesfordecontaminatingspillsofbloodandotherbodyfluids(e.g.vomit,urine)differbasedonthe settinginwhichtheyoccurandthevolumeofthespill: inpatientcareareas,healthcareworkerscanmanagesmallspillsbycleaningwithdetergentsolution; forspillscontaininglargeamountsofbloodorotherbodysubstances,workersshouldcontainand confinethespillby: removingvisibleorganicmatterwithabsorbentmaterial(e.g.disposablepapertowels); removinganybrokenglassorsharpmaterialwithforceps;and soakingupexcessliquidusinganabsorbentclumpingagent(e.g.kittylitter). Thefollowingtablemayassistinfollowingappropriateprocesseswhenmanagingspills.AppropriatePPE shouldbewornatalltimes.
Table B1.11: Management of blood or body substance spills
Spot cleaning Small spills (up to 10cm diameter) Large spills (greater than 10cm diameter) Wipe up spot immediately with a damp cloth, tissue or paper towel Discard contaminated materials Perform hand hygiene Wipe up spill immediately with absorbent material Place contaminated absorbent material into impervious container or plastic bag for disposal Clean the area with warm detergent solution, using disposable cloth or sponge Wipe the area with sodium hypochlorite and allow to dry Perform hand hygiene Cover area of the spill with an absorbent clumping agent and allow to absorb Use disposable scraper and pan to scoop up absorbent material and any unabsorbed blood or body substances Place all contaminated items into impervious container or plastic bag for disposal Discard contaminated materials Mop the area with detergent solution Wipe the area with sodium hypochlorite and allow to dry Perform hand hygiene
Spill kit
Aspillkitshouldbereadilyavailableineachclinicalareaandshouldincludeascoopandscraper,single usegloves,protectiveapron,facemaskandeyeprotection,absorbentagent,clinicalwastebagsandties,and detergent.Allpartsshouldbedisposabletoensurethatcrosscontaminationdoesnotoccur. RECOMMENDATION

13 Site decontamination after spills of blood or other potentially infectious materials Spills of blood or other potentially infectious materials should be promptly cleaned as follows: wear utility gloves and other PPE appropriate to the task; confine and contain spill, clean visible matter with disposable absorbent material and discard the used cleaning materials in the appropriate waste container; clean the spill area with a cloth or paper towels using detergent solution, wipe with appropriately diluted sodium hypochlorite and allow the surface to dry. Grade C
Spillage of tissues from patients with CJD
ContaminationbyspillageofhigherinfectivitytissuesfrompatientswithclassicalCreuzfeldtJakobdisease (cCJD)shouldbecleanedbyfirstexposingtheareatofreshlypreparedsodiumhydroxide(NaOH)or 20,000ppm(freechlorine)sodiumhypochloritefor1houratambienttemperature,followedbyarinsewith water.WhensurfacescannottolerateNaOHorhypochlorite,cleaningusinganionicdetergentsolutionwill partiallyreduceinfectivitybydilution.
CONSULTATIONDRAFTJANUARY2010 B1.4.4 Putting it into practice

Make sure you are familiar with facility policies on routine cleaning Familiarise yourself with the cleaning frequencies outlined in Table B1.11 (see page 56). Report any concerns you have about hygiene Consider ways to involve patients in monitoring the cleanliness of the patient care area (e.g. through comments books on the ward, or a short questionnaire to be filled in before discharge)
Patientsareanintegralpartoftheriskmanagementprocess.Followingarepointsofadvicetoassistpatients inbecominginvolvedinidentifyingandreducingrisksrelatedtoroutinehospitalhygiene.
All surfaces and equipment in the patient care environment are regularly cleaned to prevent transmission of infection. Equipment is cleaned immediately after use (i.e. between patients). Surfaces that are touched often (such as doorknobs, bedrails, over-bed tables, light switches) and floors are cleaned daily, while surfaces that are touched less often (such as ceilings) are cleaned less frequently. Blood or other body substances (such as urine or vomit) increase the risk of transmission of infection so they are cleaned away promptly Its okay to say something if you think there is a problem with hygiene
Table B1.12 Recommended routine cleaning frequencies for clinical, patient and resident areas
Thefollowingtableoutlinestherecommendedminimumfrequenciesforroutinecleaningofvariousitemsin healthcarefacilities.Itisapplicabletoallsettings(althoughsomeitemsmaynotberelevanttoallsettings) andispresentedbylevelofriskasperthekeybelow.Forguidanceoncleaningofspills,seeSectionB1.4.3.

Very high risk High risk Significant risk Low risk 1 Outbreak in high risk area Intensive care unit, high dependency unit, burns unit General wards Rehabilitation, aged / residential care, office based Detergent or suitable cleaning product (for areas such as windows or items that have specific manufacturers cleaning instructions) 2 Refers to multi-resistant organisms or infectious agents requiring transmission-based precautions refer to Sections B2 and B3.
Element Very high risk Alcohol hand rub dispenser, bedside Alcohol hand rub dispenser, not in patient/treatment rooms Clean daily & between patient use Clean daily
Minimum cleaning frequency High risk Clean daily & between patient use Clean daily Significant risk Clean daily & between patient use Clean daily N/A Low risk Weekly
Method
Detergent1
Detergent1
Element Very high risk Bath One full clean after use & one check clean daily Bed Frame daily Underneath weekly Whole on discharge Bed rails Clean twice daily & after discharge Bedside Table Clean twice daily Minimum cleaning frequency High risk One full clean after use & one check clean daily Frame daily Underneath weekly Whole on discharge Clean once daily & after discharge One full clean & one check clean daily Bidet Three full cleans daily Two full cleans and one check clean daily Blood pressure cuff Carpet (soft floor) Two full cleans daily One full clean & one check clean daily Shampoo or steam clean weekly Shampoo or steam clean monthly Shampoo or steam clean six monthly to annual Catheter stand / bracket Clean daily & after use Clean daily & after use Clean monthly & after use & before initial use Clean monthly & after use & before initial use Ceiling Spot clean One full wash yearly Chair One full clean & one check clean daily Chair, dental and surrounds Cleaning equipment Full clean after each use Full clean after each use Full clean after each use NA spot clean One full wash yearly One full clean & one check clean daily NA NA Daily & when visibly soiled Full clean after each use Detergent1 Detergent + disinfectant for MRO2 Spot clean One full wash yearly One full clean daily spot clean Wash once every 3 years One full clean weekly Detergent1 Detergent + disinfectant for MRO2 Detergent1 Detergent1 / Damp Dust Detergent1 One full clean daily One full clean & one check clean weekly Shampoo or steam clean biannually Shampoo or steam clean Vacuum with HEPA filter After use Daily & after use After use After use One full clean daily One full clean daily One full clean daily One full clean weekly Frame daily Underneath weekly Whole on discharge Clean daily & after discharge Clean weekly & after discharge Detergent1 Detergent + disinfectant for MRO2 Detergent1 Detergent + disinfectant for MRO2 Detergent1 and disinfectant N/A Detergent1 Detergent + disinfectant for MRO2 Significant risk One full clean after use or daily Low risk One full clean after use or daily Detergent1 Method
Element Very high risk Clipboard Clean daily & between patient use Commode Clean contact points after each use One full clean daily Computer & keyboard Clean weekly Minimum cleaning frequency High risk One full clean daily & between patient use Clean contact points after each use One full clean daily Clean weekly Significant risk One full clean daily & between patient use Clean contact points after each use One full clean daily Clean weekly Clean contact points after each use One full clean weekly Clean weekly Manufacturers recommendations. Install key board covers or washable key boards where feasible Detergent1 Curtains and blinds Patient bed curtains change or clean weekly upon discharge Patient bed curtains change or clean ? this frequency monthly Patient with MRO2 or infectious disease1 Change bed curtains or clean upon discharge Clean, change or replace yearly Clean, change or replace yearly Clean, change or replace yearly Clean change or replace biannually Door knob/handle, general Door knob/ handle, patient room Drip/ Intravenous stands Clean contact points after each use Fan, patient One full clean daily & between patient use One full clean weekly Clean contact points after each use One full clean daily & between patient use One full clean monthly One full clean quarterly Clean contact points after each use Daily & between patient use Clean contact points after each use Weekly & between patient use One full clean yearly Detergent1 Clean twice daily Clean once daily Clean daily Clean daily Detergent1 Detergent + disinfectant for MRO2 One full clean daily One full clean daily One full clean daily One full clean weekly Detergent1 Patient with MRO2 Change bed curtains or clean upon discharge Patient with MRO2 Change bed curtains or clean upon discharge Patient with MRO2 Change bed curtains or clean upon discharge Bed curtains change or clean biannually Bed curtains change or clean annually Replace with laundered curtains or steam clean while in place. Follow manufacturers recommendations Detergent1 Detergent + disinfectant for MRO2 Low risk Weekly Detergent1 Method
Element Very high risk Floor, non slip Wet mop two full cleans daily Minimum cleaning frequency High risk Wet mop one full clean & one check clean daily Floor, polished Dust removal twice daily Dust removal one full clean Dust removal daily Significant risk Wet mop daily Low risk Wet mop one full clean & one check clean weekly Dust removal one full clean & one check clean weekly Detergent for routine Consider Electrostatic mops Detergent + disinfectant for MRO2 Fridges Clean daily Clean daily Three check cleans daily One full clean weekly Fridge (drug) Glazing, internal (incl partitions) Hoist, bathroom Weekly One full clean daily Clean contact points after each use IV stand & poles Daily & after use One full clean weekly Weekly One check clean daily Clean contact points after each use Daily & after use One full clean weekly Weekly One check clean daily Clean contact points after each use Weekly & after use One check clean daily One full clean weekly Weekly One full clean weekly Clean contact points after each use Monthly & after use Detergent1 Detergent + disinfectant for MRO2 Light Switch One full clean daily Locker Clean twice daily (contact points on the surface of the locker) Manual handling equipment (I.e. hoists) Mattress Clean contact points after each use Weekly & after discharge Clean contact points after each use Weekly & after discharge Clean contact points after each use Monthly & after discharge Clean contact points after each use Monthly & after discharge Detergent1 Detergent + disinfectant for MRO2 Preferable that entire mattress has waterproof cover Medical equipment One full clean (e.g. IV infusion pumps, pulse oximeters) NOT connected to a patient B1.4 Routine management of the physical environment 59 daily & between patient use One full clean daily & between patient use One full clean daily & between patient use One full clean weekly & between patient use Detergent1 Detergent + disinfectant for MRO2 One full clean daily One full clean & one check clean daily One full clean weekly One full clean daily One full clean weekly N/A Detergent1 Detergent + disinfectant for MRO2 Detergent1 Detergent1 Detergent1 Detergent1 Detergent1 Detergent1 Detergent1 Detergent + disinfectant for MRO2 Method
Element Very high risk Medical gas equipment Microwave One full clean daily One full clean & two check cleans daily Nebuliser, portable When in use: Clean daily & after use Minimum cleaning frequency High risk One full clean daily One full clean & two check cleans daily Clean daily & after use Clean monthly & after use & before initial use Clean bimonthly & after use & before initial use Notes folder Daily Daily One full clean weekly Oxygen equipment Clean daily & after use Clean daily & after use Clean monthly & after discharge & before initial use Clean monthly & after discharge & before initial use Patient slide/ board Clean daily & after use Clean daily & after use Clean monthly & after use Clean monthly & after use Detergent1 Detergent + disinfectant for MRO2 Full clean monthly Pillow (waterproof cover) Sharps bin trolley Clean daily Clean weekly & after discharge Full clean monthly Clean bi-monthly & after discharge Clean twice weekly Shower One full clean & one check clean daily Sink (hand washing) Two full cleans daily One full clean & one check clean daily Two full cleans & one check clean daily Surfaces (general) in patient room e.g. ledges Telephone Clean twice Daily Toilet Two full cleans daily Clean twice daily & discharge One full clean & one check clean daily & discharge Clean twice daily One daily full cleans and one check clean daily One full clean daily One full clean daily Detergent1 + disinfectant Clean daily Clean weekly Detergent1 One full clean daily & discharge One full clean weekly & discharge Detergent1 Detergent + disinfectant for MRO2 One full clean daily One full clean daily One full clean daily One full clean daily Detergent1 Detergent + disinfectant for MRO2 Detergent1 Clean weekly Full clean monthly Clean monthly & after discharge Full clean monthly Clean monthly & after discharge Clean monthly Detergent1 Detergent + disinfectant for MRO2 Detergent1 Detergent1 Weekly Detergent1 Detergent1 Significant risk One full clean daily One full clean daily Low risk One full clean weekly One full clean daily Detergent1 Method
Element Very high risk Toilet seat, raised Twice daily & after use Minimum cleaning frequency High risk Clean daily & after use Significant risk Clean monthly & after use & before initial use Low risk Clean monthly & after use & before initial use Trolley, dressing Clean before & after use Clean before & after use Clean before & after use Clean before & after use Detergent1 Detergent + disinfectant for MRO2 Trolley, linen Clean contact points daily One full clean weekly Trolley, resuscitation TV TV, patient bedside Clean weekly One full clean daily & between patients Walls Washbowl, patient Spot clean Between patient use Clean daily Clean contact points daily One full clean weekly Clean twice weekly Clean weekly One full clean daily & between patients Spot clean Between patient use Clean weekly One full clean weekly & between pts Spot clean Between patient use Clean weekly One full clean monthly & between pts Spot clean Between patient use Detergent1 / Damp dust Detergent1 Detergent + disinfectant for MRO2 Waste receptacle Weekly clean & spot cleaning as required for visible soiling Wheelchair Daily & after use Weekly clean & spot cleaning as required for visible soiling Daily & after use Weekly clean & spot cleaning as required for visible soiling Monthly & after use Weekly clean & spot cleaning as required for visible soiling Monthly & after use Detergent1 Detergent1 Detergent1 Detergent/Damp dust Clean contact points daily One full clean weekly Clean weekly Clean contact points weekly One full clean monthly Clean monthly Detergent1 Detergent1 Detergent for routine Detergent + disinfectant for MRO2 Method
Source: AdaptedfromNHSnationalspecificationsforcleanlinesslaunchedinApril2001;WalesWHC(2003)59 NationalStandardsofCleanlinessforNHSTrusts,WelshAssemblyGovernment,June2003;NHSEstates NHSEstates.StandardsofcleanlinessintheNHS:aframeworkinwhichtomeasureperformanceoutcomes. Leeds:NHSEstates;2003.Availableat: http://patientexperience.nhsestates.gov.uk/clean_hospitals/ch_content/home/home.asp;NationalPatientSafety Agency2007http://www.nrls.npsa.nhs.uk/resources/?entryid45=59818.
Risk management case study Spillsmanagementinabusypaediatricward Avisitortothepaediatricwardinasmallregionalhospitalnoticesthatthechildinthenextbedisvomitingandhas diarrhoea.Thewardisextremelybusyandthetwonursesondutyarefullyoccupied.Thechildsmotherhascleanedup anyspills,buttherearestilltracesofvomitonthebedsidetable.Laterthevisitornoticesthatequipmentisbeingplaced onthistable.Whenthereisalullinactivityintheward,thevisitorapproachesoneofthenursesandmentionswhat shehasnoticed.Thenurseisgratefulfortheadviceandthequietperiodisusedformorethoroughcleaningofsurfaces aroundthevomitingchild.Thenursethanksthemotherforherassistanceandexplainstohertheimportanceof thoroughcleaningandhandhygieneinthepreventionoftransmissionofinfection.
Eliminating risks Ideally, this risk can be eliminated through immediate removal and cleaning of spills. However, in many situations it is more likely that the risk will be managed. Identifying risks The risk has been identified as potential cross-transmission of Norovirus through environmental contamination. Analysing risks One source of the risk has been identified as inadequate environmental cleaning by a visitor resulting in potential contamination of equipment placed on environmental surfaces (bedside table) or hands touching this surface. There is then potential for direct or indirect spread of infection to other patients, visitors and healthcare workers. There are likely to be other infectious agents that could be transmitted in the same way (e.g. Rotavirus). Evaluating risks The balance of likelihood and consequences identify this as a high risk situation requiring immediate response. Treating risks Immediate measures may include raising patient and visitor awareness of hygiene measures (including hand hygiene as well as environmental cleaning). This could be done through posters and/or discussion with patients/carers on admission. Longer-term measures could include revision and implementation of environmental cleaning policies and involvement of patients/visitors in this review. Monitoring Changes in practice could be monitored through observation of patient/visitor behaviour.
CONSULTATIONDRAFTJANUARY2010 B1.5 B1.5.1 PROCESSING OF INSTRUMENTS AND EQUIPMENT What are the risks?
Anyinfectiousagentsintroducedintothebodycanestablishinfection.Inallhealthcaresettings,instruments andequipmentshouldbehandledinamannerthatwillpreventpatient,healthcareworkerand environmentalcontactwithpotentiallyinfectiousmaterial.Equipmentandinstrumentsmustbecleanedand maintainedincompliancewithguidelinesandanystate/territoryregulations,andtakingintoaccount manufacturersinstructions. InstrumentsandequipmentrequiringspecialprocessingarediscussedinSectionB4.4.2. B1.5.2 Assessing the degree of risk
Anyinstrumentorpieceofequipmentthatistobereusedrequiresprocessingcleaning,disinfection and/orsterilisation.Theminimumlevelofprocessingrequiredforreusableinstrumentsandequipment dependsontheindividualsituation(i.e.thebodysitewheretheinstrumentwillbeused). Therationalapproachtodisinfectionandsterilisationofpatientcareitemsandequipmentdevisedby Spauldingover30yearsagohasbeenretainedandrefinedandisstillsuccessfullyusedbyinfectioncontrol practitionersandotherswhenplanningmethodsfordisinfectionorsterilisation(CDC2008).Thesystemis basedoninstrumentsanditemsforpatientcarebeingcategorisedintocritical,semicriticalandnoncritical, accordingtothedegreeofriskforinfectioninvolvedinuseoftheitems.

Table B1.13: Categories of items for patient care
Critical These items confer a high risk for infection if they are contaminated with any microorganism and must be sterile at the time of use. This includes any objects that enter sterile tissue or the vascular system, because any microbial contamination could transmit disease. Semi-critical These items contact mucous membranes or non-intact skin, and should be single use or sterilised after each use. If this is not possible, high-level disinfection is the minimum level of reprocessing that is acceptable. Non-critical These items come in contact with intact skin but not mucous membranes. Thorough cleaning is sufficient for most non-critical items after each individual use, although either intermediate or low-level disinfection may be appropriate in specific circumstances.
Computersandpersonaldigitalassistantsusedinpatientcareshouldbeincludedinpoliciesforcleaning anddisinfectingnoncriticalitems.Althoughkeyboardcoversandwashablekeyboardsthatcanbeeasily disinfectedareinuse,theinfectioncontrolbenefitofthoseitemsandoptimalmanagementhavenotbeen determined. B1.5.3 Cleaning
Cleaningistheremovalofforeignmaterial(e.g.soilandorganicmaterial)fromobjectsandisnormally accomplishedusingdetergentsolution. Cleaningtoremoveorganicmaterialmustalwaysprecedehighleveldisinfectionandsterilisationofcritical andsemicriticalinstrumentsanddevicesbecauseresidualproteinaceousmaterialreducestheeffectiveness ofthedisinfectionandsterilisationprocesses.Ifanitemcannotbecleaned,itcannotbedisinfectedor sterilised. Instrumentsshouldbecleanedassoonaspracticalafteruse(e.g.preferablyatthepointofuse)beforesoiled materialsbecomedriedontotheinstruments.Driedorbakedmaterialsontheinstrumentmaketheremoval processmoredifficultandthedisinfectionorsterilisationprocesslesseffectiveorineffective.
B1.5 Processing of instruments and equipment 63
Methods of cleaning
Automated Automatedcleaners(ultrasoniccleanersandwasherdisinfectors)reducethehandlingofinstrumentsand arerecommendedforcleaningbasicinstrumentsthatcanwithstandtheprocess. Ultrasoniccleanersworkbysubjectinginstrumentstohighfrequency,highenergysoundwaves,thereby looseninganddislodgingdirt. Washerdisinfectorsusedetergentsolutionsathightemperaturestowashinstruments.Whenawasher disinfectorisused,careshouldbetakeninloadinginstruments:hingedinstrumentsshouldbeopened fullytoallowadequatecontactwiththedetergentsolution;stackingofinstrumentsinwashersshouldbe avoided;andinstrumentsshouldbedisassembledasmuchaspossible. Manual Cleaningisdonemanuallyforfragileordifficulttocleaninstrumentsandinareaswithoutautomaticunits. Thetwoessentialcomponentsofmanualcleaningare:
frictionrubbing/scrubbingthesoiledareawithasoftbrush;and fluidicsuseoffluidstoremovesoilanddebrisfrominternalchannelsafterbrushingandwhenthe
designdoesnotallowpassageofabrushthroughachannel. HealthcareworkersshouldwearappropriatePPEforthetaskplasticapron,utilityglovesandface protection(protectiveeyewearandmaskorfaceshield).Careshouldbetakentopreventsplashingof mucousmembranesorpenetrationoftheskinbysharpinstruments.
Cleaning agents
Forinstrumentcleaning,aneutralornearneutralpHdetergentsolutioniscommonlyusedassuchsolutions generallyprovidethebestmaterialcompatibilityprofileandgoodsoilremovalandmildlyacidicsolutions maydamageinstruments. Enzymes,usuallyproteases,aresometimesaddedtoneutralpHsolutionstoassistinremovingorganic materialsuchasbloodandpus.Cleaningsolutionscanalsocontainlipases(enzymesactiveonfats)and amylases(enzymesactiveonstarches).Enzymaticcleanersarenotdisinfectants,andproteinaceousenzymes canbeinactivatedbygermicides. Aswithallchemicals,enzymesmustberinsedfromtheequipmentoradversereactionscouldresult.

Checking effectiveness of cleaning
Duringthepastfewyears,datahavebeenpublisheddescribinguseofanartificialsoil,protein,endotoxin, Xraycontrastmedium,orblood,toverifymanualorautomatedcleaningprocessesandadenosine triphosphatebioluminescenceandmicrobiologicsamplingtoevaluatetheeffectivenessofenvironmental surfacecleaning(CDC2008).However,thesearenotusedroutinelyinmosthealthcarefacilities. Ataminimum,allinstrumentsshouldbeindividuallyinspected(withmagnificationwherepossible)andbe visiblyclean. B1.5.4 Disinfection
Disinfectionisaprocessthatinactivatesnonsporinginfectiousagents,usingeitherthermal(moistordry heat)orchemicalmeans.Itemsneedtobecleanedbeforebeingdisinfected. Instrumentsshouldberemovedfromthedisinfectantafterreprocessingandstoreddry.Topreservethe surfacesoftheinstruments,dissimilarmetalsshouldbeseparatedbeforecleaning. Thermaldisinfectionifitemscanwithstandheatandmoistureanddonotrequiresterilisation,thermal disinfectionusingheatandwater,attemperaturesthatdestroyinfectiousagents,isthesimplest,most efficientandcosteffectivemethodofdisinfection.Itcanbeachievedinanautomatedthermalwasher disinfectorbychoosingtheappropriatecycle.
ChemicaldisinfectioncanbeachievedwithacompatibleTherapeuticGoodsAdministration(TGA)
registeredinstrumentgradedisinfectantoftherequiredlevel,usedaloneortogetherwithanautomated
CONSULTATIONDRAFTJANUARY2010 washerdisinfector.Chemicaldisinfectantsincludealcohols,chlorineandchlorinecompounds, formaldehyde,hydrogenperoxide,phenolicsandquaternaryammoniumcompounds.Commercial formulationsbasedonthesechemicalsareconsidereduniqueproductsandmustberegisteredwithTGA. Inmostinstances,eachproductisdesignedforaspecificpurpose;therefore,usersshouldreadlabels carefullytoensurethecorrectproductisselectedfortheintendeduseandappliedefficiently. Therearethreelevelsofdisinfection,dependingontheintendeduseoftheinstruments. Disinfectionisnotasterilisingprocess.Whereverpossible,steriliseitemstobeusedinsemicriticalsites,or employsingleuseitems. B1.5.5 Sterilisation
Sterilisationdestroysallmicroorganismsonthesurfaceofaninstrumentordevice,topreventdisease transmissionassociatedwiththeuseofthatitem.Whiletheuseofinadequatelysterilisedcriticalitems representsahighriskoftransmittinginfectiousagents,documentedtransmissionassociatedwithan inadequatelysterilisedcriticalitemisrare.Thisisprobablyduetothewidesafetymarginassociatedwith thesterilisationprocessesusedinhealthcarefacilities. Ifcriticalitemsareheatresistant,therecommendedsterilisationprocessissteamsterilisation,becauseit hasthelargestmarginofsafetyduetoitsreliability,consistencyandlethality. Reprocessingheatandmoisturesensitiveitemsrequiresuseofalowtemperaturesterilisation technology(e.g.ethyleneoxide,hydrogenperoxideplasma,peraceticacid). Sterilisationmethodsaredesignedtogiveasterilityassurancelevel(SAL)ofatleast106,providedthe sterilisationprocessisvalidatedbytheuser.Recordsofsterilisationmustalsobekept;theseenableitemsto betracedtoanindividualpatient(e.g.incaseofarecallorsterilisationbreachidentifiedafterthecase). DetailsofthedocumentationrequiredcanbefoundinAustralianStandardsAS/NZS4187andAS/NZS4815. Inthisrapidlychangingarea,processingstandardsshouldevolvetoaccommodatechangesinequipment designandemergingtechnologiesinsterilisation. B1.5.6 Storage and maintenance
Allitemsmustbestoredinawaythatthatmaintainstheirlevelofprocessing(e.g.sterile,highlevel disinfected).Dry,sterile,packagedinstrumentsandequipmentshouldbestoredinaclean,dryenvironment andprotectedfromsharpobjectsthatmaydamagethepackaging.Thisisessentialforinstrumentsand equipmentthatareintendedforuseoncriticalsitesandthatmustbesterile. Equipmentandinstrumentsurfacesshouldberegularlyexaminedforbreaksinintegritythatwouldimpair eithercleaningordisinfection/sterilisation.Equipmentthatnolongerfunctionsasintendedorcannotbe properlycleanedanddisinfectedorsterilisedshouldberepairedordiscarded.
Table B1.14: General criteria for reprocessing and storage of equipment and instruments in healthcare settings
Level of risk *Critical Entry or penetration into sterile tissue, cavity or blood stream Process Clean thoroughly as soon as possible after using Sterilise after cleaning by steam under pressure If heat or moisture sensitive, sterilise through an automated low temperature chemical sterilant system, other liquid chemical sterilants or ethylene oxide sterilisation Example Invasive surgical and dental equipment e.g. surgical oral instruments, arthroscopes, laparoscopes, rigid and flexible bronchoscopes, heat stable scopes Cardiac and urinary catheters, implants and ultrasound probes used in sterile body cavities Storage Sterility must be maintained: packaged items must go through a drying cycle and then be checked to ensure drying has taken place before use or storage the integrity of the wrap must be maintained wraps should act as an effective biobarrier during storage unpackaged sterile items must be used immediately (without contamination in transfer from steriliser to site of use) or resterilised Semi-critical Contact with intact mucous membranes or non- intact skin Clean thoroughly as soon as possible after using Steam sterilisation is preferable If the equipment will not tolerate steam use a high level chemical or thermal disinfectant Respiratory therapy and anaesthesia equipment, some endoscopes, vaginal speculae, laryngoscope blades, oesophageal manometry probes, cystoscopes, anorectal manometry catheters, diaphragm fitting rings, routine dental instruments Non-critical Contact with intact skin Clean as necessary with detergent solution If decontamination necessary, disinfect with compatible low or intermediate level TGAregistered disinfectant after cleaning Stethoscopes, sphygmomanometers, blood pressure cuffs, mercury thermometers, non-invasive ultrasound probes Commodes, intravenous pumps and ventilators Store in a clean dry place to prevent environmental contamination Store to prevent environmental contamination
Notes: Criticalitems,particularlyendoscopes,mustbesterilisedbetweenpatientuses. Aninvasiveprocedureisdefinedasentryintotissues,cavitiesororgansorrepairoftraumaticinjuries. Source: CDC(2008)GuidelinefortheDisinfectionandSterilizationinHealthcareFacilities2008. Further considerations:
Steamsterilisationandtheothermethodslistedabovearenotsufficientforreprocessingitemspotentially contaminatedwithcertaintypesofinfectiousagents.Thisincludesprions,suchascCJD,forwhichsingle useitemsshouldbeusedwhereverpossibleandsubsequentlydestroyedbyincineration.Otheritemsshould bequarantinedorkeptforexclusiveuseonanindividualpatientand: immersedinadedicatedcontainercontainingsterilewateruntilreprocessed; cleanedinanionicdetergentsolutionpriortofurtherreprocessing;and reprocessedusingsteamsterilisationat134Cfor3minutes.

CONSULTATIONDRAFTJANUARY2010 ForfurtherinformationoninfectioncontrolrelatingtocCJD,referto http://www.health.gov.au/internet/main/publishing.nsf/Content/icgguidelinesindex.htm. B1.5.7 Putting it into practice
Individual actions for reducing risk

Become familiar with standards and facility protocols on cleaning, disinfecting and sterilising Use the appropriate product for the situation and use it as directed Participate in education sessions and professional development sessions on reprocessing instruments and equipment, particularly when new sterilising or disinfecting equipment is introduced.
Thefollowinginformationmaybeprovidedtopatientstoassisttheminbecominginvolvedinidentifying andreducingrisksrelatedtoprocessingofinstrumentsandequipment.
Many instruments and equipment in the hospital are reusable All reusable instruments and equipment are cleaned thoroughly and then either disinfected or sterilised before being used on the next patient. The system for cleaning, disinfecting and sterilising instruments and equipment protects patients and health care workers from contact with potentially infectious material. Any instrument that enters a part of the body (e.g. in surgery) is sterilised and completely free of all potentially harmful organisms Any instrument that goes inside the nose, mouth or other orifice, or touches broken skin, is either sterilised or disinfected to a high level. Any equipment that touches the patient or is touched by the patient, is cleaned thoroughly and if necessary disinfected. Its okay to ask about the cleaning and sterilising practices in the hospital
CONSULTATIONDRAFTJANUARY2010 Risk management case study Apatientattendsadentalsurgeryforascalingandcleaningofhisteeth.Hehasmoderateperiodontaldiseasewith inflamedgingiva(gums).Thedentistusesbothanultrasonicscaler(whichcreatesaerosol)andverysharphandscalers andcurettes.Neitherthedentistnortheassistantwearsamask.Toprotectthetongueandcheeksofthepatientfrom beinginjuredbythesharpinstruments,adentalmirrorisusedtoretractthem.Themirrorconsistsofahandleinto whichamirrorheadisscrewed.Thehandleofthemirrorhasacorrugatedsurfacesothatitdoesntslip.Duringthis procedurethemirrorgetscoveredinbloodfromthebleedingoftheinflameddiseasedgums.
Eliminating risks Proper reprocessing of the instrument, operator and assistant care in the use of sharp instruments and protecting against possible aerosol exposure has the potential to eliminate the risk. Identifying risks There is a risk of exposure of other patients to bloodborne viruses if the mirror is not reprocessed properly (i.e. still has blood on it or if the mirror head was constantly loose during the procedure). There is also a risk of exposure of staff to aerosol infectious agents (influenza in particular) and a risk of staff exposure to bloodborne viruses through sharps injury (either during the treatment or during reprocessing). Analysing risks Sources of the risk are difficulties in reprocessing the mirror, the use of multiple sharp instruments in a bloody field and aerosolisation caused by the treatment. Evaluating risks The balance of likelihood and consequences identify this as a medium risk situation requiring management by specific monitoring or audit procedures. Treating risks Immediate measures include making sure that mirror handles are clean before sterilisation, operator care in the use of sharp instruments, use of high volume evacuation to reduce aerosolisation caused by this treatment and wearing of masks by operator and assistant. Longer-term measures could include revising practice PPE and instrument cleaning and reprocessing policies. Monitoring Repeated checking of reprocessed instruments, audits of staff sharps injuries and monitoring of PPE use would assist in assessing of the level of risk on an ongoing basis.
CONSULTATIONDRAFTJANUARY2010 B2 TRANSMISSION-BASED PRECAUTIONS
Summary The aim of instituting early transmission-based precautions is to reduce further transmission opportunities that may arise due to the specific route of transmission of a particular pathogen. While it is not possible to prospectively identify all patients needing transmission-based precautions, in certain settings, recognising an increased risk warrants their use while confirmatory tests are pending (see Table B2.2, page 82). Transmission-based precautions are applied in addition to standard precautions. Table B2.3 (see page 83) outlines recommended precautions for specific infectious agents.
When transmission-based precautions are applied during the care of an individual patient, there is potential for adverse effects such as anxiety, mood disturbances, perceptions of stigma and reduced contact with clinical staff. Clearly explaining to patients why these precautions are necessary may help to alleviate these effects. Evidence supporting practice
Themajorityoftherecommendationsinthissectionhavebeenadaptedfrom: 10 UnitedStatesCentersforDiseaseControlandPrevention(CDC)GuidelineforIsolationPrecautions: PreventingTransmissionofInfectiousAgentsinHealthcareSettings(2007);and Prattetal(2007)Epic2:NationalEvidenceBasedGuidelinesforPreventingHealthcareAssociatedInfectionsin NHSHospitalsinEngland. Furtherreviewoftheevidenceconcerningcertainaspectsofimplementationoftransmissionbased precautionsallowedthedevelopmentofrecommendationsandgoodpracticepointsspecifictothe Australiancontext.Literaturereviewsconductedaspartofthedevelopmentoftheseguidelinesorthatwere releasedduringtheguidelinedevelopmentprocessidentifiedthefollowing: 11 goodqualityevidenceontheuseofalcoholbasedhandrubsinreducingtransmissionofinfectious agents; alackofhumanclinicaltrialsintothebenefitofP2(N95)respiratorsinreducingtheriskoftransmission ofinfluenza;and apaucityofstudiesevaluatingtheeffectivenessofnegativepressureroomsinreducingthetransmission ofinfectiousagentsinhealthcaresettings.
10
11
Duetoapaucityofevidenceorlowqualityevidencesomesystematicreviewswerenotusedtodraft recommendations.ThereportsofthosereviewsthatwereusedareavailablefromtheNHMRCuponrequest.
B2.1 Application of transmission-based precautions 69
CONSULTATIONDRAFTJANUARY2010 B2.1 B2.1.1 APPLICATION OF TRANSMISSION-BASED PRECAUTIONS What are the risks?
Transmissionofinfectiousagentscanoccurinanumberofways. Indirectordirectcontacttransmission,whenhealthcareworkerhandsorclothingbecomecontaminated, patientcaredevicesaresharedbetweenpatients,infectiouspatientshavecontactwithotherpatients,or environmentalsurfacesarenotregularlydecontaminated. Droplettransmission,whenhealthcareworkershandsbecomecontaminatedwithrespiratorydroplets andaretransferredtosusceptiblemucosalsurfacessuchastheeyes,wheninfectiousrespiratorydroplets areexpelledbycoughing,sneezingortalking,andareeitherinhaledorcomeintocontactwithanothers mucosa(eyes,noseormouth),eitherdirectlyintoorviacontaminatedhands. Airbornetransmission,whenattendinghealthcareworkersorothersinhalesmallparticlesthatcontain infectiousagents. Transmissionbasedprecautionsinvolvetheuseofthefollowingmeasurestopreventtransmissionofthe infectiousagent: useofpersonalprotectiveequipment(includinggloves,apronorgowns,andsurgicalorP2(N95) respirators,visorsorprotectivegoggles); dedicatedpatientequipment; allocationofsingleroomsorcohortingofpatients; appropriateairhandlingrequirements; enhancedcleaninganddisinfectingofthepatientenvironment;and restrictedtransferofpatientswithinandbetweenfacilities. Fordiseasesthathavemultipleroutesoftransmission,morethanonetransmissionbasedprecaution categoryisapplied.Whetherusedsinglyorincombination,transmissionbasedprecautionsarealways appliedinadditiontostandardprecautions.Transmissionbasedprecautionsremainineffectforlimited periodsoftimeuntilsignsandsymptomsoftheinfectionhaveresolvedoraccordingtorecommendations frominfectioncontrolpractitionersspecifictotheinfectiousagent(seeTableB2.2,page82).
B2 Transmission-based precautions 70
CONSULTATIONDRAFTJANUARY2010 B2.2 B2.2.1 CONTACT PRECAUTIONS What are the risks?
Thereisclearevidencethatcertaininfectiousagentsaretransmittedbydirectorindirectcontactduring patientcare. Directtransmissionoccurswheninfectiousagentsaretransferredfromonepersontoanotherperson withoutacontaminatedintermediateobjectorperson.Forexample,bloodorotherbodyfluidsfroman infectiouspersonmaycomeintocontactwithamucousmembraneorbreaksintheskinofanotherperson (Rosen1997;Beltramietal2003). Indirecttransmissioninvolvesthetransferofaninfectiousagentthroughacontaminatedintermediateobject (fomite)orperson.Contaminatedhandsofhealthcareworkershavebeenshowntobeimportant contributorstoindirectcontacttransmission(Boyce&Pittet2002;Bhallaetal2004;Duckroetal2005).Other opportunitiesforindirectcontacttransmissioninclude: whenclothingbecomescontaminatedaftercareofapatientcolonisedorinfectedwithaninfectious agent,whichcanthenbetransmittedtosubsequentpatients(Perryetal2001,Zacharyetal2001); whencontaminatedpatientcaredevicesaresharedbetweenpatientswithoutcleaninganddisinfecting betweenpatients(Brooksetal1992;Desenclosetal2001;CDC2008);and whenenvironmentalsurfacesbecomecontaminated(seeSectionB1.4onroutineenvironmentalcleaning). B2.2.2 When should contact precautions be implemented?
Contactprecautionsareintendedtopreventtransmissionofinfectiousagentsthatarespreadbydirector indirectcontactwiththepatientorthepatientsenvironment(suchasresistantbacteria[seeSectionB3.1], C.difficile,orhighlycontagiousskininfections/infestations[e.g.impetigo,scabies]).Contactprecautionsare alsoappliedwhenthepresenceofexcessivewounddrainage,faecalincontinence,orotherbodilydischarge suggestsanincreasedpotentialforenvironmentalcontaminationandriskoftransmission. Therequirementsforcontactprecautionsaresummarisedonpage81.TableB2.2(seepage82)lists conditionswarrantingtransmissionbasedprecautionsinadditiontostandardprecautions,pending confirmationofdiagnosis.Informationaboutwhichprecautionstoapplyforspecificconditionsisgivenin TableB2.3(seepage83). RECOMMENDATION
14 Implementation of contact precautions In addition to standard precautions, implement contact precautions in the presence of known or suspected infectious agents that are spread by direct or indirect contact with the patient or the patients environment. Grade GPP
B2.2.3
How should contact precautions be applied?
Thekeyaspectsofapplyingcontactprecautionsrelateto: handhygiene(seeSectionB1.1.7)anduseofappropriatePPE; specialhandlingofequipment; patientplacement;and minimisingpatienttransferortransport.

Hand hygiene and PPE
Effectivehandhygieneisparticularlyimportantinpreventingcontacttransmissionandthe5momentsof handhygieneoutlinedinSectionB1.1.7shouldbefollowedatalltimes. Puttingonbothglovesandgownuponenteringthepatientcareareahelpstocontaininfectiousagents, especiallythosethathavebeenimplicatedintransmissionthroughenvironmentalcontamination(e.g.VRE,

B2.2 Contact precautions 71
CONSULTATIONDRAFTJANUARY2010 C.difficile,norovirusandotherintestinaltractpathogens,respiratorysyncytialvirus)(Hall&Douglas1981; CDC1995;Evansetal2002;Bhallaetal2004;Donskey2004;Duckroetal2005;Wuetal2005). Ifthereispotentialforbodyfluidsofapatientoncontactprecautionstosplashontothehealthcareworkers face,faceprotection(includingprotectiveeyewear)shouldalsobeworn. RECOMMENDATIONS

15 Hand hygiene and personal protective equipment to prevent contact transmission When working with patients who require contact precautions: 16 perform hand hygiene; put on gloves and gown upon entry to the patient care area; ensure that clothing and skin do not contact potentially contaminated environmental surfaces; and remove gown and gloves and perform hand hygiene before leaving the patient care area. Grade GPP Grade C
Hand hygiene when Clostridium difficile is suspected or known to be present To facilitate the mechanical removal of spores, meticulously wash hands with soap and water and pat dry with single-use towels. Use of alcohol-based hand rubs alone may not be sufficient to reduce transmission of Clostridium difficile.
Single-use or dedicated patient care equipment
Standardprecautionsconcerningpatientcareequipment(seeSectionB1.5)areveryimportantinthecareof patientsoncontactprecautions.Ifpatientcaredevices(e.g.bloodpressurecuffs,nebulisers,mobilityaids) aresharedbetweenpatientswithoutbeingreprocessedbetweenuses,theymaytransmitinfectiousagents (Brooksetal1992;Desenclosetal2001;CDC2008). RECOMMENDATION

17 Patient care equipment for patients on contact precautions Use patient dedicated equipment or single-use non-critical patient care equipment (e.g. blood pressure cuffs). If common use of equipment for multiple patients is unavoidable, clean the equipment and allow it to dry before use on another patient. Patient placement Grade C
Asinglepatientroomisrecommendedforpatientswhorequirecontactprecautions.Whenasinglepatient roomisnotavailable,consultationwithinfectioncontrolpractitionersisrecommendedtoassessthevarious risksassociatedwithotherpatientplacementoptions(e.g.cohorting). Ifitisnecessarytoplaceapatientwhorequirescontactprecautionsinaroomwithapatientwhoisnot infectedorcolonised: avoidplacingthesepatientswithpatientswhoareatincreasedriskofanadverseoutcomefrominfection (e.g.patientswhoareimmunocompromised,haveopenwoundsorhaveanticipatedprolongedlengths ofstay);and changeprotectiveattireandperformhandhygienebetweencontactwithpatientsinthesameroom, regardlessofwhetheroneorbothpatientsareoncontactprecautions.
Transfer of patients
Limitingtransferofapatientoncontactprecautionsreducestheriskofenvironmentalcontamination.If transferwithinorbetweenfacilitiesisnecessary,itisimportanttoensurethatinfectedorcolonisedareasof thepatientsbodyarecontainedandcovered.ContaminatedPPEshouldberemovedanddisposedofand handhygieneperformedbeforethepatientismoved.CleanPPEshouldbeputonbeforethepatientis handledatthedestination. Risk-management case study

Klebsiella pneumoniae sepsis in a neonatal unit
Duringa7monthperiod,seveninfantsinaneonatalunitdevelopedsepticaemiafrommultiresistantextended spectrumlactamaseproducingKlebsiellapneumoniae,andtwobabiesdied.Moleculartypingrevealedthatfourofthe strainswereidentical;notallisolateswereavailablefortyping.Screeningofallbabieswasnotcarriedout,asitwas expectedthatmanywouldalreadybecolonised,andthatbabieswhosegutwascolonisedbythebacteriawouldbethe sourceofinfectionthroughthehandsofhealthcareworkers.Theoutbreakwasbroughtundercontrolbyinservice educationandimprovementofhandhygienecompliance,andwearingofsingleusegloveswhenbabiesnappieswere beingchanged.Nursesweredeclaredtobetheadvocatesforthebabies,andthenursecaringforeachbabywas responsibleforensuringthatallattendingpersonnelperformhandhygienebeforeandafterhandlingthebaby,with noncompliancebeingreportedtotheinfectioncontrolteam.

Source: BasedonRoyleetal(1999).
Eliminating risks Identifying risks Analysing risks In this situation it is not possible to eliminate the risk entirely, so it must be managed. In this case, the risk has been identified as cross-transmission of Klebsiella pneumoniae. The major source of the risk is transmission between neonates by healthcare workers hands, with failure to wear gloves when changing nappies, and lack of appropriate hand hygiene practices by some staff members. Evaluating risks The balance of likelihood and consequences identify this as a very high risk situation requiring immediate response. Treating risks Immediate measures include implementation of contact precautions, with strict enforcement of hand hygiene, wearing of personal protective equipment (e.g. gloves), and provision of in-service education on hand hygiene. Longer-term measures might include increased frequency of environmental cleaning, performance of surveillance cultures, and cohorting of colonised babies, if the outbreak could not be brought under control by immediate measures. Monitoring Changes in rates of infection could be monitored through ongoing surveillance.
B2.2 Contact precautions 73
CONSULTATIONDRAFTJANUARY2010 B2.3 B2.3.1 DROPLET PRECAUTIONS What are the risks?
Anumberofinfectiousagentsaretransmittedthroughrespiratorydroplets(i.e.largeparticledroplets >5 micronsinsize)thataregeneratedbyapatientwhoiscoughing,sneezingortalkingorduringsuctioning orbronchoscopy.Transmissionvialargedropletsrequiresclosecontactasthedropletsdonotremain suspendedintheairandgenerallyonlytravelshortdistances(usually1metreorless).Aswell,any infectiousagenttransmittedbythedropletroutecanpotentiallybetransmittedbytouch. Dropletprecautionsarebasedonevidencethatshowsthat:
handhygieneiseffectiveinpreventingtransmissionofvirusesandreducingtheincidenceofrespiratory infectionsbothwithinandoutsidehealthcaresettings(Pittet&Boyce2001;Aiello&Larson2002;CDC 2002);
physicalinterventionsarehighlyeffectiveagainstthespreadofabroadrangeofrespiratoryviruses (Jeffersonetal2009); surgicalmasksprotectthewearerfromdropletcontaminationofthenasalororalmucosa(DoHA2006); physicalproximityoflessthanonemetrehaslongbeenassociatedwithanincreasedriskfor transmissionofinfectionsviathedropletroute(e.g.N.meningitidisandgroupAstreptococcus (Hamburger&Robertson1948;Feiginetal1982);and placingmasksoncoughingpatientsisaprovenmeansofpreventinginfectedpatientsfromdispersing respiratorysecretionsintotheair(Siegeletal2007). B2.3.2 When should droplet precautions be implemented?
Dropletprecautionsareintendedtopreventtransmissionofinfectiousagentsspreadthroughclose respiratoryormucousmembranecontactwithrespiratorysecretions.Becausethesemicroorganismsdonot traveloverlongdistances,specialairhandlingandventilationarenotrequired. Infectiousagentsforwhichdropletprecautionsareindicatedincluderespiratorysyncytialvirusand meningococcus(seeAppendices3and4). Therequirementsfordropletprecautionsaresummarisedonpage81.TableB2.2(seepage82)lists conditionswarrantingtransmissionbasedprecautionsinadditiontostandardprecautions,pending confirmationofdiagnosis.Informationaboutwhichprecautionstoapplyforspecificconditionsisgivenin TableB2.3(seepage83). RECOMMENDATION
18 Implementation of droplet precautions In addition to standard precautions, implement droplet precautions for patients known or suspected to be infected with agents transmitted by respiratory droplets (i.e. large-particle droplets >5 in size) that are generated by a patient when coughing, sneezing, talking, or during suctioning. Grade C
B2.3.3
How should droplet precautions be applied?
Thekeyaspectsofapplyingdropletprecautionsrelateto: handhygiene(seeSectionB1.1.7)anduseofpersonalprotectiveequipment; specialhandlingofequipment; patientplacement;and minimisingpatienttransferortransport.

Hand hygiene and personal protective equipment
Droplettransmissionis,technically,aformofcontacttransmissionandsomeinfectiousagentstransmitted bythedropletroutemayalsobetransmittedbycontact(Siegeletal2007).Handhygieneisthereforean
CONSULTATIONDRAFTJANUARY2010 importantaspectofdropletprecautionsandthe5momentsofhandhygieneoutlinedinSectionB1.1.7 shouldbefollowed. Althoughsurgicalmasksdonotprotectthewearerfrominfectiousagentsthataretransmittedviathe airborneroute,masksthatmeetAustralianStandardsarefluidresistantandprotectthewearerfromdroplet contaminationofthenasalororalmucosa(DoHA2006).Themaskisgenerallyputonuponroomentry. ThereisinsufficientevidencetosupporttheuseofP2(N95)respiratorsforreducingtheriskofinfections transmittedbythedropletroute. Indirectlyventedgogglesprovidethemosteyeprotectionfromrespiratorydropletsfrommultipleangles. RECOMMENDATION
19 Personal protective equipment to prevent droplet transmission When entering the patient care environment, put on a surgical mask. Placement of patients on droplet precautions Grade C
Placingpatientsondropletprecautionsinasinglepatientroomreducestheriskofpatienttopatient transmission.Whensinglepatientroomsareinshortsupply,thefollowingprinciplesapplyindecision makingonpatientplacement: prioritisepatientswhohaveexcessivecoughandsputumproductionforsinglepatientroomplacement; and placetogetherinthesameroom(cohort)patientswhoareinfectedwiththesamepathogenandare suitableroommates. Ifitbecomesnecessarytoplacepatientswhorequiredropletprecautionsinaroomwithapatientwhodoes nothavethesameinfection: avoidplacingpatientsondropletprecautionsinthesameroomwithpatientswhohaveconditionsthat mayincreasetheriskofadverseoutcomefrominfectionorthatmayfacilitatetransmission(e.g.those whoareimmunocompromised,haveorhaveanticipatedprolongedlengthsofstay);and ensurethatpatientsarephysicallyseparated(>1metreapart)fromeachotheranddrawtheprivacy curtainbetweenbedstominimiseopportunitiesforclosecontact. Inallcases,theimportanceofcoughetiquetteshouldbeexplainedtopatientsondropletprecautions(see TableB1.1). RECOMMENDATION
20 Placement of patients requiring droplet precautions Place patients who require droplet precautions in a single-patient room when available. Transport of patients on droplet precautions Grade GPP
Whentransferofapatientondropletprecautionswithinorbetweenfacilitiesisnecessary,thereisthe potentialforotherpatientsandhealthcareworkerstocomeincontactwithinfectiousagentswhenthe patientcoughsorsneezes.Thiscanbeaddressedbyaskingthepatienttowearamaskwhiletheyarebeing transferredandtofollowcoughetiquette. Risk management case study Aclusterofcasesofinfluenzaoccurredinalongtermagedcarefacilitywhenprotectionmeasuresagainstaheatwave wereimplemented,namelyresidentsspendingthewholedayinanairconditioneddiningroom.Morecasesoccurred overthefollowingsixdays,latercasesbeingfoundchieflyamongthenursingstaff.Influenzawassuspectedand provisionallyconfirmedbyarapiddiagnostictestperformedonspecimensfromfourpatients. Inall,39.5%residents
B2.3 Droplet precautions 75
CONSULTATIONDRAFTJANUARY2010 showedsignsmeetingthecasedefinitionand12.5%ofstaffwhowereincontactwiththeresidentsduringtheoutbreak developedrespiratorysymptomswithfever.Thecasefatalityrateintheresidentswas15.6%. Thevaccinationcoverageofthestaffwas41.7%.Noneofthestaffmemberswithinfluenzasymptomshadbeen immunised.

Source: BasedonGaillatetal(2008).
Eliminating risks Identifying risks Analysing risks In this situation, it is not possible to eliminate risk immediately, so it must be managed. In this case, the risk has been identified as cross-transmission of influenza. One source of the risk is the assembling of all residents in a confined, air-conditioned area, which probably led to an unusually efficient spread of the virus affecting all residents irrespective of their normal location within the establishment. Low levels of staff immunisation also contributed to the spread of the infection. Evaluating risks The balance of likelihood and consequences identify this as a very high risk situation requiring immediate response. Treating risks Immediate measures may include establishment of an outbreak management team, diagnostic investigations and antiviral treatment of residents, isolation of sick residents, wearing of surgical masks by residents and staff, educating residents and visitors in cough etiquette, and asking sick staff members to stay home. In the longer term, encouraging staff to become immunised would reduce the risk of crosstransmission. Alternative measures in response to high temperatures might also be investigated. Monitoring Ongoing monitoring of resident symptoms may lead to earlier diagnosis and treatment and lower risk of an outbreak.
CONSULTATIONDRAFTJANUARY2010 B2.4 B2.4.1 AIRBORNE PRECAUTIONS Why are airborne precautions important?
Certaininfectiousagentsaredisseminatedthroughairbornedropletnucleiorsmallparticlesinthe respirablesizerangethatremaininfectiveovertimeanddistance. Airborneprecautionsarebasedonevidencethatshowsthat: theuseofP2(N95)respiratorspreventstheinhalationbythewearerofsmallparticlesthatmaycontain infectiousagentstransmittedviatheairborneroute(DoHA2006); theuseofnegativepressureroomsmayalsoreducethetransmissionofinfection;and wearingofcorrectlyfittedmasksbycoughingpatientspreventsdispersalofrespiratorysecretionsinto theair(Siegeletal2007). B2.4.2 When should airborne precautions be implemented?
Airborneprecautionspreventtransmissionofmicroorganismsthatremaininfectiousovertimeanddistance whensuspendedintheair.Theseagentsmaybeinhaledbysusceptibleindividualswhohavenothadface tofacecontactwith(orbeeninthesameroomas)theinfectiousindividual. Infectiousagentsforwhichairborneprecautionsareindicatedincluderubeolavirus(measles),varicella virus(chickenpox)andM.tuberculosis. Therequirementsforairborneprecautionsaresummarisedonpage81.TableB2.2(seepage82)lists conditionswarrantingtransmissionbasedprecautionsinadditiontostandardprecautions,pending confirmationofdiagnosis.Informationaboutwhichprecautionstoapplyforspecificconditionsisgivenin TableB2.3(seepage83). RECOMMENDATION
21 Implementation of airborne precautions In addition to standard precautions, implement airborne precautions for patients known or suspected to be infected with infectious agents transmitted person-toperson by the airborne route (i.e. airborne droplet nuclei or particles <5 in size). Grade B
B2.4.3
How should airborne precautions be applied?
Thekeyaspectsofapplyingairborneprecautionsrelateto: handhygieneandcoughetiquette(seeSectionB1.1); useofappropriatepersonalprotectiveequipment(particularlycorrectlyfittedmasks);and minimisingexposureofotherpatientsandstaffmemberstotheinfectiousagent.

Personal protective equipment
Whenthereisahighprobabilityofairbornetransmissionduetotheinfectiousagentorprocedure,sound scientificprinciplessupporttheuseofP2(N95)respiratorstopreventtransmission(seealsoTableB1.6;page 38).Respiratorsaredesignedtohelpreducethewearersrespiratoryexposuretoairbornecontaminantssuch asparticles,gasesorvapours.N95referstotherespiratorbeingcertifiedtoexclude95%ofnonoilbased sodiumchlorideparticles,sizedat0.3micronsindiameter.TobeeffectiveP2(N95)respiratorsmustfitso thatinhaledandexhaledairtravelsthroughthefiltermedium. Theneedforpersonalprotectiveequipmentvarieswiththeconditioninquestionandtheimmunestatusof thehealthcareworker.Forexample,ifitisconfirmedthatapatienthasmeaslesandthehealthcareworkeris hasknownantibodiesagainstmeaslesthenuseofaP2(N95)respiratorisnotrequired.Forhighrisk proceduressuchasbronchoscopywheretheriskofdropletandairborneinfectionishigh,aP2(N95) respiratorshouldbeworniftheinfectiousstatusofthepatientisunknownorunconfirmed.
B2.4 Airborne precautions 77
CONSULTATIONDRAFTJANUARY2010 ConsiderationswhenusingP2(N95)respiratorinclude(DoHA2006): ifagoodfacialsealcannotbeachieved(e.g.theintendedwearerhasabeardorlongmoustache),an alternativerespiratorsuchasapoweredairpurifyingrespirator(PAPR)shouldbeused; respiratorsshouldnotbetouchedwhilebeingworn; respiratorsshouldbechangedwhentheybecomemoist; respiratorsshouldneverbereappliedaftertheyhavebeenremoved; respiratorsshouldnotbeleftdanglingaroundtheneck;and handhygieneshouldbeperformedupontouchingordiscardingausedrespirator. RECOMMENDATION
22 Personal protective equipment to prevent airborne transmission Wear a correctly fitted P2 (N95) respirator when entering the patient care area when an airborne-transmissible infectious agent is known or suspected. Patient placement Grade D
Whenpatientshaveaconfirmedorsuspectedairbornetransmissibleconditionorifnebulisationistobe performed,itisimportanttoplacetheminanareathatcanbecontained(e.g.placingtheminasingleroom and,providing itistolerated,askingthemtowearasurgicalmaskwhilenotinasingleroom,untiladvised toremoveitbyattendingstaff).Itisimportantthatthedoortotheroomremainsclosedandthat,where possible,onlystafforvisitorswhoareimmunetothespecificinfectiousagententertheroomorare providedwithappropriatePPE.Whilethereisapaucityofevidencetoconfirmtheireffectiveness,theuseof negativepressureroomsmayreducethetransmissionofairborneinfectionwithinhealthcaresettings. RECOMMENDATION

23 Placement of patients requiring airborne precautions Patients on airborne precautions should be placed in negative pressure rooms or in a room from which the air does not circulate to other areas. Exceptions to this should be justified by risk assessment. Transfer of patients Grade GPP
Iftransferofthepatientoutsidethenegativepressureroomisnecessary,askingthepatienttowearacorrectly fittedsurgicalmaskwhiletheyarebeingtransferredandtofollowcoughetiquette,aswellas coveringofanyskin lesionsassociatedwiththecondition(e.g.varicella)willreducetheriskofcrosstransmission.

M. tuberculosis among immunocompromised patients attending outpatient services
AninvestigationintothehealthcareassociatedtransmissionofM.tuberculosisfollowedreportsoftwo epidemiologicallylinkedpatients(Patient1andPatient2)withhaematologicmalignanciesandactivepulmonaryTB. SubsequentlyitwasfoundthatfouroncologypatientshadspentmorethananhourinthesameroomasPatient1. Patient1spulmonaryTBwasnotdiagnosedfor3monthsasclinicalfindingswereattributedtolowerrespiratorytract infectionfromotherinfectiousagentsoradverseeffectsofoncologytreatments.Patient1wasnotplacedonairborne precautionsduringthisperiod.TheinvestigationfoundthatdelayedTBdiagnosisinPatients1and2ultimately resultedinthetransmissionofM.tuberculosisto19patientsandstaffatthreehospitalsandaresidentialfacility.

Source: BasedonMaloneetal(2004).
Eliminating risks Identifying risks In this situation, it is not possible to eliminate risk, so it must be managed. In this case, the risk has been identified as cross-transmission of M. tuberculosis from a single patient attending a number of outpatient facilities. Analysing risks The sources of risk are a failure to consider the possibility of tuberculosis and delays in screening and diagnostic tests. These resulted in a lack of transmission-based precautions applied to Patient 1, a source of risk to subsequent patients. Evaluating risks The balance of likelihood and consequences identify this as a very high risk situation requiring immediate response. Treating risks Immediate measures may include avoidance of potential exposures in outpatient settings, implementation of airborne precautions and treatment of febrile, coughing patients with pulmonary TB. Longer-term measures could include implementation of baseline TB screening for immunocompromised patients and protocols to assist with earlier diagnosis of active disease. Further measures would include increasing awareness of tuberculosis generally, educating staff about identifying the high-risk patients for a particular facility, and development of specific protocols, such as cough protocols. Monitoring Ongoing surveillance would assist in reducing the risk of subsequent outbreaks. Retrospective review and screening of other contacts and laboratory typing of M. tuberculosis isolates to identify unrecognised, linked transmission could also inform future actions.
B2.4 Airborne precautions 79
CONSULTATIONDRAFTJANUARY2010 B2.5 PUTTING IT INTO PRACTICE
Individual actions for reducing risk

Consult with infection control practitioners to ensure that appropriate transmission-based precautions are applied and that they remain in place until the risk of transmission of the infectious agent has passed. Remember that transmission-based precautions are applied AS WELL as standard precautions. Advise patients why particular measures are needed to control infection (see above). Become familiar with local policy on appropriate personal protective equipment, and when it should be donned and doffed, when attending patients on transmission-based precautions. Make sure you know which type of mask is needed in different situations and how to check that they are properly fitted. Always contain or cover the infected or colonised areas of a patient on contact precautions before moving them from one patient care area to another. Ask patients on droplet or airborne precautions to wear a mask if they are being moved from one patient care area to another. If patients are moved to a single-patient room (contact or droplet precautions) or negative pressure room (airborne precautions) explain why this is necessary to prevent transmission of infection. Make sure you are fully immunised against vaccine-preventable diseases as recommended in the Australian Immunisation Handbook.
Thefollowinginformationmaybeprovidedtopatientstoassisttheminbecominginvolvedinidentifying andreducingrisks.
When a patient has a condition that can easily be transmitted to others, extra measures beyond normal practices to prevent and control infection are needed these are for everybodys safety. Hand hygiene is the most important aspect of preventing the spread of infection. This means everyone, including visitors, should perform hand hygiene after any contact with the patient or environment that could lead to contamination. Hand hygiene is also important for the patient, especially after activities when hands come in contact with possible sources of infection (such as blowing your nose, going to the toilet, touching infected wounds). Healthcare workers wear gloves and gowns when there is a chance that touching the patient could transmit infection. For some infections, the patient needs to wear a mask so that they do not infect others (for example when they are sneezing or coughing), especially if they are moving between patient care areas. Regular cleaning of the patients room and objects around them helps to prevent the spread of infection. If a healthcare worker might be splashed by the patients body fluids, he or she should wear face protection. Any piece of equipment that might come in contact with infectious agents is thrown away or cleaned and disinfected before it is used again. For some types of infection, it is necessary to place patients in a single room or to keep them more than a metre away from other patients. Sometimes patients with the same infection are placed in a room together. Its okay to question a healthcare worker about whether they have taken measures to prevent infection (like performing hand hygiene, wearing a gown or mask or using clean equipment).
Table B2.1: Application of standard and transmission-based precautions
Type of precautions Standard Examples of infectious agents Standard practice for all patients MROs, C. difficile, intestinal tract pathogens (e.g. norovirus), RSV, highly contagious skin infections Hand hygiene Single room or cohort Single use or reprocess before reuse on next patient Gloves Gown Mask Eye protection Handling of equipment Visitors* In general, precautions as for staff Restrict visitor number & precautions as for staff Restrict visitor number & precautions as for staff
Contact
Surgical mask if isolated from sputum
Droplet
Influenza, RSV, norovirus, pertussis (whooping cough), meningococcus
Surgical mask
Single use or reprocess before reuse on next patient
Airborne
Pulmonary TB, chickenpox1, measles1, SARS,
Negative pressure
P2 (N95) respirator
Single use or reprocess before reuse on next patient
Notes: * Visitorsshouldbegiveninstructionaboutcorrectprocedureswhentransmissionbasedprecautionsareappliedandgivenappropriateresourcestosupport theminmeetingtheserequirements. AsrequiredGlovestobewornwheneverpotentialexposuretobodyfluids;gownifcontaminationwithblood,bodyfluids,secretionsorexcretions likely;faceand/oreyeprotectionifsplashlikely(includingduringaerosolgeneratingprocedures).
Chickenpox/MeaslesifstafforvisitorHAVEHADChickenpox/Measlesinthepastorvaccinationforthesediseases,mask,gownandglovesarenotrequired ifstafforvisitorsHAVENEVERhadChickenpox/Measlesinthepastorvaccinationforthesediseases,itispreferablethattheydonotenterthisroom.Ifrequired toentertheroomuseprecautionsasabove. PulmonarytuberculosisMaskrequired.Gownandglovesrequirediflikelycontactwithbodyfluids. Source: AdaptedfromTheCanberraHospitalInpatientIsolationGuidelines
B2.5 Putting it into practice 81
Table B2.2: Infections warranting transmission-based precautions before laboratory confirmation of infection
Infection Chickenpox and shingles (varicella-zoster) Type Viral Transmission Airborne Contact CreutzfeldtJakob disease Gastroenteritis Gastroenteritis Hepatitis A Influenza (during outbreaks) Measles Prion Bacterial Viral Viral Viral Viral Contact (CNS instruments) Contact (faecal-oral) Airborne Contact (faecal-oral) Droplet Airborne Contact Meningococcal infection Bacterial Droplet Contact Norovirus Viral Contact Droplet (aerosolized vomitus) Parvovirus B19 Respiratory syncytial virus Viral Viral Droplet Contact (oral, fomites) Droplet Rotavirus Rubella Viral Viral Contact (faecal-oral) Droplet Contact SARS Viral Droplet Contact Staphylococcal infection Bacterial Contact Droplet Tuberculosis Viral haemorrhagic fevers Whooping cough (pertussis) Bacterial Viral Bacterial Airborne Contact Droplet
Table B2.3: Type and duration of precautions for specific infections and conditions
DISEASE TYPE OF INFECTION TTRTRANSMISSION ROUTE PRECAUTIONS DURATION OF PRECAUTIONS SPECIAL REQUIREMENTS FOR HCWs Immunocompromised IMMUNISATION/ TESTING OF HEALTHCARE WORKERS
TYPE S= standard C=contact D=droplet A=airborne

Chickenpox and shingles (Varicella-Zoster Virus) Viral (enveloped) Contact; airborne C,A
TARGET
Non-immune
All patients
Until all lesions dry and crusted over
Pregnant
Infected
Screen by history and serology; preemployment Varicella vaccine. ZIG postexposure prophylaxis may be indicated (if pregnant) Susceptible healthcare workers must not attend the patient.
Clostridium difficile
Bacterial
Contact
All patients
Duration of illness
Creutzfeldt-Jakob disease (CJD)
Prion
Iatrogenic (CNS, instruments); grafts, hormones; zoonotic (vCJD)
Cryptosporidium Cytomegalovirus (CMV) infection
Protozoan Viral (enveloped)
Contact Contact (mucosal)
C S
All patients None
Duration of illness
Pregnant healthcare workers may be tested

Gastroenteritis - bacterial (Salmonella, Shigella, Campylobacter) Bacterial Contact C
TARGET
Non-immune
Faecally incontinent Duration of illness patients single room with ensuite desirable
Hepatitis A
Viral (nonenveloped)
Contact
Incontinent patients single room with ensuite desirable
Pregnant Immunise if at high risk; provide hepatitis A vaccine or normal human immunoglobulin (NHIG) post-exposure as recommended Immunise and test all healthcare workers. Blood incident protocol Blood incident protocol Blood incidents: protocol applies; postexposure prophylaxis if indicated
For 7 days after onset of jaundice
Hepatitis B
Viral (enveloped)
Bloodborne
None
Hepatitis C
Viral (enveloped)
Bloodborne
None
Herpes simplex virus infection
Viral (enveloped)
Contact (droplet, fomites, lesions)
Patients with lesions; healthcare workers with lesions
Human Immunodeficiency Virus (HIV)
Viral (enveloped)
Bloodborne
Patients with complicating conditions (e.g. tuberculosis)
Infected

Infectious mononucleosis (glandular fever) Influenza Viral (enveloped) Viral (enveloped) Saliva via oropharyngeal route Contact; droplet C,D S
TARGET
Non-immune
none
All patients during outbreak
Until 3-5 days from onset of illness, longer in children
Pregnant
Infected
Annual immunisation recommended
Legionellosis (Legionnaires Disease)
Bacterial
Aerosolised contaminated water (not person to person)
None
Listeriosis
Bacterial
Usually via contaminated foods
None
Measles
Viral (enveloped)
Contact; droplet (respiratory secretions)
All patients
Until 4 days after rash appears
Screen by history/serology; preemployment measles, mumps, rubella vaccine (MMR) if not pregnant
Meningococcal infection
Bacterial
Droplet
All patients
For 24 hours after beginning treatment
Immunisation possible in outbreaks. Postexposure prophylaxis if indicated

Mumps Viral (enveloped) Contact; droplet (respiratory secretions) C,D
TARGET
Non-immune
All patients
Until 9 days after onset of swelling. Exposed nonimmune people should be considered infectious from 12th25th day after exposure, with or without symptoms
Pregnant Screen by serology; preemployment MMR if not pregnant Pre-employment booster/vaccination recommended; postexposure prophylaxis for healthcare worker in late pregnancy and high risk areas
Norovirus
Contact; sometimes airborne Droplet
Faecally incontinent Duration of illness patients
Parvovirus B19 Infection
All patients
Pediculosis (head, body lice) Pertussis (Whooping cough)
Arthropod infestation Bacterial
Contact (skin to skin, hair brushes) Droplet
All patients
All patients
Until 5 days after treatment commenced; Single patient room preferred
Infected

Rotavirus gastroenteritis Viral (nonenveloped) Rubella Viral (enveloped) Contact; droplet D Contact; droplet C
TARGET
Non-immune
All patients
Duration of illness

Screen by serology; preemployment MMR if not pregnant; non-immune pregnant staff should not attend patient
All patients
Until 7 days after onset of rash
Scabies
Arthropod infestation
Contact (skin to skin)
All patients
Until 24 hours after treatment
Severe Acute Respiratory Syndrome (SARS)
Viral (enveloped)
Contact; droplet; airborne
C,D,A
All patients
Duration of illness + 10 days after resolution of fever, provided respiratory symptoms are absent or improving
Staphylococcal infection
Bacterial
Contact
S for MSSA contain wound drainage; C for MRSA
Pregnant Screen for exfoliative skin conditions
MRSA: all patients, with predisposing skin conditions
Duration of illness for draining wound
unless unable to healthcare workers
Infected

Streptococcal infection (Group A) Bacterial Contact Droplet if respiratory infection C for draining wound if unable to contain; D for respiratory infections
TARGET
Non-immune
Patients excreting large amount of organism, or with respiratory tract infections. Skin and wound infections.
24 hours after commencement of treatment
Tuberculosis
Bacterial
Airborne
All patients with smear-positive pulmonary TB
Usually after 1 week of treatment and 3 sputum smears negative consult with respiratory physician
Pregnant Pre-employment, screening. Regular screening for at-risk healthcare workers/ BCG may be offered in specific situations
Viral haemorrhagic fevers (VHF)
Viral (enveloped)
Blood or body fluids (mucosal, parenteral). Lassa fever: aerosols
S,D,C
All patients. Contact state/territory quarantine officer. Get advice from health authorities
Duration of illness; isolation room
Varicella Zoster Virus see Chickenpox Vancomycin-resistant Enterococcus (VRE) Bacterial Contact C All patients; single room for faecally incontinent patients B2 Transmission-based precautions 88 Duration of illness
Infected
CONSULTATIONDRAFTJANUARY2010 B3 MANAGEMENT OF RESISTANT ORGANISMS AND OUTBREAK SITUATIONS
Summary Effective hand hygiene is the most important measure to prevent and control the spread of multi-resistant organisms (MROs). Rigorous adherence to hand hygiene is also integral to any outbreak control and management program. The application of transmission-based precautions is particularly important in containing MROs such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and multiresistant Gram-negative bacteria (MRGN) (see Section B3.1). Transmission-based precautions are also an integral part of outbreak management (see Section B3.2). Specific precautions required for each infectious agent are listed in Table B2.3 (see page 83).
When a patient is infected or colonised with an MRO or involved in an outbreak, there is potential for adverse effects such as anxiety, mood disturbances, perceptions of stigma and reduced contact with clinical staff. Clearly explaining to patients the measures being undertaken and why they are necessary may help to alleviate these effects. Evidence supporting practice
ThemajorityoftherecommendationsinthissectionhavebeenadaptedfromUnitedStatesCentersfor DiseaseControlandPrevention(CDC)ManagementofMultidrugResistantOrganismsinHealthcareSettings (2006). 12 FurtherreviewoftheevidenceconcerningthemanagementofMROsallowedthedevelopmentof recommendationsandgoodpracticepointsspecifictotheAustraliancontext.Literaturereviewsconducted aspartofthedevelopmentoftheseguidelinesorthatwerereleasedduringtheguidelinedevelopment processidentifiedthefollowing: goodqualityevidenceontheuseofalcoholbasedhandrubsinreducingtransmissionofMROs; apaucityofevidenceregardingtheuseofPPEforpreventingthetransmissionofMRSAandVRE; apaucityofprospectivelydesignedexperimentalstudiesintotheeffectivenessofpatientisolationin reducingtransmissionofMROs; lackofevidenceregardingthevalueofscreeningforMROsintheabsenceofimplementationofother infectioncontrolmeasures;and apaucityofevidenceconcerningroutinescreeningofhealthcareworkersforMRSAcolonisation.
12
B3 Management of resistant organisms and outbreak situations 89
CONSULTATIONDRAFTJANUARY2010 B3.1 B3.1.1 MANAGEMENT OF MULTI-RESISTANT ORGANISMS What are the risks?
MROs,whicharepredominantlybacteria,areresistanttomultipleclassesofantimicrobialagents.Antibiotic resistanceincreasesthemorbidityandmortalityassociatedwithinfections,andcontributestoincreased costsofcareduetoprolongedhospitalstaysandotherfactors,includingtheneedformoreexpensivedrugs (Struelens1998).Amajorcauseofantibioticresistanceistheexposureofahighdensity,highacuitypatient populationinfrequentcontactwithhealthcareworkerstoextensiveantibioticuse,alongwiththeattendant riskofcrossinfection(Gold&Moellering1996;Christiansenetal2008). Forthepurposeoftheseguidelines,MROsaretakentoinclude: allmethicillinresistantStaphylococcusaureusMRSAscauseuptoathirdofhospitalacquired bloodstreaminfections(Christiansenetal2008),withmortalityfromBSIrangingfrom10%to50% accordingtothesetting(Herwaldt1999); allvancomycinresistantenterococciwithmobileresistancedeterminants(e.g.VanA,VanB)theratio ofinvasiveVREinfectiontocolonisationappearstobeproportionatelylowerthanthatofMRSAs (Christiansenetal2008). arangeofGramnegativebacteriawithmultipleclassesofdrugresistanceorresistantmechanismsto criticallyimportantantibioticshighlytransmissibleresistanceisaparticularfeatureofantibiotic resistanceamongtheGramnegativebacteria,especiallytheEnterobacteriaceae.Multidrugresistanceis alsocommonandincreasingamongnonfermentingGramnegativebacteria(e.g.Pseudomonasaeruginosa andAcinetobacterbaumannii)andanumberofstrainshavenowbeenidentifiedthatexhibitresistanceto essentiallyallcommonlyusedantibiotics.Theseorganismsareassociatedwithtreatmentfailureand increasedmorbidity(Christiansenetal2008). AtwolevelapproachisnecessaryforthepreventionandcontrolofMROs.Thisinvolvesimplementationof: corestrategiesforMROpreventionandcontrolinanysituationwhereMROinfectionorcolonisationis suspectedoridentified(seeSectionB3.1.2);and organismbasedorresistancemechanismbasedapproachesifincidenceorprevalenceofMROsarenot decreasingdespiteimplementationofthecorestrategies(seeSectionB3.1.3). IntheeventofanMROoutbreak,investigationandcontrol/containmentshouldbeconductedasoutlinedin SectionB3.2. B3.1.2 Core strategies for MRO prevention and control
SuccessfulcontrolofMROsisbasedonacombinationofinterventions.Theseinvolvecontinuedrigorous adherencetohandhygiene,appropriateuseofpersonalprotectiveequipmentandimplementationof specifictransmissionbasedprecautions(isolationofinfectedorcolonisedpatients,increasedenvironmental cleaninganddedicatedpatientequipment)untilpatientsareculturenegativeforatargetMROorhavebeen dischargedfromthefacility. Innonacutehealthcaresettings,generalmeasuresofinfectioncontrol(particularlyhandhygienebyboth patientsandhealthcareworkers)maybeenoughtopreventtransmission.However,contactprecautions, suchasgownsandgloves,maybenecessaryiftheindexpatientisheavilycolonisedorthereisknown continuingtransmission.Localguidelinesandcircumstancesshoulddeterminepracticeinsettingswherethe patientpopulationisvulnerable(Matlow&Morris2009). OrganisationalmeasuressuchasstaffeducationonpreventionandmanagementofMROtransmission, antibioticstewardshipprogram,andappropriateresponsetoactivesurveillanceculturesarediscussedin PartC.
Hand hygiene
MROscanbecarriedfromonepersontoanotherviathehandsofahealthcareworker.Contaminationcan occurduringpatientcareorfromcontactwithenvironmentalsurfacesincloseproximitytothepatient, particularlywhenpatientshavediarrhoeaandthereservoiroftheMROisthegastrointestinaltract.Effective handhygieneisthereforethemostimportantmeasuretopreventandcontrolthespreadofMROs.Alcohol

CONSULTATIONDRAFTJANUARY2010 basedhandrubofatleast70%v/vethanolorequivalenthasbeenshowntobeeffectiveagainstMRSAand VRE(Picheansathian2004)andisrecommendedforallroutinehandhygienepracticesinthehealthcare environment.

Bothdirectpatientcontact(e.g.routinepatientcare)andlessdirectcontact(e.g.involvingenvironmental contamination)canleadtocontaminationofthehealthcareworkershandsandclothing.Appropriateuseof gloves(seeSectionB1.2.5)hasbeenfoundtobeaseffectiveastrategyaspatientisolationincontaining MROs,particularlywhenisolationmaynotbefeasible(Tricketal2004;Bearmanetal2007).Gloveuseis moreeffectivewhencombinedwithwearingofgowns(Puzniaketal2002;Srinivasanetal2002;Haydenet al2008).

Isolation
Placingcolonisedorinfectedcarriersinsinglerooms,cohortroomsorcohortareasasacomponentofa multifacetedinfectioncontrolpolicycanreduceacquisitionrateandinfectionwithMROsinacutecare settings.CohortingpatientswiththesamestrainofMROhasbeenusedextensivelyformanagingoutbreaks ofspecificMROs,includingMRSA,VRE,extendedspectrumbetalactamase(ESBL)producingbacteria,and Pseudomonasaeruginosa.However,itisnotalwaysappropriatetocohortpatientswiththesameMROspecies iftheyhaveadifferentresistancemechanismorphenotype(e.g.ifonehasacommunityacquiredstrainof likelyPVLpositiveMRSAandtheotherhasahospitalacquiredstrainofMRSA). Inlongtermcarefacilities,isolationandcohortingmaynotbepossible,sohandhygienewithappropriate routineuseofglovesforindividualresidentandenvironmentalcontactispreferred(Tricketal2004).

Environmental cleaning
WhenpatientsareinfectedorcolonisedwithMROs,environmentalcleaningofpatientcareareasshouldbe prioritisedandparticularattentionpaidtocleaninganddisinfectionoffrequentlytouchedsurfaces (e.g.bedrails,trolleys,bedsidecommodes,bedrails,doorknobs,lightswitchesortaphandles,ensuite facilities).CleaningwithdetergentsolutionshouldthenbefollowedbytheuseofaTGAregisteredchemical germicideappropriateforthesurfacetobedisinfected(e.g.eitherhospitalorcommercialgradedisinfection) asspecifiedinthemanufacturersinstructions.Thismeansthatsurfacesarecleanedtwice.Alternatively, surfacescanbecleanedwithacombineddetergent/disinfectantsolution,whichcombinesatwostep process.

Patient equipment
Standardprecautionsconcerningpatientcareequipment(seeSectionB1.5)areveryimportantinthecareof patientswithMROs.Patientcaredevices(e.g.electronicthermometers)maytransmitinfectiousagentsif devicesaresharedbetweenpatients.Toreducetheriskoftransmission,disposableordedicatedpatientcare equipmentispreferred.

Monitoring
MonitoringoftheincidenceoftargetMROinfectionandcolonisationshouldcontinueafterthese interventionsareimplemented.Ifratesdonotdecrease,moreinterventionsmaybeneededtoreduceMRO transmissionasoutlinedinSectionB3.1.3.
B3.1 Management of multi-resistant organisms 91
CONSULTATIONDRAFTJANUARY2010 RECOMMENDATION
24 Implementation of core strategies in the control of multi-resistant organisms (MRSA, MRGN, VRE) (Grade C) Implement transmission-based precautions routinely for all patients colonised or infected with a multi-resistant organism, including: putting on gloves and gowns before entering the patient care area; using patient dedicated or disposable noncritical patient care equipment (e.g. blood pressure cuff, stethoscope); using a single-patient room or, if unavailable, cohorting patients with the same strain of multi-resistant organism in designated patient care areas; and ensuring consistent cleaning and disinfection of surfaces in close proximity to the patient and those likely to be touched by the patient and healthcare workers. Grade C
When patients are placed on transmission-based precautions due to infection or colonisation with an MRO, efforts should be made to counteract potential psychological adverse effects of isolation such as anxiety and depression, and feeling of stigmatisation.
B3.1.3
Organism-specific approach
WhentheincidenceorprevalenceofMROsisnotdecreasingdespiteimplementationofthecorestrategies outlinedabove,furthermeasurestocontroltransmissionneedtobeconsidered.Ariskmanagement approachfocuseson: thetypeofMRO(e.g.prioritisationofavailableisolationfacilitiesaccordingtoMRO); thehealthcarearea(e.g.intensivecareorhaematology/oncologyunitshavehigherrisksoftransmission); patientfactors(e.g.whethertheconsequencesofinfectionaresevere); availableresources(e.g.whetherscreeningacertainpatientpopulationisfeasible);and whetherinterventionstointerrupttransmissionareavailable(e.g.decolonisationforMRSA).
Furthermeasuresmayinclude: targetedscreeningtimelyactivescreeningtoidentifycolonisedpatientscombinedwiththeuseof contactprecautionsforthecareofcolonisedpatientshasbeenfollowedbyasignificantreductioninthe ratesofbothcolonisationandinfectionofpatientswithMRSA(Calfee&Farr2002;PopVicas&DAgata 2005).Screeninginvolvescollectingspecimensfromthepatientandsubsequentlaboratoryanalysisof thesesamples.Inariskassessmentapproachtoscreening,considerationsincludetheendemicityofthe MRO,theprevalenceofMROinfection,andthelikelihoodofMROcarriage.Cliniciansandtheinfection controlpractitionershouldbeinformedofbothnegativeandpositivescreeningresultspromptly.If screeningreturnsapositivesample,contactprecautionsshouldbeappliedandappropriateuseof isolationandcohortingfacilitiesshouldbeimplemented.
decolonisationinterventionsmaybetopicalwholebodywashes(usingchlorhexidine)andtopically appliedantimicrobialagents(e.g.mupirocin);systemicorallyadministeredantibiotics(tetracyclines, fusidicacid,ciprofloxacin,rifampinandtrimethoprimsulfamethoxazole);andcombinationsofsystemic andtopicaltherapy. surveillanceandtimelyfeedbackincreasedsurveillancemaybeappropriatetomonitortheeffectof interventionsdesignedtocontrolparticularMROs.Surveillanceinformationshouldbefedbacktohealth careworkersandfacilitymanagementpromptly. Currentlythereisnoconsensusnationallyorinternationallyaboutthemostappropriatemannertoconduct screeningforMROs.Controlmeasuresspecifictolocalfactorsshouldbedeterminedandendorsedbythe healthcarefacilitymanagementstructure,andthescreeningprotocolsforMROsshouldbeinfluencedby the: localprevalenceoftheMRO; thereasonforadmissionofthepatient;
CONSULTATIONDRAFTJANUARY2010 theriskstatusoftheunittowhichtheyareadmitted;and thelikelihoodthatthepatientiscarryinganMRO.
Otherriskgroupsmaybedefinedbylocalexperience,basedonscreeninginitiativesoroutbreak epidemiology. AsaminimumstandardtoreducetheriskoftransmissionofMROs,itisrecommendedthatthefollowing approachestoscreeningbeimplemented.

Table B3.1
Organism MRSA
Suggested approach to screening for MRSA

Screen who Patients at high risk of carriage: those who are known to have been previously infected or colonised with MRSA frequent re-admissions to any healthcare facility transfers from other acute care facility residence in long term care facilities patients with chronic wounds recent inpatients at hospitals known or likely to have a high prevalence of MRSA locales or populations where communityacquired strains of MRSA are prevalent Screen when Screened routinely at the time of admission unless they are being admitted directly to isolation facilities and it is not planned to attempt to clear them of MRSA carriage Sample collection Multiple sites including one from the nose and a mucosal surface. Reasonable sites to swab include nares, skin lesions and wounds, sites of catheters, catheter urine, groin/perineum, tracheostomy and other skin break in all patients, and sputum from patients with a productive cough. Where maximum sensitivity is required, consideration should be given to adding a throat swab. The umbilicus should be After confirmation of epidemiological evidence 2 weeks after decolonisation therapy All patients on admission, discharge and once weekly sampled in all neonates.
Healthcare workers epidemiologically linked to single-strain outbreak in health care facility
Patients in high risk units ICU/high dependency unit (admission and discharge) Spinal unit Burns unit Pre-operative clinics Patients with planned prosthetic surgery (joint replacement, cardio-thoracic surgery)
Management Apply stringent hand hygiene, contact precautions (gloves and gown) and core strategies outlined in B.3.1.2 including isolating and cohorting patients, increased environmental cleaning and dedicated patient equipment. Patients positive for MRSA have electronic alert placed on case record for easy identification on readmission. Consider topical plus/minus systemic decolonisation for: Healthcare workers epidemiologically linked to transmission Patients having prolonged hospitalisation Patients with chronic conditions likely to be readmitted (e.g. haemodialysis).
MRSA clearance should be considered successful only after: All wounds healed, no indwelling medical devices present No exposure to antibiotics or antiseptic body washes for at least 2 weeks prior to screening More than 6 months elapsed time from the last positive specimen Negative screening swabs on at least three occasions over a 10-week period.
ThedecisiontoscreenforVREandMRGNisoptionalandshouldbemadeonthebasisoflocal epidemiology,necessityforscreeningandresourcefactors.Thefollowingtablesprovideguidancefor screeningbasedonpatientriskfactorsfortheseorganisms.Otherriskgroupsmaybedefinedbylocal experience,basedonscreeninginitiativesoroutbreakepidemiology.

Table B3.2
Organism
Suggested approach to screening for VRE and MRGN dependent on local acquisition rates
Suggested targeted screening dependent on local acquisition rates and risk factors Frequency of screening Sample collection
VRE
High risk units Intensive care unit Nephrology Haematology Solid organ transplant unit Patients epidemiologically linked to single-strain outbreak in health care facility Patients at high risk of carriage Dialysis patients Recent hospitalisation in any health care facility Critical illness in intensive care units Long duration of stay and severity of illness Chronic disease and impaired functional status Patients with urinary catheters Prolonged or broad-spectrum antibiotic use, particularly vancomycin
For endemic VRE screen on admission to intensive care unit, discharge and once weekly
Multiple sites including rectal or perianal swabs,
Reasonable sites include groin, wounds and respiratory secretions or tracheal aspirates depending on the infectious agent
For VRE in ambulatory haemodialysis unit, or an haemotology/oncol ogy facility screen periodically every 36 months
Organism Suggested targeted screening dependent on local acquisition rates and risk factors MRGN ESBLs, plasmid AmpC, MR-Pa, MR-Ab, transferable carbapene maseproducing organisms High risk units Intensive care unit Solid-organ transplant unit Speciality centres (e.g. burns, neurosurgery) Patients epidemiologically linked to single-strain outbreak in health care facility Patients at high risk of carriage Those with recent broad spectrum antibiotic therapy (carbapenem, quinolones, and 3rd and 4th generation cephalosporins) Long duration of stay and severity of illness Chronic disease and impaired functional status Presence of invasive medical devices Management Staff screening and decolonisation is not recommended for VRE and MRGN Apply stringent hand hygiene, contact precautions (gloves and gown) and core strategies outlined in B.3.1.2 including isolating, cohorting, increased environmental cleaning and dedicated patient equipment. Patients positive for VRE or MRGN should have an electronic alert placed on case record for easy identification on readmission. All the following criteria should be satisfied prior to certifying that a patient has cleared a particular MRO: More than 6 months elapsed time from the last positive specimen All wounds healed, no indwelling medical devices present No exposure to antibiotics or antiseptic body washes for at least 2 weeks prior to screening Negative screening swabs on at least three occasions over a 10-week period. Multiple sites including rectal or perianal swabs, Reasonable sites to include nares, groin, wounds and respiratory secretions or tracheal aspirates depending on the infectious agent Frequency of screening Sample collection
Some patients with VRE may appear to clear with time but relapse with antibiotic therapy. Where VRE or MRGN are prevalent, admission and interval screening in specialised units is an important way to detect new or relapsed VRE or MRGN colonisation.
Withanincidencerateof1.09per100,000populationin2006,WesternAustralia(WA)hasconsistently reportedlowratesofacquisitionofMRSAcomparedtootherstatesinAustralia(Ferguson2007).TablesB3.3 andB3.4provideexamplesofapproachesthathavebeensuccessfulinreducingratesofcrosstransmission inhospitalsinWA.Approacheswillvaryacrossthestatedependingonthesetting(e.g.availableresources andaccesstolaboratorytechniques).
Table B3.3: Example of a successful strategy to prevent endemicity of MRSA in a tertiary hospital in WA
Patient screening Infection control precautions Patients hospitalised or in longterm care facility outside WA in previous 12 months Healthcare workers who have worked outside WA in 12 months prior to commencing employment in WA Patients / healthcare workers epidemiologically linked to single-strain outbreak in health care facility Patients from WA long-term care facilities Patients in high risk units: ICU/high dependency unit (admission and discharge) Spinal unit Burns unit Pre-operative clinics Core strategies plus Contact precautions: Single room or cohort Gown and gloves Topical plus/minus systemic Healthcare workers Patients having prolonged hospitalisation Patients with chronic conditions likely to be readmitted Clearance only after negative screening swabs on at least three occasions over a ten week period Multiple sites including the nose and a mucosal surface. Reasonable sites to swab include nares, throat and wounds Decolonisation Sample collection
All MRSA isolates are typed using molecular techniques. Some community MRSA strains (PVL negative) in low-risk wards may have less stringent precautions applied. Patients positive for MRSA should have an electronic alert placed on case record for easy identification on readmission
Table B3.4: Example of a successful strategy to prevent endemicity of VRE in a tertiary hospital in WA
Patient screening Infection Control Precautions Patients epidemiologically linked to single-strain outbreak in health care facility Dialysis patients monthly High risk units (admission and discharge) Intensive care unit Nephrology Haematology Solid organ transplant unit Transfers from hospitals outside WA Patients positive for VRE have electronic alert placed on case record for easy identification on readmission. Decolonisation not possible Healthcare workers not screened Core strategies plus Contact precautions: Single room or cohort Gown and gloves Rectal swab All faeces specimens submitted to laboratory are screened All enterococcal isolates are screened Sample collection Laboratory surveillance
CONSULTATIONDRAFTJANUARY2010 B3.1.4 Antibiotic stewardship 13
Overthelast40years,theprevalenceofMROssuchasMRSAhasrisenalarmingly,initiallymainlyin hospitalsbutnowincreasinglyinthecommunity.Thereisgoodevidencethatoverallratesofantibiotic resistancecorrelatewiththetotalquantityofantibioticsused,asdeterminedbythenumberofindividuals treated,priorexposureandtheaveragedurationofeachtreatmentcourse.Someantibioticspromotethe developmentofresistancemorereadilythanothers,dependinginpartonthebreadthoftheirantibacterial spectrum.Inindividuals,theriskofcolonisationandinfectionwithMROscorrelatestronglywithprevious antibiotictherapy. Unnecessaryantibioticuseforselflimitingornoninfectiveillnessandinappropriateantibioticchoice,dose ordurationoftherapydrivestheselectionofresistantbacteria,disruptnormalbacterialfloraandincrease theriskofcolonisationwithresistantorganisms.ThereisalagperiodbetweenacquisitionofanMROandits detection;duringthisperiod,theinfectionmayspreadbetweenpatientsifriskfactorsforacquisitionarenot consideredcarefully.Cliniciansmaybeunderpressuretoprescribebroadspectrumagentsagainstlikely pathogensinanenvironmentwhereMROsarecommon,therebyfurtherincreasingthedevelopmentof resistantorganisms. Asmanyas2550%ofantibioticregimensprescribedinhospitalsmaybeinappropriate.Thereasonsforthe continuedunnecessaryand/orinappropriateuseofantibiotics,inthefaceofincreasingantibioticresistance andavailabilityofwellestablishedevidencebasedtreatmentguidelines,arevaried. Antibioticstewardshipprogramsinvolveasystematicapproachtooptimisingtheuseofantibiotics(see SectionC5).Effectivehospitalantibioticstewardshipprogramshavebeenshowntodecreaseantibioticuse andimprovepatientcare.4Alongwithinfectioncontrol,handhygieneandsurveillance,antibiotic stewardshipisconsideredakeystrategyinlocalandnationalprogramstodecreaseMROsandHAIs.
13
ThissectionisdrawnfromACSQHC(2009)NationalReportonAntibioticStewardship.
CONSULTATIONDRAFTJANUARY2010 Risk management case study VREoutbreakinalargetertiarycarereferralhospital TwomonthsafterthefirstindexcaseofVREwasdetectedintheintensivecareunitofalargeteachinghospital,68 patientshadbecomeeitherinfectedorcolonisedwithanepidemicstrainofvanBvancomycinresistantEnterococcus faecium,despitestandardinfectioncontrolprocedures.Subsequently,169patientsin23wardswerefoundtobe colonisedwithasinglestrainofvanBvancomycinresistantE.faecium.Introducingadditionalcontrolmeasures rapidlybroughttheoutbreakundercontrol.Hospitalwidescreeningfound39previouslyunidentifiedcolonised patients,withonly7morenonsegregatedpatientsbeingdetectedinthenext2months.Theoutbreakwasterminated within3monthsduetoawellresourced,multifacetedapproach.
Source:BasedonChristiansenetal(2004).
Eliminating risks Identifying risks Analysing risks In this situation, it is not possible to eliminate risk immediately, so it must be managed. In this case, the risk has been identified as cross-transmission of VRE. The source of the risk is multidrug resistance coupled with a vulnerable patient population (intensive care unit). Each time there is contact with an infected patient there is potential for cross-transmission to the healthcare worker and/or other patients. Evaluating risks The balance of likelihood and consequences identify this as a very high risk situation requiring immediate response. Treating risks Immediate measures to control the outbreak may include; formation of a VRE executive group; rapid laboratory identification (30 to 48 hours) using culture and polymerase chain reaction detection of vanA and vanB resistance genes; screening of hospitalised patients with isolation of carriers and cohorting of contacts; increased cleaning; electronic flagging of medical records of contacts; and antibiotic restrictions (third-generation cephalosporins and vancomycin).
In the longer term, hospital policies may be changed to restrict antibiotic use, institute targeted screening and increase environmental cleaning efficiency and frequency. These measures are relevant to a recent outbreak in an area of low endemicity. Some of these approaches may also be relevant in an area of high endemicity. Monitoring Repeated screening would identify whether the outbreak recurred.
CONSULTATIONDRAFTJANUARY2010 B3.2 OUTBREAK INVESTIGATION AND MANAGEMENT
Whentherearemorecasesofinfectionwiththesameorganismthanwouldnormallybeexpectedinone areaorperiodoftime,thisconstitutesanoutbreak. Anoutbreakmaybedefinedas: occurrenceofmorecasesofdiseasethanexpectedinagivenareaamongaspecificgroupofpeopleover aparticularperiodoftime;or twoormorelinkedcasesofthesameillness.
Commonlydetectedoutbreaksinvolve: MRSA(seeSectionB3.1.3); aminoglycosideormultiresistantenterobacteriaceaeorpseudomonads; diarrhoealpathogens; respiratorypathogens(e.g.Salmonella,Campylobacter,norovirus); measles,varicella; hepatitisA; Clostridiumdifficileenterocolitis;and Legionnairesdisease. B3.2.1 Outbreak investigation and management
Asuspectedoutbreakmaybeidentifiedbyahealthcareworker,bylaboratorypersonnel,orby state/territoryhealthauthoritiesconductingroutinesurveillanceorinvestigatingreportsofillnessandfrom reportablediseasenotifications.Whenanoutbreakisdetected,thehealthcarefacilitysinfectioncontrol managementsystemshouldbenotifiedandanoutbreakcontrolteamformedrelevanttothesizeand seriousnessoftheoutbreakandthehealthcarefacilityinvolved.Theremayalsobearequirementtonotify thestate/territorypublichealthunit. Theresponsibilityforinvestigationandtheextentofinvestigationswillvaryaccordingtotheoutbreaktype andcircumstances.Itisimportanttoinvestigateanoutbreakimmediately,astheavailabilityandqualityof microbiologicalevidenceandepidemiologicaldatadiminishesrapidlywithtimebetweenillnessand investigation. Anoutbreakmanagementplanshouldbedevelopedbasedonlocalpolicyandconsultationbetweenthe infectioncontrolpractitioner,healthcareworkers,patients,facilitymanagementandstate/territoryhealth authoritiesasappropriate.Suchaplanismultifactorialanditsimplementationistypicallyoverseenbya personwithdesignatedresponsibilityforinfectioncontrol,suchasaninfectioncontrolpractitioner,clinical microbiologistorinfectiousdiseasesphysician. Theoutbreakresponsemaydifferaccordingtothenatureofdisease,thevirulenceoftheorganismandthe vulnerabilityofthepatientsconcerned,howevertheprinciplesthatunderlieanoutbreakinvestigationare similar:identificationoftheaetiologicalagent;theroute(s)oftransmission;exposurefactorsandthe populationatrisk. TableB3.5outlinestheprocessofoutbreakinvestigationandcorrespondingmanagement. Inpracticemany stepsaretakenmoreorlesssimultaneously,whiletheresultsofinvestigationsandimplementationof strategiestocontainandcontrolwillvarywiththeavailabilityandtimelinessofinformationandseriousness oftheoutbreak.Inprimarycaretheremaybealimitedabilitytoinvestigateanoutbreak,whichwillbe generallyconductedbypublichealthauthoritiesoncetheyhavebeennotified.Alloutbreaks,however minor,shouldbeinvestigatedpromptlyandthoroughlyandtheoutcomesoftheinvestigations documented.
B3.2 Outbreak management 99
Table B3.5: Steps in an outbreak investigation
Steps Suggested approach Responsibilities (dependent on facility and type of outbreak) Step 1. Recognise outbreak and prepare to investigate Determine existence of the outbreak Determine if immediate control measures are needed (refer to B3.2.2) Notify and communicate Formation of an outbreak investigation/manage ment team (OMT) this will vary according to location/resources, made up of one or more people with designated responsibility Confirm that there are more than expected number of cases meeting the surveillance case definition of the disease of interest in the period under review Consider likely outbreak definition and whether criteria are met Are there more cases than expected compared to previous weeks / months? Review scientific literature Consider epidemiology of cases - are there two or more linked cases of the same illness? Step 3. Establish case definition and find cases Establish a set of standard criteria to decide whether or not a person has the disease of concern. Case definition should be based on: Clinical information about the disease Characteristics of the people who are affected Information about the location Specification of time period for the outbreak Case definition can be refined later after collection of primary data Cases can be classified as Confirmed (usually laboratory verification); Probable (usually has typical clinical features); Suspect (usually has fewer typical clinical features) B3 Management of resistant organisms and outbreak situations 100 OMT representatives (Clinical microbiologist, senior clinicians) OMT representatives (Clinical microbiologist, senior clinicians) Establish background rate of disease Consider if observed number of cases is in excess of the usual number and cases are typical. Examine surveillance data reinforcement of standard precautions application of appropriate transmission based precautions Health care workers and ancillary staff in immediate area Infection Control Practitioner Executive Laboratory Public health unit (if notifiable disease or required pursuant to public health legislation) Membership may include but is not limited to: Administrators (medical and nursing) Managers of implicated areas Infection Control Practitioner or designated person with infection control experience Clinical Microbiologist/ID Physician Infectious diseases physician/epidemiologist/statistician Lead investigator or chair nominated Others as defined by circumstances Confirm clinical diagnoses (symptoms and features of illness) Review laboratory data and request additional laboratory tests if necessary, e.g. molecular typing of organisms to confirm clonality Laboratory personnel to report results Clinicians to verify clinical diagnosis Management as soon as notified Health care workers - as soon as outbreak is suspected Laboratory personnel (e.g.. routine screening can identify outbreak) as soon as outbreak is suspected Health care workers - as soon as outbreak is suspected Health care workers Laboratory personnel
Step 2. Verify the diagnosis and confirm that an outbreak exists
Steps Find cases Suggested approach Gather critical information by: Identify and count cases Tabulate this information in a line list, that is updated as new cases appear Review descriptive epidemiology of all cases Create epidemic curve to determine hypotheses Step 5. Determine who is at risk Identify groups at risk Initiate precautionary measures Number of people ill Time and place of onset Personal characteristics Use of standard precautions and appropriate transmission-based precautions Increase frequency and efficiency of environmental cleaning using appropriate products; Develop hypotheses from the factual information gathered to date on potential source, vector, pathogen, route of transmission Prophylactic treatment/immunisation Antibiotic restrictions Exclusion of cases from high risk activities Isolation and/or cohorting of patients Restricting movement of patients, staff and visitors Screening of patients with isolation of carriers and cohorting of contacts; Provision of health information and advice Data collected by interview Common links Plausible exposures Environmental test results where appropriate Review literature OMT representative Step 6. Develop hypothesis the how and why Health care workers Infection control practitioner OMT representative Interview Follow-up of disease notification Health alerts Identifying information Demographic information Clinical information Risk factor information (including environmental tests) Time date of onset of illness Person age, sex Place where did the exposure occur? Other relevant information Person: sex, age, occupation, residence Place: information that provides information on possible source of agent and nature of exposure Time: date and time of onset; record relevant events in a timeline No. of cases on y-axis Time on x-axis OMT representative OMT representative OMT representative Responsibilities (dependent on facility and type of outbreak) Health care workers OMT representatives Health care facility management OMT representative
Collect the following types of information
Step 4. Characterise outbreak by person, place, and time
Steps Suggested approach Responsibilities (dependent on facility and type of outbreak) Step 7. Test hypothesis with established facts Perform epidemiologic study Analyse the data Cohort Case-control Compare risk factors among ill (cases) vs. not ill (controls) Attack rates Relative risk OMT representative or outsourced to consultant with knowledge of statistical methods OMT representative
Step 8. Carry out further studies if necessary To support the hypothesis or If analytic studies do not confirm the hypothesis Further study to refine case definition May involve testing of environmental samples, food samples or environmental screening in some situations (e.g. Legionella, Pseudomonas) OMT
Step 9. Implement ongoing control / prevention measures (This can be done at any time during the outbreak as deemed necessary). Review measures initiated for immediate control (Step 1 and Step 5) Implement appropriate ongoing control measures and strategies to prevent further illness (see B.3.2.2) Communicate and coordinate with all stakeholders Make plans to evaluate their effectiveness Step 10. Communicate findings Prepare written report that evaluates methods used for the control of the outbreak Include discussion of factors leading to outbreak, comprehensive timelines, summary of investigation and documented actions Short and long term recommendations for prevention of similar outbreak Disseminate to appropriate stakeholders including publication OMT Health care facility management Electronic flagging of medical records of contacts; Reinforcement of infection control precautions to staff, patients and visitors Document type and time of implementation of infection control measures Monitor factors contributing or affected by outbreak and any associated changes Health care workers OMT Infection control practitioner Health care workers OMT Infection control practitioner Restrict spread from the case Interrupt chain of infection Interrupt transmission or reduce exposure Reduce susceptibility to infection Assessment of policy, regulations, standards Are infection control measures adequate to reduce risk of transmission? Health care workers OMT Health care facility management Health care workers OMT Health care facility management
B3.2.2
Infection control strategies to control/contain an outbreak
Goodgovernanceandadministrativeormanagerialsupportarecrucialtosupportoutbreakmanagement (seeSectionC1).Thehealthcareworkersroleinoutbreakmanagementwillinclude: reinforcementofstandardprecautions,includingrigorousadherencetothe5momentsofhandhygieneand environmentalcleaningprotocolsandappropriateuseofPPE;and implementationofrelevanttransmissionbasedprecautions,includingisolationandcohorting. ThespecificprecautionsrequiredforeachinfectiousagentarelistedinTableB2.3(seepage83).
CONSULTATIONDRAFTJANUARY2010 Environmental cleaning Increasefrequencyandefficiencyofenvironmentalcleaningtoensureanycontaminantsareremoved.A targetedcleaningregimemaybeintroducedandcontinuedforthedurationoftheoutbreakdependenton themodeoftransmissionoftheinfectiousagent.Considerwhetherthesurroundingenvironmentwillneed tobedisinfectedinadditiontocleaning. Patient isolation Theisolationofinfectedpatientsthroughallocationofsingleroomsorcohortingofpatientsis importantwhenmanaginganoutbreak.Infectedpatientsshouldbeisolatedusingsinglerooms,cohorting andnegativepressureroomsifavailableandasadvisedbyaninfectioncontrolpractitionerorpersonwith designatedresponsibilityforinfectioncontrol.Awarningsignshouldbepostedonthedoor,whichshould bekeptclosedforpatientsonairborneprecautions.
Single room
Singlepatientroomsarealwaysindicatedforpatientsplacedonairborneprecautionsandarepreferredfor patientswhorequirecontactordropletprecautions.Intheeventofanoutbreak,singlepatientroomsare preferredforallmodesoftransmission. Whenthereisonlyalimitednumberofsinglepatientrooms,theyshouldbeprioritisedforpatientswho haveconditionsthatfacilitatetransmissionofinfectiousmaterialtootherpatients(e.g.drainingwounds, stoolincontinence,uncontainedsecretions)andforthosewhoareatincreasedriskofacquisitionand adverseoutcomesresultingfrominfection(e.g.immunosuppression,openwounds,indwellingcatheters, anticipatedprolongedlengthofstay,totaldependenceonhealthcareworkersforactivitiesofdailyliving).

Cohorting
Cohortingpatientswhoarecolonisedorinfectedwiththesamestrainconfinestheircaretooneareaand preventscontactwithotherpatients.Cohortsarecreatedbasedonclinicaldiagnosis,microbiologic confirmationwhenavailable,epidemiology,andmodeoftransmissionoftheinfectiousagent.Itisgenerally preferrednottoplaceseverelyimmunosuppressedpatientsinpatientcareareaswithotherpatients. Cohortingallowsmoreefficientuseofstaff. CohortinghasbeenusedformanagingoutbreaksofMROsandpandemicinfluenza,andmodellingstudies provideadditionalsupportforcohortingpatientstocontroloutbreaks.

Placement of large numbers of patients
Intheeventofanoutbreakorexposureinvolvinglargenumbersofpatientswhorequireairborne precautions,aninfectioncontrolpractitionershouldbeconsultedbeforepatientplacement.Appropriate measuresmayinclude: cohortingofpatientsinareasofthefacilitythatareawayfromotherpatients;and usingtemporaryportablesolutions(e.g.exhaustfan)tocreateanegativepressureenvironmentinthe convertedareaofthefacility.

Restricting movement within the facility
Restrictingmovementofpatientsduringanoutbreakreducestheriskoffurthertransmission.Iftransfer withinthefacilityortransporttoanotherfacilityisnecessary,adviceshouldbesoughtfromaninfection controlpractitioner.Ifaninfectedpatientmustbemovedthereceivingareaorfacilityshouldbenotifiedof thenatureofthepatientsinfection. Itisimportantto: ensurethatinfectedorcolonisedareasofthepatientsbodyarecoveredifrelevant;and ifthetargetinfectionistransmittedbythedropletorairborneroute,askthepatienttowearamaskwhile theyarebeingmoved. ContaminatedPPEshouldberemovedanddisposedofandhandhygieneperformedbeforethepatientis moved.CleanPPEshouldbeputonbeforethepatientishandledatthedestination.
Exclusion policies
Exclusionpoliciesmayalsobeimplementedtorestrictthespreadofdiseasethroughoutahealthcare facility.Thiscouldinclude: excludingpatientsfromparticipatinginspecificactivities; restrictingorcancellingvisitinghoursforpatientsinoutbreakareas;and excludingstafffromworkuntilwelliftheyareimplicatedinthetransmissionofinfection(fore.g.food handlers) Inanoutbreakofviralgastroenteritis,healthcareworkersshouldnotreturntoworkuntildiarrhoeaand vomitinghaveceasedfor2days.Itisextremelyimportantthathealthcareworkerscomplywithappropriate handhygienemethodsandstringentinfectioncontrolpracticesuponreturntowork,giventhatsome studieshaveshownprolongedviralshedding.
Notifications and contact tracing
Allhealthcarefacilitiesshouldhavesystemsinplacetoensuretimelyreportingofnotifiablediseasestothe relevantstate/territoryhealthdepartment.Aspatientsmaypresenttoahealthcarefacilityandbelater confirmedtohaveatransmissiblediseasestate/territoryhealthauthoritiesneedtobenotifiedtoenable tracingofcontactsoftheinfectedpatientinordertoinitiateappropriatecounselling,quarantineandpost exposureprophylaxis.Healthcarefacilitiesmayneedtoidentifystaffondutyandotherpatientspresent whomayhavebeenexposedtotheinfectiouspatientandbeatrisk.

Communication
Oneoftheimportantaspectsofthecontroleffortisthewrittenandoralcommunicationoffindingstothe appropriateauthorities,theappropriatehealthprofessionalsandthepublic.Thiscommunicationisbasedon thetypeandseverityoftheoutbreak.Duringanoutbreakitisimportanttoprovideeducationtothekey stakeholdersandcliniciansabouttheorganism,itsmodeoftransmissionanditsbehaviourindisease. Withinahealthcarefacility,effectivecommunicationcouldconsistof: appropriatesignagetolimitaccesstoaroomoraclinicalunit; electronicalertsonthemedicalrecordtomanagecasesandcontacts; emailsandmultimediatotargetallstakeholderswithinthehealthcarefacility;and provisionofeducationandwrittenmaterialstovisitorstoinformthemofthesituationandtheinfection controlmeasureswithwhichtheyshouldcomply.
Patients, their families, and visitors may experience concern or fear or may feel they are not being given enough information in an outbreak situation. Clearly explaining the process of outbreak management and the importance of infection control measures may assist them in understanding the situation and improve compliance with infection control directives.
B3.2.3
Applying transmission-based precautions during an outbreak
Successfuloutbreakmanagementisbasedonacombinationoftransmissionbasedprecautions.Specific interventionswillbedeterminedbytheinfectioncontrolpractitioner,basedonthemodeoftransmissionof theinfectiousagent.Theseinclude: rigorousadherencetothe5momentsofhandhygiene(seeSectionB1.1.7); useofappropriatepersonalprotectiveequipment(includinggloves,apronorgowns,andsurgicalorP2 (N95)respirators); implementingpatientdedicatedorsingleusenoncriticalequipment(e.g.bloodpressurecuff, stethoscope)andinstrumentsanddevices; followingstandardproceduresforcontainment,cleaninganddecontaminationofspills;and increasingthefrequencyofenvironmentalcleaning,usingappropriateproducts.
CONSULTATIONDRAFTJANUARY2010 Risk management case study Norovirusinanagedcarefacility Apatientfromaselfcontainedunitwithinanagedcarefacilityistransferredtoahospitalunitwithdehydration resultingfromdiarrhoea.Theinfectiousagentinvolvedisidentifiedasnorovirus.Theagedcarefacilityiscontactedand advisedtoimplementcontactanddropletprecautions,butthesecanonlybeimplementedinthemainfacilityandthe followingdaythepatientsneighbourisalsoadmittedwithdiarrhoea.Whenheandathirdpatientwithinthehospital unitarealsoconfirmedashavingnorovirus,thethreepatientsareisolatedinsingleroomswithensuites.Healthcare workerscaringforthepatientspayparticularattentiontohandhygieneandappropriateuseofPPE.Nofurthercases areidentified.Investigationrevealslowlevelsofhygiene,inparticularhandhygiene,amongresidentsintheunits.An educationprogramisdevelopedandprovidedtoassistinpreventingfurtherinfections.
Eliminating risks Identifying risks In this situation, it is not possible to eliminate risk, so it must be managed. In this case, the risk has been identified as cross-transmission of norovirus by contact (faecal-oral) or droplet route. Analysing risks One source of the risk is the lack of appropriate hand hygiene practices by some residents. Each time there is social contact between these and other residents there is potential for crosstransmission. Depending upon hand hygiene practices among residents more broadly, there is potential for the infection to spread through the facility. There is also potential for residents with comorbidities who use the hospital to become reservoirs for transmission of the virus. Healthcare workers and visitors are also at risk of cross-contamination. Evaluating risks The balance of likelihood and consequences identify this as a very high risk situation requiring immediate response. Treating risks Immediate measures may include increasing availability of alcohol-based hand rub across the facility and raising residents awareness of the highly transmissible nature of norovirus infection, its modes of transmission and the particular need for hand hygiene practices. Frequency of environmental cleaning across the facility should also be increased. Longer-term measures could include providing education to residents and visitors on hand hygiene and other infection control measures. Education for healthcare workers could also be used to raise awareness of the high transmissibility of noroviruses, and their capacity to spread very rapidly within units where there are poor or inadequate hygiene practices among residents and staff. Visitors should be requested not to enter the facility if they have any symptoms. Monitoring Changes in practice could be evaluated by surveying residents/patients on hand hygiene practice.
CONSULTATIONDRAFTJANUARY2010 B3.3 PUTTING IT INTO PRACTICE

Become familiar with local policy on the implementation of transmission-based precautions in the event of an outbreak. If an outbreak is suspected or identified, implement core strategies for prevention and control and seek advice from an infection control practitioner or person with designated responsibility for this task regarding intensified strategies appropriate to the specific organism. Practice hand hygiene assiduously and wear appropriate PPE when caring for patients who may be colonised or infected. Become familiar with local policy on antibiotic stewardship.
Thefollowinginformationmaybeprovidedtopatientstoassisttheminunderstandingoutbreak management.
Hand hygiene is the most important part of preventing transmission of an infection this applies to everyone including healthcare workers, patients, visitors and families. If infected patients are transferred, they may be asked to wear a mask. Infected patients should avoid unnecessary movement around other parts of the healthcare facility. To minimise transmission of infection In hospitals, visitors should perform hand hygiene using alcohol-based hand rub before entering or exiting the patient care area; they may also be asked to wear gloves and gowns while they are with the patient. In hospitals, staff must respond quickly to an outbreak of an infection to contain the infection and stop it spreading any further. Actions may include testing patients to see who may be carrying the infection, placing patients in single rooms or with other patients who have the same infection, and limiting movement of people around the facility.
CONSULTATIONDRAFTJANUARY2010 B4 APPLYING STANDARD AND TRANSMISSION-BASED PRECAUTIONS DURING PROCEDURES
Summary Medical and dental procedures increase the risk of transmission of infectious agents between patients and healthcare workers. Procedure includes any situation in which there is a potential for contact between the skin of the healthcare worker and the patients tissues, body cavities or organs, either directly or via surgical instruments or therapeutic devices. The more invasive the procedure, the greater the risk of transmission of infection. Before a procedure is undertaken, consideration should be given to whether there is a safer, less invasive alternative. The level of perceived infection risk depends on a range of factors including the site and complexity of the procedure and patient characteristics (e.g. age, underlying illness). Healthcare workers should be trained and competent in safe procedural techniques and participate in regular education sessions about minimising the infection risk of procedures. If there is any uncertainty, healthcare workers should contact the person with designated responsibility for infection control.
Patients and their carers should be offered clear, consistent information and advice through all stages of their care. This should include the risks of procedure-related infections, what is being done to reduce them and how they are managed.
Thissectionoutlinesprocessesforriskidentificationandtheapplicationofstandardandtransmissionbased precautionsforcertainprocedures.Itisnotintendedtoprovideguidanceonperformingprocedures,but outlinestheprinciplesinvolvedinthedeliveryofcarethatreducetheriskoftransmissionofinfection duringtheinsertionandmaintenanceoftherapeuticdevicesandforsurgery.

Evidence supporting practice
Theadviceinthissectionhasbeenadaptedfrom: 14 the InstituteforHealthcareImprovement(www.ihi.org); Pratt et al (2007) epic2: Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals (Sections B4.2.1 and 4.2.2); MuscedereJetalfortheVAPGuidelinesCommitteeandtheCanadianCriticalCareTrialsGroup(2008) Comprehensiveevidencebasedclinicalpracticeguidelinesforventilatorassociatedpneumonia: Prevention.JournalofCriticalCare23:12637(SectionB4.2.3); NICE(2003)PreventionofHealthcareassociatedInfectioninPrimaryandCommunityCare(SectionB4.2.4); NICE(2008)Surgicalsiteinfectionpreventionandtreatmentofsurgicalsiteinfection(Section4.3); Astertonetal(2008)GuidelinesforthemanagementofhospitalacquiredpneumoniaintheUK:Reportofthe WorkingPartyonHospitalAcquiredPneumoniaoftheBritishSocietyforAntimicrobialChemotherapy(Section B4.2.3);and Tenkeetal(2008)EuropeanandAsianguidelinesonmanagementandpreventionofcatheterassociatedurinary tractinfections(SectionB4.2.1). Furtherreviewoftheliteratureconductedfortheseguidelinesprovidedadditionalevidenceoninfection controlmeasuresrequiredintheuseofintravasculardevices. 15
14
B4.1 Risk management approach to procedures 107
15
ThereportofthisreviewisavailablefromtheNHMRCuponrequest.
CONSULTATIONDRAFTJANUARY2010 B4.1 TAKING A RISK MANAGEMENT APPROACH TO PROCEDURES
Allproceduresinvolvesomeriskofinfection.Minimisingtheinfectionriskassociatedwithaprocedure shouldbeanintegralpartofconsideringtheoverallrisksandbenefitsofthatproceduretothepatient.The aimshouldbetoperformtheprocedurewiththelowestlevelofperceivedinfectionriskthatwillmeetthe treatmentgoalsforthatpatient.Whenperformingtheprocedure,associatedinfectionrisksshouldbe identifiedandminimised. B4.1.1 Classifying procedures
Procedurescanbeclassifiedaccordingtothelevelofperceivedrisk,byapplyingtheprinciplesof Spauldingscriteriaforassessingtheriskofmedicalinstrumentsandequipmentaccordingtotheirintended use(seeSectionB1.5).

Table B4.1: Level of risk to patients from different types of procedures
Level of risk High risk (critical site) Criteria Any surgical entry into tissue, body cavities or organs, or repair of traumatic injury. Medium risk (semi-critical site) Contact with mucous membranes or non-intact skin Respiratory procedure Internal/instrument examination (e.g. ultrasound, endoscopy) Minor skin surgery Minor dental procedures Low risk (non-critical site) Contact with intact skin Non-invasive examinations or procedures (e.g. abdominal ultrasound) Blood pressure measurement, ECG, injection through intact skin Dental examination Example Abdominal surgery Dental surgery
B4.1.2
Appropriate use of devices
Appropriateuseofdevicesisintegraltoreducingtheriskofprocedures.Singleuseorsinglepatientitems shouldbeusedwhereverpractical,anditemsdesignedforsingleusemustnotbeusedformultiplepatients. Healthcareworkersshouldbeawareofsituationswherecrosscontaminationmayoccurduringroutine procedures. Healthcareworkersmustadheretoinfectioncontrolprinciples,includingsafeinjectionpracticesandaseptic techniqueforthepreparationandadministrationofparenteralmedications.

Single-dose vials
Medicationsorsolutionsthatcomeintocontactwithnormallysteriletissueshouldbesterile.Themost effectivewaytoavoidcrossinfectionviainjectionofmedicationisthroughtheuseofsingledosevialsor ampoulesandsingleusesterileinjectingequipment.Singledosevialsorampoules,orprefilledsyringes, shouldbeusedwherevertheseareavailable.Theseincludetheuseofasterile,singleuseneedleandsyringe foreachinjectiongiven,andadherencetopracticesthatpreventcontaminationofinjectionequipmentand medication.

Multi-dose vials
TheAustralianDrugEvaluationCommittee(ADEC)hasadvisedthatinjectableproductspackagedinmulti dosevialsshouldnotbeusedexceptwhereproductssuchasinsulinareintendedsolelyfortheexclusiveuse ofanindividualpatient.Intheseparticularcases,specificprotocolsshouldbeinplacetoensuretheproducts areusedforthoseindividualsonly,andpracticesthatpreventcontaminationofinjectionequipmentand medicationareadheredto. Currentlysomeinjectableproducts(e.g.BacillusCalmetteGurin[BCG]andbotulinumtoxin)areonly availableinmultidosevials.Whensingledosevialsorampoulesarenotavailable,thereisahighriskof

B4 Applying standard and transmission-based precautions during procedures 108
CONSULTATIONDRAFTJANUARY2010 crosscontaminationifinjectableproductsareusedonmultiplepatients.Stepsshouldbetakentoensure thesebecomeavailableinsingledosevials,howevertheriskofinfectiousdiseasetransmissionmaybe mitigatedby(Siegeletal2007): compliancewithmanufacturersrecommendations(adheretoinstructionsforrefrigeration,storage,use withinaspecifiedtime,expirydate); establishingaseparateareadesignatedfortheplacementofthesemedicationsawayfromanywork area; havingonlythecurrentpatientsmedicationintheimmediateworkingenvironment; usingacleanneedleandsyringetodrawuptherequireddosefromthevialorampouleonevery occasion; usingacleanneedletodrawupallthecontentsofthecontainerintoindividualsyringesbefore administeringtopatients; discardinganyopenampoule(s)attheendofeachprocedure;and discardingproductifsterilityiscompromisedorquestionable.
Theuseofmultidosevialsforvaccinationprogramshasbeenassociatedwiththetransmissionofinfectious diseasesincludingHIV(Chantetal1993;Katzensteinetal1993),hepatitisB(Hutinetal1999;Dumpisetal 2003;Samandarietal2005),hepatitisC(Widelletal1999;Massarietal2001;Trasancosetal2001;Kokuboet al2002;Silinietal2002;Dumpisetal2003;Germainetal2005;Verbaanetal2008),Staphylococcusaureus (Kellawayetal1928),Streptococcuspyogenes(Stetleretal1985;Olsonetal1999)andPseudomonasaeruginosa. InternationalagenciessuchastheCDCandWHOrecommendthatsingledosevialsbeusedforparenteral additivesormedicationswheneverpossible,especiallywhenmedicationswillbeadministeredtomultiple patients(Hutinetal2003;Siegeletal2007). Theremaybesomeexceptionalcircumstanceswhereforshortperiods(e.g.afewmonths)multidosevials maybetheonlywaytodelivervaccinesordrugstoalargeproportionofthepopulationinatimelyfashion. Anexamplewouldbewhenahealthemergencyisdeclaredbecauseofaninfectionthathasahigh associatedmortalityandrapidspread(e.g.smallpoxoutbreak)andwhentheremaybeadelayinsingle dosevaccinesordrugsbecomingavailableforaperiodoftime.
Table B4.2: Summary of processes for appropriate use of devices
Injection equipment Single-use items Avoid contamination of the needle Do not use the same needle, cannula or syringe for more than one patient nor to access a medication or solution that might be used for a subsequent patient Do not administer medications from a single syringe to multiple patients, even if the needle or cannula on the syringe is changed. Single-patient items Single-use medications Use single-patient items for one patient only and dispose of them appropriately. Only use single dose vials when administering drugs, therapeutic agents and vaccines to multiple patients Do not administer medications from single-dose vials or ampoules to multiple patients or combine leftover contents for later use Multi-dose vials Multi dose vials should not be used except where they are intended solely for the exclusive use of an individual patient (e.g. insulin) Fluid infusion and administration sets (i.e. intravenous bags, tubing and connectors) Use for one patient only and dispose of appropriately after use Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients Consider syringes or needles/cannulae as contaminated once they have been used to enter or connect to a patients intravenous infusion bag or administration set These should be changed on a regular basis, depending on their use (see Section B4.2.2) B4.1 Risk management approach to procedures 109
CONSULTATIONDRAFTJANUARY2010 B4.1.3 The care bundle approach
TheInstituteforHealthcareImprovement(IHI)intheUSdevelopedastructuredcarebundleapproachto helphealthcareworkersconsistentlydeliverthesafestpossiblecareforpatientsundergoingtreatmentswith inherentrisks.Abundleisasetofevidencebasedpracticesthat,whenperformedcollectivelyandreliably, improvepatientoutcomes. Manybundleelementsarewellestablishedpractices,combinedinastructuredprotocolthatisagreedupon andistheresponsibilityofthewholeclinicalteam.Bundlecharacteristicsincludethefollowing. Abundleisacohesiveunitofstepsthatmustallbecompletedtosucceed. Theelementsareallbasedonrandomisedcontrolledtrialevidence. Theelementsinvolveallornothingmeasurement,makingimplementationclearcut. Bundleelementsoccurataspecifictimeandinaspecificplace(e.g.duringmorningroundseveryday). Examplesofcarebundlesaregivenineachsectionofthischapter.Thesecanbeusedtomonitor,assessand improveperformanceaswellastoincreaseconsistencyofcare. Existingcarebundlescanbeusedasatoolandbedevelopedbyeachfacilitytomeetitsneeds.Formore information,refertotheIHIwebsiteatwww.ihi.org. B4.2 THERAPEUTIC DEVICES
Therapeuticdevicesincludecathetersinsertedfordrainage(e.g.urinarycatheter),forintravascularaccess (e.g.centralvenousline),formechanicalventilation(e.g.intubation)andforfeeding(e.g.enteralfeeding tube). Indwellingdevicesprovidearouteforinfectiousagentstoenterthebody.Asepticinsertionandcareful maintenanceofdevicesiscriticaltoreducinginfectionrisk. TherapeuticmedicaldevicesareacommonsourceofHAIsinintensivecareunits.Pneumonia,urinarytract infectionsandbloodstreaminfectionaccountforaround70%ofintensivecareunitHAIs,andmostofthese areassociatedwithinvasivedevices(Cruickshank&Ferguson2008).

Table B4.3: Key concepts in minimising the risk of infection related to the use of invasive devices
Consider the infection risk during decision-making about whether or not to perform the procedure, ensuring that a therapeutic device is absolutely necessary for the patient Ensure you are adequately trained and competent in the skills required for safe insertion and maintenance of the device Choose the most appropriate device for the patient Minimise the period of time a device remains in a patient Use processes identified as those that minimise the risk of infection (see summary tables in this section) Regularly monitor patients for any signs and symptoms of infection Provide patient education on the infection risk associated with the insertion of devices and the importance of proper maintenance
B4.2.1
Indwelling urinary devices
Anindwellingurinarycatheterisaflexibletubularinstrumentpassedintothebladdereitherthroughthe urethraorthoughtheabdominalwallabovethesymphysispubis.Theyareusedtoemptythecontentsof thebladderinpatientswithacuteurineretentionorperioperatively,andforurinarymeasurementsin criticallyillpatients.
What are the risks?
Bacterialinfectionsassociatedwithurinarycatheterisationgainaccesstotheurinarytracteitherthrough: extraluminalcontaminationthiscanoccurifthereisabreakinaseptictechniqueduringinsertionofthe catheterorservicingthedrainagesystem,fromthehealthcareworkershandsorfromthepatientsown colonicorperinealflora;or intraluminalcontaminationthiscanoccurthroughrefluxofbacteriafromacontaminatedurinedrainage bag. Catheterisingpatientsplacesthematsignificantriskofacquiringaurinarytractinfection.Theriskof infectionisassociatedwiththemethodanddurationofcatheterisation,thequalityofcathetercareandhost susceptibility.Thelongeraurinarycatheterisinplace,thegreatertheriskofinfection. Between15and25%ofpatientsinhospitalmayreceiveshorttermindwellingurinarycatheters,andabout 5%ofresidentsinlongtermcarefacilities(CDC).Around20%ofHAIsareurinarytractinfections,anda largeproportionofthesearecatheterassociatedurinarytractinfections(CAUTIs)(Smyth2008).Upto97% ofurinarytractinfectionsinintensivecareunitshavebeenassociatedwithindwellingcatheters(ACSQHC 2008).
Minimising the risk from indwelling urinary devices
LimitingcatheteruseandminimisingdurationareprimarystrategiesinreducingtheriskofCAUTI. Healthcarefacilitiesshouldhavedocumentedpoliciesregardinginsertion,maintenanceandsurveillanceof indwellingurinarycatheters.Facilitiesshouldclearlyoutlinetheindicationsforcatheterinsertion. Healthcareworkersperformingcatheterisationshouldbetrainedandcompetentinthetechniqueand familiarwithpoliciesandproceduresforinsertion,maintenanceandchangingregimesofindwelling urinarydevices. Insertion Theneedforinsertionofanindwellingurinarydeviceshouldbereviewedbeforetheprocedureis performed. Principlesofgoodpractice,clinicalguidanceandexpertopinion,togetherwithfindingsfroma systematicreviewagreethaturinarycathetersshouldbeinsertedusingsterileequipment(includinga steriledrape)andanaseptictechnique,usingthesmallestborecatheterpossiblethatwillnotbe associatedwithleakage.Staffperformingtheproceduremustbetrainedandcompetentinthetechnique. Expertopinionindicatesthatthereisnoadvantageinusingantisepticpreparationsoversterilesalinefor cleansingtheurethralmeatuspriortocatheterinsertion.Theuseoflubricantoranaestheticgelminimises urethraltraumaanddiscomfort. Maintainingthesystem Maintainingasterile,continuouslyclosedurinarydrainagesystemiscentraltothepreventionofCAUTI. Breachesintheclosedsystem,suchasunnecessaryemptyingoftheurinarydrainagebagortakinga urinesample,increasetheriskofcatheterrelatedinfection.Refluxofurinefromthedrainagebagisalso associatedwithinfection. Studiesinvestigatingtheadditionofdisinfectantsandantimicrobialstodrainagebagsasawayof preventingCAUTIshownoreductionintheincidenceofbacteriuriafollowingtheadditionofhydrogen peroxideorchlorhexidine. Thedeviceshouldberemovedimmediatelyitisnolongerneeded. Patientcare Noreductioninbacteriuriahasbeendemonstratedwhenantiseptic/antimicrobialagentsareusedfor meatalcarecomparedwithroutinebathingorshowering.Expertopinionandasystematicreview supporttheviewthatvigorousmeatalcleansingisnotnecessaryandmayincreasetheriskofinfection andthatdailyroutinebathingorshoweringisallthatisneededtomaintainmeatalhygiene.
B4.2 Therapeutic devices 111
CONSULTATIONDRAFTJANUARY2010 Evidenceindicatesthatbladderirrigation,instillationandwashoutmayhavelocaltoxiceffectsand contributetothedevelopmentofresistantmicroorganisms.However,continuousorintermittentbladder irrigationmaybeindicatedduringurologicalsurgeryortomanagecatheterobstruction. Documentationandsurveillance Theliteratureemphasisestheimportanceofdocumentingallproceduresinvolvingthecatheteror drainagesysteminthepatientsrecordsandprovidingpatientswithadequateinformationinrelationto theneedforcatheterisationanddetailsoftheinsertion,maintenanceandremovaloftheircatheter. Surveillancerelatingtoindwellingcathetersisrecommendedintheliteratureandcanincludemonitoring compliancewithindicationsforinsertionanddocumentation.
Given the risk of urinary tract infection associated with urinary catheterisation, it is important that patients and relatives understand about infection prevention, are aware of the signs and symptoms of urinary tract infection and know how to access expert help if difficulties arise. Table B4.4: Summary of processes for urethral catheter insertion and maintenance
Insertion Maintenance Ensure documented facility policy on urethral catheter insertion is being followed and that staff members performing the procedure are trained in the specific technique. Use sterile equipment (including a sterile drape) and aseptic technique when inserting urinary catheters and connecting to the sterile system Clean the urethral meatus with sterile normal saline before insertion of the catheter Use an appropriate sterile, single-use lubricant or anaesthetic gel Use a sterile closed system and avoid breaches to this system (e.g. unnecessary emptying of the urinary drainage bag) Before manipulation, perform hand hygiene and put on non-sterile gloves Position drainage bag to prevent back-flow of urine or contact of bag with the floor Do not add antiseptic or antimicrobial solutions into drainage bags Empty the drainage bag frequently enough to maintain urine flow and prevent reflux, using a separate container for each patient and avoiding contact between the drainage tap and the container Change drainage bags only when necessary (i.e. according to either manufacturers recommendations of the patients clinical needs) Clamping is unnecessary Daily meatal hygiene can be maintained through routine bathing or showering Avoid use of bladder irrigation, instillation or washouts as routine measures to prevent catheterassociated infection Document all procedures involving the catheter or drainage system
Table B4.5: CAUTI maintenance bundle
An example of a bundle procedure for maintenance of urinary catheters is to: Perform a daily review of the need for the urinary catheter Check the catheter has been continuously connected to the drainage system Ensure patients are aware of their role in preventing urinary tract infection, or if the patient is unable to be made aware, perform routine daily meatal hygiene Regularly empty urinary drainage bags as separate procedures, each into a clean container Perform hand hygiene and put on gloves and apron before each catheter care procedure; on procedure completion, remove gloves and apron and perform hand hygiene again These practices can be measured and used to monitor performance by the clinical team.
B4.2.2
Intravascular access devices
Indwellingintravascularaccessdevices(catheters)providearoutefor: administeringfluids,bloodproducts,nutrientsandintravenousmedications; monitoringhaemodynamicfunction; maintainingemergencyvascularaccess;and obtainingbloodspecimens. Intravasculardevices(IVDs)areusuallyinsertedintoveins,andaremostoftenshort(lessthan5cm) cathetersinsertedintoperipheralveins(e.g.smallveinsinthearms).Peripheralarterialdevicesarealso usedforsomepatients. Centralvenouscathetersareusuallymorethan15cmlongandareinsertedintolargerveinswithinthechest andabdomen.Theygenerallyremaininplaceforlongerthanperipheralveincatheters. Somecentralvenouscathetersareinsertedthroughaperipheralveinsite(peripherallyinsertedcentral catheters[PICCorPIClines]).Theycanbeusedforaprolongedperiodoftime(e.g.forlongchemotherapy regimens,extendedantibiotictherapy,ortotalparenteralnutrition). IVDinsertionisthemostcommonlyperformedinvasivehealthcareprocedurewithapproximately 14millionIVDsusedinAustraliaeachyear(Collignon1994;ABS2008).
What are the risks?
IVDsprovidepotentialroutesforinfectiousagentstocauselocalinfectionortoenterthebloodstream.Asa result,despitetheirimportantroleindiagnosticandtherapeuticcare,IVDsareapotentialsourceofHAIs, themostsevereformbeingbloodstreaminfections(BSI)associatedwiththeinsertionandmaintenanceof centralvenousaccessdevices.Thereareabout5,000casesofIVDrelatedBSIayearinAustralia(Collignon 1994;ABS2008).IVDrelatedBSIsareassociatedwithsignificantmortality,worsentheseverityofthe patientsunderlyingillhealth,prolongtheperiodofhospitalisationandincreasethecostofcare. Thereisriskofinfectionwhenthedeviceisinsertedandwhileitremainsinsitu.Therisksinherentin insertionofIVDsincludebypassingtheskin,whichissuchanimportantbarrieragainstmicroorganisms gainingentrytosterilesitessuchasthebloodstream,andleavingaforeignbodyinthepatientforseveral daysorlongerwhichislikelytobecomecolonisedbymicroorganisms.
Table B4.6: Risk factors for IVD-related BSI
Prolonged hospitalisation before the IVD is inserted Prolonged placement of the device Heavy microbial colonisation of the insertion site that contaminate the catheter during insertion and migrate along the cutaneous catheter track Heavy microbial colonisation of the cannula/catheter hub, usually secondary to contamination from healthcare workers hands during care interventions such as injections Antibiotic use during catheterisation.
Themicroorganismsthatcolonisecatheterhubsandtheskinadjacenttotheinsertionsitearethesourceof mostIVDrelatedBSI.Coagulasenegativestaphylococci,particularlyStaphylococcusepidermidis,arethemost frequentlyimplicatedmicroorganisms.OthermicroorganismscommonlyinvolvedincludeStaphylococcus aureus,Candidaspeciesandenterococci. ProlongeddurationofperipheralIVcathetersgreatlyincreasestheriskofinfectionwhileonly12%of peripheralcathetersremaininplaceforlongerthan2days,theseareassociatedwith90%ofIVDrelated BSIs(CollignonP,unpublishedstudy).

Minimising the risk from intravascular access devices
Tominimisetherisktopatients,IVDsshouldonlybeusedwhenabsolutelynecessary.Theymustbe removedassoonastheyarenolongerneededoralternativemeansareavailabletodeliverappropriatecare (e.g.oraldrugsinsteadofIVdelivery).PreventionofcatheterrelatedBSIrequiresasetofinfectioncontrol measures(seecarebundlesboxbelow). DecisionmakingaboutIVDs DecisionmakingaboutIVDsshouldinvolvethefollowingconsiderations.Ineverycase,thedevicethat posesthelowestrisktothepatientshouldbeused. Whereverpossible,oraladministrationispreferabletoadministrationthroughanIVD. Ifthisisnotpossible,aperipheralvenousaccesscatheterissaferthanacentralvenousaccesscatheter. Ifacentralvenousaccesscatheterisnecessary,itmustbeinsertedunderfullsterileconditions (i.e.similartosurgicalprocedures). Iflongtermadministrationisrequired(e.g.forhaemodialysis),arranginginsertionofapermanentaccess device(e.g.afistula)assoonaspossiblewillreducetheriskofsepsis. IVDsshouldberemovedassoonastheyarenolongerneededorasaferalternativecanbeused.
Table B4.7: Central venous catheter decision tree for adults
Assess the physical status and vascular access history of the patient Base a decision on the type and duration of therapy required Carefully consider the need for central v peripheral vascular access Do not lose sight of the patient as the focus for your decision Ensure clear documentation of all key events in the clinical record
Source: The Canberra Hospital Sitepreparation Selectingthebestinsertionsiteforthepatientcanminimisetheriskofinfection.Factorsthatmay influencesiteselectionincludepatientspecificfactors(e.g.preexistingcentralvenousaccessdevice, anatomicdeformity,bleedingdiathesis,sometypesofpositivepressureventilation),relativeriskof mechanicalcomplications(e.g.bleeding,pneumothorax,thrombosis)andtheriskofinfection.

CONSULTATIONDRAFTJANUARY2010 Sufficientcontacttimeshouldbeallowedforappropriateskinpreparation.Thesitepreparedmustbe largeenoughfortheinsertionandshouldbecleanedbeforeantisepsisisapplied.Theskinpreparation productmustbecompletelydrybeforeinsertionoftheIVD,asthisallowstimefortheantiseptictowork anddryingisanessentialcomponentofitsaction. Thereisstrongevidence(GradeA)thatskinpreparationwithchlorhexidinegluconatesolutionreduces devicecolonisation(althoughthereisnoclearevidencethatthisaffectsIVDrelatedBSIsorphlebitis incidence).Chlorhexidinehasconsistentlybeenshowntobesuperiortoothersolutions,including povidoneiodine,70%alcoholandsodiumhypochlorite(ExSept)inawiderangeofdevices.A chlorhexidinealcoholsolutionwithaminimumconcentrationof0.5%chlorhexidineand70%isopropyl alcoholshouldbeusedforskinpreparation.Iftherearespecificallergiesinpatients,thenalternatives suchaspovidoneiodinecanbeused. Thereissomeevidencethatatwostepapplicationof0.5%alcoholbasedchlorhexidine,followedby 10%aqueouspovidoneiodine,reducesdevicecolonisationrates,morethaneithersolutionusedalone, inshorttermcentralvenousdevices. Thereissomeevidencethatalcoholbasedchlorhexidineandpovidoneiodinesolutionscanreduce devicecolonisation,incomparisontouseofaqueousbasedpreparationsofthesameantiseptics,for shorttermcentralvenousandperipheralarterialdevices. Ifchlorhexidineiscontraindicatedorunavailable,thereissomeevidencethat5%alcoholbased povidoneiodineissuperiorto10%aqueouspovidoneiodineforpreventionofbothdevicecolonisation andIVDrelatedBSIinshorttermcentralvenousdevices. Thereiscurrentlynodirectevidencefortheefficacyandsafetyofanycleansingproductinlow birthweightneonateswhomaybeatriskofskinand/orsystemictoxicity.
InsertionofIVDs Thereissomeevidence(GradeB)thatmaximumbarrierprecautions(inserterwearsmask,cap,sterile gown,sterilegloves,useslargesteriledrape;assistantwearscapandmask)reduceimmediatepost insertionskincolonisationinshorttermcentralvenousdevices.Maximumbarrierprecautionsshould thereforebeusedfortheinsertionofallcentralvenouscatheters,includingperipherallyinsertedcentral venouscatheters(PICClines). Ifanintravasculardeviceisinsertedinanemergency,itshouldberemovedwithin24hoursandanew deviceinsertedunderappropriateconditions. WhenPICCinsertionisdoneatthebedside(i.e.inthepatientsroom),asuitablesterilefieldshouldbe establishedandmaintainedthroughouttheprocedure. Thereissomeevidencethatmaximumbarrierprecautionsarenotnecessaryforinsertionofshort peripheralvenousorarterialdevices;devicecolonisationorIVDrelatedBSIwasnotreducedcompared towhenstandardgoodpracticecarewasused(inserterwearssterileglovesandusessterileequipment).
Maintenance Thesafemaintenanceofanintravasculardeviceincludesgoodpracticeincaringforthepatients catheterhubandconnectionporttoavoidcontaminationbystaffhands,theuseofanappropriatesite dressingregimen,andusingflushsolutionstomaintainthepatencyoftheline. Handantisepsisandaseptictechniqueareessentialforchangingcatheterdressingsandforaccessing thesystem. Forpatientswhorequirelongtermvenousaccess(e.g.renaldialysis),itisdesirabletoputinpermanent accessdevicesassoonaspossible(e.g.fistulas),asthesereducetheriskofinfectioncomparedtoother formsofIVaccess.
Choiceofdressings Thereisstrongevidence(GradeB)thattheuseofchlorhexidineimpregnated(CHG)spongesatthe catheterinsertionsitesignificantlyreducesIVDrelatedbloodstreaminfectionanddevicecolonisation rates.TheuseofCHGspongesisthereforerecommendedforperipheralarterialdevices,shortterm andlongtermcentralvenousdevices.Thesafetyofthesespongeshasnotbeenestablishedinlow birthweightneonateswhomaybeatriskofskinorsystemictoxicity.

CONSULTATIONDRAFTJANUARY2010 Eithersterilegauzeorsterile,transparent,semipermeabledressingshouldbeusedtocoverthecatheter site.Ifthepatientisdiaphoretic,orifthesiteisbleedingoroozing,agauzedressingispreferabletoa transparent,semipermeabledressing. Thereissomeevidencethatafter3weeksinsitu,tunnelledandcuffedcentralvenouscathetersin oncologypatientswillhaveequivalentinfectionrateswhennodressingorgauzedressingisused. Thereissomeevidencethatgauze,transparent,ortapedressingshaveequivalentphlebitisincidencein peripheralintravenousdevices. Thereissomeevidencethatgauzewithtape,ortransparentpolyurethanedressings(includinghighly moisturepermeabledressings)areequivalentinpreventinginfectiouscomplicationsinshortandlong termcentralvenousdevices. Thereissomeevidencethattransparentdressingsandgauzedressingsareequivalentinlongterm centralvenousdevicesusedforhaemodialysis. Antibioticorantimicrobialointments(suchascalciummupirocinandpolysporin)arestrongly recommendedforuseinthemanagementoftunnelledhaemodialysiscentralvenouscathetersasthey significantlyreducethenumberofIVDrelatedBSIs(GradeA).
Changingdressings Theevidence(GradeC)supportsdailyexaminationofshorttermvascularcatheterdressingstoassess whethertheyrequirechanging.Dressingchangeisindicatedwherethedressingislooseorsoiled. Thereisstrongevidencethatscheduledsevendayreplacementoftransparentdressingsforshortterm centralvenousandperipheralarterialdevices(withorwithoutCHGsponges)isequallyaseffectivein preventingdevicecolonisationandIVDrelatedBSIasscheduledthreedayreplacement.Inconjunction withscheduledsevendayreplacement,dressingsmustbevigilantlymonitoredandadditionaldressing changesperformedwheneverdressingsaresoiledorloose. Thereissomeevidencethateightdayreplacementoftransparentdressingsfortunnelledcentral venousdevicessignificantlyreducesskintoxicity,anddoesnotchangeIVDrelatedBSIrates,compared withfourdayreplacement.Inconjunctionwitheightdayreplacement,dressingsmustbevigilantly monitoredandadditionaldressingchangesperformedwheneverdressingsaresoiledorloose. Evidenceregardingpaediatriccentralvenousdevicedressings(GradeC)suggeststhattheseshouldbe changedatleasteverysevendays.Dressingsshouldbeexamineddailyandchangediftheybecome soiledofloosenedorthepatientsclinicalpresentationindicatesaBSI.
Devicereplacement Whilemoststudiesusephlebitis(whichmayhaveachemicalortraumaticbasis)asanendpointand findlittleornobenefitsforroutinelychangingshortperipheralveincatheters,evidencesuggeststhat bacteraemiaisdisproportionatelyassociatedwithcathetersinplaceformorethan2days.Removinga cathetereliminatestheriskforassociatedsepsis.Thereforeallintravasculardevicesshouldberegularly assessedandremovedassoonastheyarenolongerrequiredorifcomplicationsoccur.
Intheadultpopulation Peripheralintravenousdevicesshouldbemonitoredcloselyandroutinelyreplacedevery2to3daysor soonerifclinicallyindicated. Centralvenouscathetersandperipherallyinsertedcentralvenouscatheter(PICC)linesshouldnotbe replacedroutinelytopreventcatheterrelatedinfections.Thereissomeevidencethatroutine replacementofshorttermcentralvenousdevicescomparedwithreplacementonclinicalindicationhas noeffectonIVDrelatedBSIratesperpatient. It is recommended to leave peripheral venous catheters in place until IV therapy is completed unless a complication, such as a blood stream infection, occurs. Do not routinely replace central venous catheters, PICCs or pulmonary artery catheters to prevent catheter-related infections. Use clinical judgment regarding the appropriateness of removing and changing the catheter.
Inneonatesandchildren
CONSULTATIONDRAFTJANUARY2010 Replacementofadministrationsets Thereisstrongevidence(GradeB)thatadministrationsetsthatdonotcontainlipids,bloodorblood productsmaybeleftinplaceforintervalsofupto4days. Tubingusedtoadministerblood,bloodproducts,orlipidemulsionsshouldbereplacedwithin24hours ofinitiatingtheinfusion.
Patient care Before discharge from hospital, patients and their carers should be provided with education, supported by written instructions, on the management and care of an indwelling device, including the prevention of infection. Table B4.8: Summary of processes for insertion and maintenance of intravascular access devices
Site preparation In selecting the best insertion site, consider patient-specific factors and the relative risk of mechanical complications Allow sufficient contact time for site preparation Before insertion of the device, decontaminate the skin site using a single-use application of alcohol-based chlorhexidine gluconate solution (0.5% chlorhexidine gluconate in 70% isopropyl alcohol) For patients with a history of chlorhexidine sensitivity, use 5% alcohol-based povidone-iodine solution Insertion Maintenance Use maximum barrier precautions for insertion of all central venous catheters, including PICC lines Use aseptic technique for insertion of peripheral venous or arterial devices Use hand antisepsis and aseptic technique for catheter site care and for accessing the system Use CHG sponge dressings for peripheral arterial devices, short-term and long-term central venous devices Use sterile gauze or sterile, transparent, semi-permeable dressings to cover the catheter site Assess devices daily and remove if no longer needed or if complications occur Examine dressings daily and change if soiled or loosened Do not replace central venous lines or PICC lines routinely Routinely replace peripheral intravenous devices every 2 to 3 days or sooner if clinically indicated In paediatrics, replace all catheters once IV therapy is complete unless there are indications of a blood stream infection
IVD care bundles
Thereanumerouscarebundlesinuseonthemanagementofcentralandperipheralvasculardevices. InformationonbundlesandtheirimplementationisdiscussedearlierinchapterB.4.2. Someexamplesofbundlesonmanagingintravasculardeviceshavebeenprovidedbelow.Priorto implementingacarebundleitisimportanttoidentifythecurrentpracticeusedinthatparticulararea. Identificationofgapsorneedsinserviceprovisionneedtobeanalysedandsystematicallyaddressthrough theimplementationofthebundle. Therearemanybundlesavailable.Someexamplesare: iCAREhttp://www.health.qld.gov.au/chrisp/icare/about.asp HealthProtectionScotlandhttp://www.hps.scot.nhs.uk/haiic/ic/bundles.aspx
CONSULTATIONDRAFTJANUARY2010 B4.2.3 Ventilation
Certainpatientsrequiremechanicalventilatorysupportbyendotrachealtubeortracheostomy.Common medicalindicationsincludeacutelunginjury,chronicobstructivelungdiseaseandacuterespiratory acidosis.

What are the risks?
Ventilatorassociatedpneumonia(VAP)isatypeofhospitalacquiredpneumoniathatcanoccurinpatients whohavebeenonmechanicalventilationformorethan2days.VAPprimarilyoccursbecause microorganismscolonisetheendotrachealortracheostomytubeandareembolisedintothelungs,oftenin patientswhomayhaveunderlyinglungorimmuneproblems.Bacteriamayenterthelungswithprocedures suchasbronchoscopy. VAPisacommoncauseofmorbidityandmortality,occurringinupto25%ofallpeoplewhorequire mechanicalventilation.VAPcandevelopatanytimeduringventilation,butoccursmoreofteninthefirst fewdaysafterintubation,becausetheintubationprocessitselfcontributestothedevelopmentofVAP.Itis associatedwithanincreaseddurationofmechanicalventilation,crudedeathratesof5to65%,andincreased healthcarecosts.
Minimising the risks of VAP
ManypracticeshavebeendemonstratedtoreducetheincidenceofVAPanditsassociatedburdenofillness. Thefirstconsiderationshouldalwaysbewhetherintubationisnecessary. Physicalstrategies OralendotrachealintubationisassociatedwithatrendtowardareductioninVAPcomparedto nasotrachealintubationandwithadecreasedincidenceofsinusitis(theincidenceofVAPislowerin patientswhodonotdevelopsinusitis).Reintubationshouldbeavoidedifpossible. ThefrequencyofventilatorcircuitchangesdoesnotinfluencetheincidenceofVAP.Circuitsshouldbe changediftheybecomesoiledordamaged.Newventilatorcircuittubingshouldbeprovidedforeach patient. ThereisnodifferenceintheincidenceofVAPbetweenpatientswhoseairwaysarehumidifiedusinga heatandmoistureexchangerandthosewhoseairwaysarehumidifiedusingaheatedhumidifier.The decisionshouldbemadeforeachpatient,withtheaimtoensureadequatemoistureoutputtominimise theriskofairwayobstruction. Lessfrequentheatandmoistureexchangerchangesmaybeassociatedwithaslightlydecreased incidenceofVAP.Reducingthefrequencyofhumidifierchangesmightbeconsideredasacostreduction measure. ThetypeofsuctioningsystemhasnoeffectontheincidenceofVAP.Safetyconsiderations(patientand healthcareworkerexposuretoaerosolisedsecretions)favourtheuseofclosedsystems.Thenumberof disconnectionsofsuctionequipmentshouldbeminimisedtoreducetheriskofexposuretostaffto potentiallyinfectedsecretions ScheduleddailychangesandunscheduledchangesofclosedsystemshavenoeffectonVAP. SubglotticsecretiondrainageisassociatedwithadecreasedincidenceofVAP.Toincreasetheirutility andcosteffectiveness,thesetubesshouldonlybeplacedinpatientsexpectedtorequireprolonged mechanicalventilation. Positionalstrategies TheuseofrotatingbedsisassociatedwithadecreasedincidenceofVAP. SemirecumbentpositioningmaybeassociatedwithadecreasedincidenceofVAP.However,semi recumbentpositioningmaybeunsafeforsomepatients. Pharmacologicstrategies TheuseoftheoralantisepticchlorhexidinemaydecreasetheincidenceofVAP.Safety,feasibility,and costconsiderationsforthisinterventionareallveryfavorable.
CONSULTATIONDRAFTJANUARY2010 TheuseoftheoralantisepticpovidoneiodinedecreasestheincidenceofVAPinpatientswithsevere headinjuries.Safety,feasibility,andcostconsiderationsforthisinterventionareallveryfavorable.There areinsufficientdatatomakearecommendationincriticallyillpatientsotherthanthosewhohavesevere headinjury.

Table B4.9: Summary of strategies for preventing VAP
Physical strategies Positional strategies When intubation is necessary, use the oro-tracheal route Use new circuits for each patient and change these if they become soiled or damaged Change heat and moisture exchangers for each patient every 57 days and as clinically indicated Use a closed endotracheal suctioning system Change the endotracheal system for each patient and as clinically indicated Use subglottic secretion drainage in patients expected to be mechanically ventilated for more than 3 days Assess patients for sedation, weaning and extubation each day Consider the use of rotating beds Elevate the head of the bed to 45. Where this is not possible, raise the head of the bed as much as possible Pharmacological strategies Consider the use of the oral antiseptic chlorhexidine For patients with severe head injury, consider the use of the oral antiseptic povidone-iodione
Table B4.10: VAP care bundle

Sedation to be reviewed and, if appropriate, stopped each day Assess all patients for weaning and extubation each day Avoid supine position, aiming to have the patient at least 30 head up Use chlorhexidine as part of daily mouth care Use subglottic secretion drainage in patients likely to be ventilated for more than 2 days
Source: ReproducedfromtheHealthProtectionScotlandInfectionControlTeamBundles http://www.hps.scot.nhs.uk/haiic/ic/bundles.aspx
B4.2.4
Enteral feeding tubes
Enteralfeedingisusuallyprescribedforpatientsinhospitalrequiringartificialnutritionsupportfor710 daysandlongtermfeeding/homeenteraltubefeedingmaybeconsideredforpatientsneedingartificial nutritionsupportformorethan30days.

What are the risks?
Contaminationoffeedsisakeyconcerninboththehospitalandcommunitysetting,withcontamination largelyoccurringduringthepreparationoradministrationoffeedsandbeinglinkedtoseriousclinical infection.

Minimising the risks of enteral feeding tubes
Mostevidenceconcerningenteralfeedingrelatestogastrostomyorpercutaneousendoscopicgastrostomies (PEGfeeds).However,theprinciplesoutlinedherearealsoapplicabletonasogastricandjejunostomy feeding. Standardprinciplesstresstheimportanceofhandhygieneandexpertopinionstressestheneedto preparetheworksurfaceand,wherenecessarytheequipmentforreconstitutingordilutingthefeed. Evenclosedsystemscanbecomecontaminatedifhandhygieneisnotadequate.

CONSULTATIONDRAFTJANUARY2010 Closedsystems(i.e.sterileprefilledreadytousefeedsthatdonotexposefeedtotheairduring assembly)asavailablefromallmajormanufacturers,havelowercontaminationratesthanopensystems. Thedesignofthesystemisalsoimportantinordertominimisehandling. Bacterialcontaminationhasbeenassociatedwiththereuseoffeedbagsandadministrationsets.As evidencesuggestsreuseisnotadvisable,theadministrationsystemshouldbeconsideredsingleuseonly anddiscardedaftereachsession. Thereissomeevidencerelatedtoinfectionimmediatelyafterinsertionofthefirsttube,butnoevidence relatingtoinfectionsinahealedstoma. Tohelpminimisethepotentialriskofmicrobialcolonisationoftheinternalandexternalsurfacesof enteralfeedingtubes,expertopinionsuggeststhatthetubeshouldbeflushedwitheithercooledboiled waterorfreshlyopenedsterilewaterbeforeandaftereachchangeoffeed,aspirationormedication administration.Freshtapwatermaybesafelyusedforflushingenteralfeedingtubesin immunocompetentpatients.
Patients and carers should be educated in techniques of hand hygiene, enteral feeding and the management of the administration system before being discharged from hospital. Table B4.11: Summary of processes for using enteral feeding tubes
Preparation Administration Care of insertion site and enteral feeding tube Perform hand hygiene before starting feed preparation Wherever possible, use pre-packaged, ready-to-use feeds If decanting, reconstitution or dilution is required, use a clean working area and equipment dedicated for enteral feed use Mix feeds with cooled boiled water or freshly opened sterile water using a non-touch technique Perform hand hygiene immediately before administration Use minimal handling and a clean technique to connect the administration system to the enteral feeding tube Use clean technique for administration of medications Discard administration sets and feed containers after each feeding session Perform hand hygiene immediately before commencing Wash the stoma daily with water and dry thoroughly Flush the enteral feeding tube with fresh tap water before and after feeding or administering medications (use freshly boiled water or sterile water for patients who are immunosuppressed)
CONSULTATIONDRAFTJANUARY2010 B4.3 SURGICAL PROCEDURES
The discussion in this section applies to all surgical procedures regardless of setting. While there is less evidence for surgical procedures in office-based practice than in hospitals, the same principles apply. B4.3.1 What are the risks?
Themicroorganismsthatcausesurgicalsiteinfectionsareusuallyderivedfromthepatient(endogenous infection),beingpresentontheirskinorfromanopenedviscus.Exogenousinfectionoccurswhen microorganismsfrominstrumentsortheoperatingenvironmentcontaminatethesiteatoperation,when microorganismsfromtheenvironmentcontaminateatraumaticwound,orwhenmicroorganismsgain accesstothewoundaftersurgery,beforetheskinhassealed. Theriskofsurgeryrelatedinfectionisincreasedbyfactorsthat: increasetheriskofendogenouscontamination(e.g.proceduresthatinvolvepartsofthebodywithahigh concentrationofnormalflorasuchasthebowel); increasetheriskofexogenouscontamination(e.g.prolongedoperationsthatincreasethelengthoftime thattissuesareexposed);and diminishtheefficacyofthegeneralimmuneresponse(e.g.diabetes,malnutrition,orimmunosuppressive therapywithradiotherapy,chemotherapyorsteroids)orlocalimmuneresponse(e.g.foreignbodies, damagedtissueorformationofahaematoma). B4.3.2 Minimising the risk of surgical procedures
Practicestopreventsurgicalsiteinfectionsareaimedatminimisingthenumberofmicroorganisms introducedintotheoperativesite,forexampleby: removingmicroorganismsthatnormallycolonisetheskin; preventingthemultiplicationofmicroorganismsattheoperativesite,forexamplebyusingprophylactic antimicrobialtherapy; enhancingthepatientsdefencesagainstinfection,forexamplebyminimisingtissuedamageand maintainingnormothermia;and preventingaccessofmicroorganismsintotheincisionpostoperativelybyuseofawounddressings.

Patients and carers require clear, consistent information and advice throughout all stages of their care, including: the risks of surgical site infections, what is being done to reduce them and how they are managed; how to care for their wound after discharge; and how to recognise a surgical site infection and who to contact if they are concerned.
An integrated care pathway helps to communicate this information to both patients and all those involved in their care after discharge. Patients should always be informed if they have been given antibiotics.
B4.3.3
Considerations pre-procedure
TheimportanceofhandhygieneforhealthcareworkersisdiscussedinSectionB1.1.Artificialnailsand jewellerymayconcealunderlyingsoilingandimpairhanddecontamination,andshouldnotbewornby healthcareworkersperformingorassistinginsurgicalprocedures. Incarryingoutprocedures,thereisaneedtominimisetheriskofmicrobialcontaminationofthe operatingsitefromtheenvironment.Althoughthereislimitedevidenceconcerningtheuseofdedicated nonsterileoperatingattire(scrubsuits,masks,hatsandovershoes)bygeneralstaffintheoperating environment,itmaycontributetominimisingoperatingenvironmentcontaminationandreducetherisk ofsurgicalsiteinfection.
B4.3 Surgical procedures 121
CONSULTATIONDRAFTJANUARY2010 Whilethereisevidencetosupporttheefficacyofpreoperativeshoweringofpatientsinthehospital settingasameasuretoreducetherateofsurgicalsiteinfection,thereisnoevidenceofadifferenceon surgicalsiteinfectionratebetweenchlorhexidineasacleansingagentandplaindetergentorsoap.In addition,chlorhexidinehasbeenfoundnottobecosteffectiveforthisapplication. Thereisnoevidencethathairremovalfrompatientsinfluencestheincidenceofsurgicalsiteinfection, butitmightbeappropriateinsomeclinicalcircumstances. Antibioticprophylaxishasbeenusedeffectivelytopreventsurgicalsiteinfectionsforappropriate operativeproceduressince1969.Prophylaxisusuallyinvolvesasingledoseofantibioticoftengivento thepatientintravenously,closetothetimeofsurgeryanddiffersfromtreatmentthatentailsacourseof antibioticsoveraperiodoftime.Incommonwiththerapeuticuse,theuseofantibioticsforprophylaxis carriesariskofadversedrugreactions(includingClostridiumdifficileassociateddiarrhoea)andincreased prevalenceofantibioticresistantbacteria.Thechoiceofantibioticprophylaxisshouldbebasedonthe AustralianTherapeuticGuidelines. Theevidencesuggeststhatmupirocinorchlorhexidinenasaldecontaminationdoesnotreducethe overallrateofsurgicalsiteinfection.
Table B4.12: Summary of processes pre surgical procedure
Hand preparation If hands are visibly soiled, perform hand hygiene with plain soap prior to scrubbing Remove debris from underneath fingernails using a nail cleaner, preferably under running water Using a suitable antimicrobial soap, preferably with a product ensuring sustained activity, scrub hands and forearms for the length of time recommended by the manufacturer Operating suite/room or procedure attire Patient preparation The operating team must wear sterile operation or procedure attire. All operating suite/room staff who are not operating within the sterile field must wear dedicated non-sterile attire in all areas where operations are undertaken. Movements in and out of the operating area should be kept to a minimum. The operating team should remove hand jewellery before operations The operating team should not wear artificial nails or nail polish during operations Advise patients to shower or have a bath (or help patients to shower, bath or bed bath) using soap, either the day before, or on the day of, surgery Avoid routine removal of hair if clinical circumstances require hair removal, electric clippers with a single-use head are preferred to razors, and hair removal should occur on the day of surgery Provide antibiotic prophylaxis where appropriate. Do so in accordance with the Australian Therapeutic Guidelines Do not routinely use nasal decontamination with topical antimicrobial agents aimed at eliminating Staphylococcus aureus
B4.3.4 Considerations during a surgical procedure Handhygienebeforesurgeryisrequiredtominimisetheriskthattheresidentfloraofmicroorganisms thatnormallycolonisetheskin,and/ortransientorganismsacquiredbytouch,contaminatethesurgical wound.Whiletransientmicroorganismsarereadilyremovedbysoapandwater,antisepticssuchas alcoholordetergentsolutionscontainingchlorhexidineandpovidoneiodinearerequiredtoeliminate residentmicroorganismsthatresideindeepcrevicesandhairfollicles. Inthehospitalsetting,itisgoodpracticetousesterilegownsintheoperatingarea,topreventpatients frombeingexposedtotheriskofcontamination. Thereisnoavailableevidencethatdoubleglovingreducestheriskofsurgicalsiteinfectionorthatglove perforationincreasestheriskofsurgicalsiteinfection.However,currentpracticeinvolvesdoublegloving incircumstanceswhentheriskofgloveperforationanditsconsequencesforcontaminationofthe operativefield(inprostheticsurgeryforexample)ishigh.
CONSULTATIONDRAFTJANUARY2010 Thereisnoevidenceofdifferencebetweenchlorhexidineandpovidoneiodine(eitheraqueousor alcoholbasedpreparation)forantisepticskinpreparationandthecostsaresimilar. Thereisaneedforsafeoperatingsuite/roompracticewhenusingalcoholbasedantisepticskin preparationspriortoincisionwithdiathermy.Theevidencesuggeststhatthereisnodifferencebetween ratesofsurgicalsiteinfectionwherediathermyisusedtomakeanincisioncomparedwithconventional techniques. Althoughtheuseofnoniodophorimpregnatedincisedrapesisroutineinsomeoperations(suchas prostheticjointorgraftsurgery),theymaymarginallyincreasetheriskofsurgicalsiteinfection. However,adhesivedrapesmayhavearoleinmaintainingtheintegrityoftheoperativesite/field. Evidencefromsmallsurgeryspecificstudiesupto2030yearsoldsuggestthatintraoperative subcutaneouswoundirrigationwithpovidoneiodineorwithsalineunderpressurereducesthe incidenceofsurgicalsiteinfection.Althoughthiswasconsideredtobeanadjuncttoantibiotic prophylaxisincontaminatedsurgery,currentpracticehasimprovedtomakethisapproachunnecessary forthepreventionofsurgicalsiteinfection. Thereisnoevidencethatintracavitylavagewithantibiotics,otherthanasinglesmallstudyof tetracyclinelavageaftercontaminatedsurgery,reducestheincidenceofsurgicalsiteinfection.Thereis someevidencethatpostoperativelavageoftheperinealspacewithpovidoneiodinereducessurgicalsite infection. Thereisevidencethatredisinfectionoftheskinadjacenttothewoundwithiodineinalcoholsolution priortoincisionalclosurehasnoeffectontheincidenceofsurgicalsiteinfection. Theinstillationofcefotaximeintowoundspriortoclosureappearstohavenoeffectonsurgicalsite infectionincidenceaftersurgeryforperitonitis. Thereisnorobustevidencetosupporttheuseofadressingintheimmediatepostoperativeperiodfor thepreventionofsurgicalsiteinfection.However,itisgenerallyacceptedgoodclinicalpracticetocover thewoundwithanappropriateinteractivedressingforaperiodof2daysunlessotherwiseclinically indicated,forexample,ifthereisexcesswoundleakageorhaemorrhage. Thereisnorobustevidencetosupporttheuseofonedressingoveranother.However,inthemajorityof clinicalsituationsasemipermeablefilmmembranewithorwithoutanabsorbentislandispreferable.
Table B4.13: Summary of processes during a surgical procedure
Hand hygiene Perform hand hygiene before the first operation on the list using an aqueous antiseptic surgical solution, according to the manufacturers instructions for the product which is being used. Use a single-use brush or pick for the nails, and ensure that hands and nails are visibly clean Before subsequent operations, perform hand hygiene using an antiseptic surgical solution. If hands are soiled during a procedure, hand hygiene should be performed again with an antiseptic surgical solutio Operating suite/room attire Patient preparation In hospital settings, wear sterile gowns during the procedure Consider wearing two pairs of sterile gloves when there is a high risk of glove perforation Prepare the skin at the surgical site immediately before incision using an antiseptic (aqueous or alcohol-based) preparation: chlorhexidine or povidone-iodine are most suitable If diathermy is to be used, use aqueous-based preparations or ensure that antiseptic skin preparations are dried by evaporation and there is no pooling of alcohol-based preparations If an incise drape is required, use an iodophor-impregnated drape unless the patient has an iodine allergy. Do not use non-iodophor-impregnated incise drapes routinely for surgery as they may increase the risk of surgical site infection
B4.3 Surgical procedures 123
Wound management Avoid routine use of wound irrigation or intracavity antibiotic lavage as measures to reduce surgical site infection Avoid routine use of intraoperative skin re-disinfection or topical cefotaxime as measures to reduce the risk of surgical site infection in abdominal surgery It is recommended that at the end of the operation, surgical incisions are covered with an appropriate dressing such as semi-permeable film membrane with or without an absorbent island
B4.3.5 Considerations post-procedure Thereisnohighqualityevidenceavailablethatsupportsachangetothecurrentclinicalpracticeofusing anaseptictechnique.However,theuseofaseptictechniquewhenremovingorchangingsurgicalwound dressingscanminimisetheriskofcontaminatingthesitewithadditionalmicroorganisms. Manyofthetrialsinvestigatingdressingforwoundhealingbysecondaryintentionareoldandmostof thematerialsuseddonotreflecttheunderlyingprinciplesofcurrentwoundmanagementandmayhave adetrimentaleffectonthepatientsexperience(e.g.pain).Anumberofnewdressingscontaining antimicrobials,suchashoney,silverandcadexomeriodine,arenowavailableandmaybeclinically appropriate.However,todate,thereisnoevidencetoprovetheirefficacyinprophylaxisofsurgicalsite infection(SSI). Therewasnoevidenceavailablethatexaminedtheeffectsofwoundcleansingsolutionsforthe preventionofSSI. NotallSSIsrequireantibiotictreatment:minorinfectionsmayrespondtodrainageofpus(forexample, byremovalofsutures)andtopicalantisepsis.Antibiotictherapycarrieswithittheriskofadversedrug reactionsandthedevelopmentofantimicrobialresistantbacteriaaswellastheassociatedriskof C.difficilediarrhoea. Itisgoodpracticetodiscardallusedoperatingsuite/roomattirepriortoleavingtheoperatingareato preventhealthcareworkers,patientsandvisitorsfrombeingexposedtotheriskofcontamination.
Table B4.14: Summary of processes following a surgical procedure
Dressings Use an aseptic technique for changing or removing surgical wound dressings Avoid the routine use of topical antimicrobial agents for surgical wounds that are healing by primary intention as measures to reduce the risk of surgical site infection Avoid the use of use Eusol and gauze, or moist cotton gauze or mercuric antiseptic solutions to manage surgical wounds that are healing by secondary intention Use an appropriate dressing (such as semi-permeable film membrane with or without an absorbent island) to manage surgical wounds that are healing by secondary intention Cleansing Management of surgical site infection Use sterile saline for wound cleansing up to 2 days after surgery Advise patients that they may shower safely 2 days after surgery When surgical site infection is suspected, either de novo or because of treatment failure, take a culture and give the patient an antibiotic that covers the likely causative organisms. Consider local resistance patterns in choosing an antibiotic and review the selection in light of results of microbiological tests Avoid the use of Eusol and gauze, or dextranomer or enzymatic treatments for debridement in the management of surgical site infection
CONSULTATIONDRAFTJANUARY2010 B4.4 B4.4.1 PUTTING IT INTO PRACTICE Checklist of standard precautions for procedures
Thistableoutlinestheuseofstandardprecautionsforarangeofprocedures.Itisassumedthatthereisno knownorsuspectedinfection.Decisionmakingaboutthelevelofprotectionrequiredinvolvesarisk assessmentoftheproceduretobeperformed;forexample,usualwoundirrigationisunlikelytorequire surgicalmaskandeyeprotectioninprimarycare,butmayberequiredmoreofteninthehospitalsetting.

Table B4.15: Checklist of standard precautions for procedures
Procedure Activities of daily living (washing, toilet etc) Routine observations (e.g. blood pressure measurement) Hand hygiene Gloves Sterile gloves Surgical mask Eye protection Gown
General medical examination
For contact with broken skin/ rash/ mucous membrane For contact with body substances
If splash risk likely
Wound examination/dressing Blood glucose and haemoglobin monitoring Intravenous cannula insertion
For direct contact with wound
For wound irrigation if splash likely
For wound irrigation if splash likely
For grossly infected wounds
Intravascular access device insertion
(Where max. barrier precautions are used)
Intravascular access device care Sterile procedure (e.g. lumbar puncture) Insertion of urinary catheter
If exposure risk likely
If exposure risk likely When emptying drainage bag
Urinary catheter care
Suctioning: endotracheal tube, tracheostomy Major dental procedures (e.g. complex oral surgery, periodontal surgery) Routine dental procedures including dental examinations
Dominant hand (open suction system)
PART C
ORGANISATIONAL SUPPORT
For infection prevention and control to be effective at the clinical level, much organisational support is required. This includes embedding infection control into governance and management structures, initiating procedures (e.g. immunisation programs) to ensure that health care workers are protected, instituting processes for surveillance that feed into the overall quality control program, implementing systems for ongoing staff education and training, and incorporating infection control into planning for facility design and maintenance. Infection control is an occupational health and safety issue, which means that all those working in the healthcare facility managers, healthcare workers and support staff are responsible for providing a safe environment for patients and other staff. Organisational support should aim to ensure that clinical work practices provide patient-centred care this is not only essential from a safety and quality perspective but out of consideration for patient preferences. This may require consultation with patients and relevant consumer groups in the development of health care services. The information presented in this Part is particularly relevant to managers of healthcare facilities. It outlines responsibilities of management of healthcare facilities, including governance structures that support the implementation, monitoring and reporting of effective work practices. While the focus of the information is acute care facilities, much of the information is relevant in other healthcare settings.
Part C Organisational support 126
CONSULTATIONDRAFTJANUARY2010 C1 MANAGEMENT AND CLINICAL GOVERNANCE
Summary To be effective, infection prevention and control must be a priority in every healthcare facility this requires total commitment at every level of the organisation. Organisational capacity is achieved by having appropriate governance and management structures. This means that managers are aware of the healthcare facilitys performance in terms of infection transmission and there are systems in place to prevent the transmission of infection, reduce risk and address problems when they arise. The management structure and processes associated with infection control will differ depending on the size of the organisation and the types of healthcare services it delivers. However, the principles of clinical governance apply regardless of the setting and essential roles and responsibilities should be fulfilled. The person in charge of the organisation (e.g. chief executive officer [CEO] of a hospital, principal of an office-based practice) must have overall responsibility for and direct involvement in the organisations infection control program. There must be adequate resourcing for dedicated infection control staff, and resources to run the infection prevention and control program including professional development. Each organisation should define the outcome measures for monitoring infection control policies (see Section C4). All employees should understand their roles and responsibilities and have appropriate training to maintain a safe work environment (see Section C3). Patient-centred health care is safer health care patients healthcare rights must be considered during the development of programs, policies and procedures.
C1.1
CLINICAL GOVERNANCE IN INFECTION CONTROL
Addressinginfectionpreventionandcontrolrequiresafacilitywideprogramandiseverybodys responsibility. Healthcarefacilitieshavealegalresponsibilitytoprovideasafeworkenvironment,safesystemsofwork andasafeenvironmentforpatientsandvisitors. Clinicalgovernancereferstothesystembywhichmanagersandcliniciansineachhealthcarefacilityshare responsibilityandareheldaccountableforpatientcare,forminimisingriskstopatients,andfor continuouslymonitoringandimprovingthequalityofclinicalcare. Preventingtransmissionofinfectiousagentsshouldbeapriorityineveryhealthcarefacility.Thiswill involveactionto: developafacilitywidestrategicplanforinfectioncontrol; establishasystemofinfectioncontrolmanagement(suchasacommittee)withinputfromacrossthe spectrumofclinicalservicesandmanagement,andamechanismforconsideringpatientsfeedback; appointinfectioncontrolpractitionersandsupporttheirprofessionaldevelopment(e.g.attendanceat relevantstateornationalprofessionalorganisationmeetings); incorporateinfectioncontrolintotheobjectivesofthefacilityspatientandoccupationalsafety programs; provideadministrativesupport,includingfiscalandhumanresources,formaintaininginfectioncontrol programs;and provideadequatestafftrainingandprotectiveclothingandequipment,andarrangeworkplace conditionsandstructurestominimisepotentialhazards.
Allhealthcareworkersneedtobeawareoftheirindividualresponsibilityformaintainingasafecare environmentforpatientsandotherstaff.
C1 Management and clinical governance 127
CONSULTATIONDRAFTJANUARY2010 C1.2 ROLES AND RESPONSIBILITIES
Managementandclinicalgovernancecanhaveapositiveimpactontheeffectivenessofinfectionprevention andcontrol,bydrivingcontinuousqualityimprovementandpromotinganonpunitivecultureoftrustand honesty(VictorianQualityCouncil2004).Studieshavefoundthatwhereclinicalgovernanceand managementencouragecollaborationbetweenhealthcaremanagersandclinicians,changeismorelikelyto beachievedthanwherethereisunilateralgovernance(Ham2003).Changeisalsomorelikelytobeachieved andsustainedwhentheroleofpatientsaspartnersintheirhealthcareisstrengthened,andwherethereisa sharedunderstandingoftheroleofpatients,healthcareworkersandorganisationsinachievingthebest possibleoutcomes(ACSQHC2008). Therolesandresponsibilitiesdescribedbelowaremostrelevanttoacutehealthcaresettings.However,all therolesdescribedinthissectionareimportantforeffectiveinfectioncontrolandcanbereadilyadaptedto otherhealthcaresettingsforexample,withthepracticeprincipalfulfillingrelevantrolesand responsibilitiesofaCEO,andtheofficemanagerorotherstaffrepresentativewithaninterestininfection controlfulfillingtheroleofinfectioncontrolpractitioner(seeSectionC1.2.4). C1.2.1 Chief Executive Officer/Administrator
ThehealthcarefacilitysCEOordesignatedequivalentadministratorshouldsupportandpromoteinfection controlasanintegralpartoftheorganisationsculturethroughthefollowingstrategies: havingaperformanceagreementthatincludesinfectionpreventionandcontroloutcomesasakey performanceindicator; endorsingtheinclusionofspecificarticulatedinfectionpreventionandcontrolroles,responsibilitiesand accountabilitiesforrelevantstaffwithinthefacilitysmanagementplan; attendingandparticipatingineachInfectionPreventionandControl(IPC)Committeemeeting; ensuringthatinfectioncontrolpractitionersareresourced: intermsofcoworkers,informationtechnology,accesstouptodateinformation,designatedoffice/ workspaceandtoolstomeetrelevantinfectionpreventionrelatedlegislative,regulatoryand accreditationrequirements; toachievenegotiatedhealthcareassociatedinfectionreductiontargetsandtoperformtheessential tasksoutlinedinSectionC1.2.2below; ensuringthatthehospitalsIPCprogramincludesinvolvementofamedicalpractitionertosupportand playasharedleadershiprole; ensuringthattherightsofpatients,asarticulatedintheAustralianCharterofHealthcareRights,are integraltotheIPCprogram; committingtotheIPCprogramvision,mission,priorities,targetsandannualinfectionpreventionplan withspecific,measurablegoalsforhealthcareassociatedinfectionriskmitigationandreductionthese shouldbeoutlinedinanannualinfectionpreventionandcontrolbusinessplanwhichtheCEO(orhisor herdesignate)andtheinfectioncontrolpractitionerjointlydevelop; supportinganorganisationalculturethatpromotesindividualresponsibilityforinfectionprevention andcontrolamongallstaffandvaluestheIPCprogramcontributiontothesafetyofpatients,healthcare workersandothersthissupportincludesensuringIPCprogramstaffinglevelsaresufficientand incorporatingresponsibilityforinfectionpreventionandcontrolintoeverystaffmembersjob description; authorisinginfectioncontrolpractitionersto: implementIPCprogramrecommendations; intervenewhenclinicalorotherpracticesposeinfectionrisks(e.g.haltbuildingandconstruction activities,closeunitsduringoutbreaksandguidepatientplacementforisolationorcohorting);and recommendingremedialactionwheninfectionpreventionandcontrolmeasuresarecompromisedor breached.
CONSULTATIONDRAFTJANUARY2010 InsomeAustraliastatesandterritoriesandinternationally,personalperformanceagreementsforCEOs includeresponsibilityforinfectioncontrol.Forexample,inTasmania,thereisaperformancemonitoring frameworkforCEOscalledVitalSigns.Thisincludesanumberofkeyindicatorsthatneedtobeachieved, includingfiveinfectioncontrolrelatedindicators.CEOsarepersonallyaccountableforensuringthatallkey indicatorsaremet. C1.2.2 Infection control practitioners
Infectioncontrolpractitionersshouldhavetheskills,experienceandqualificationsrelevanttotheirspecific clinicalsettingandbeabletodevelop,implement,coordinateandevaluateafacilitywideIPCprogram. Theyareprimarilyresponsiblefordesigning,coordinating,implementingandundertakingongoing evaluationofthefacilitysinfectioncontrolprogramandpolicies,includingcompliancewiththerespective state/territoryand/ornationalaccreditation,licensing,policyorregulatoryrequirements.Theyneedtobe supportedbythefacilitywithresources,authorityandtimetomaintainclinicalandprofessionalcurrency (includingsupportforcredentiallingandpreferablyapostgraduatequalification[seeSectionC3.5.1]). Infectioncontrolpractitionersmustbeinvolvedindecisionsonfacilityconstructionanddesign,patient placementratios(e.g.singlerooms,negativepressurerooms)andenvironmentalassessments(see SectionC6). Theinfectioncontrolpractitionersperformanceshouldbeappraisedatleastannually,alongwith negotiationofindividualprofessionaldevelopmentgoals,support,opportunitiesandplanofwork. C1.2.3 Infection prevention and control committee
AmultidisciplinaryIPCCommitteeshouldreviewandguidethehospitalsIPCprogram,strategiesand plans.MembershipmustincludebutnotbelimitedtotheCEOorhis/herdesignate,anexecutivemember withtheauthoritytoallocatethenecessaryresourcesandtakeremedialactionasneededfromtimetotime, aseniorinfectioncontrolpractitionerandamedicalpractitioner. Themeetingfrequencyandcontentwilldependonthefacilityssize,casemixcomplexityandtheinfection riskofpopulationsserviced.IPCCommitteeactivityshouldbemeasuredagainstnegotiatedannual performancegoalsasstipulatedinthebusinessplan. TheCommitteeshouldhaveaformalmechanismforregularlyconsideringpatientsexperiencesand feedbackandmodifyingtheIPCprogramaccordingly. TheIPCCommitteeshouldhaveanorganisationalcommunicationstrategytofacilitatedaytodayactivities andreportingactivities,whichshouldbeabletobeescalatedinresponsetoanincidentoroutbreak.Regular andadhoccommunicationprocessesshouldexistbetweentheIPCteamandrelevantpublichealth authorities. C1.2.4 Infection control processes in office-based practice
Inofficebasedpractice,theprocessesassociatedwithinfectionpreventionandcontrolwilldifferalthough theresponsibilitiesarethesame.TheprincipalofthepracticeisequivalenttotheCEO,withoverall responsibilityforinfectionpreventionandcontrolinthepracticeandastrongcommitmenttoanagreed infectioncontrolplanbasedontheidentifiedrisksforthespecificofficebasedpractice.Anominatedstaff membermusttakeontheroleofinfectioncontrolpractitioner,developinginfectioncontrolproceduresand overseeingtheirimplementation.Thisstaffmemberwilllikelyneedadditionaltrainingandperhaps ongoingexternalsupportinmanaginginfectioncontrolissues.Infectioncontrolshouldbeconsideredat everystaffmeeting,withdiscussionofproceduresandprocessesofthepracticeandanyproblemareas.
CONSULTATIONDRAFTJANUARY2010 C1.3 INFECTION PREVENTION AND CONTROL PROGRAM
TheIPCprogramisthemeansbywhichinfectioncontrolpracticeisimplementedineverypartofthe healthcarefacility.ElementsofanIPCprograminclude: developmentofariskmanagementpolicyforthefacility(seeSectionC1.4); developmentofinfectionpreventionandcontrolpoliciesandproceduresthatarebasedonnational and/orstate/territoryguidelinesandrelevanttothehealthcarefacility(includingriskmanagement); educationandtrainingofstaffsothattheycanimplementthepoliciesandprocedures; oversightoftheimplementationofpoliciesandprocedures; developmentofamonitorandreviewprocesstoensurethatpoliciesandproceduresarebeing implementedcorrectly(e.g.completionofchecklistsduringcareprovision,logbooks);and oversightofsurveillanceof: specificorganismsthatarerelevanttothelocalenvironment(thismayrequireconsultationwith infectiousdiseasesspecialistsorepidemiologists); surgicalsiteinfectionsandotherdevicerelatedinfections;and notifiablediseases. TheIPCprogrammayalsoincludeantibioticstewardshipinitiativesruninconjunctionwiththepharmacy department/services. C1.3.1 Recommendations including policies and procedures
Nationaland/orstateinfectionpreventionandcontrolrecommendationsrelevanttothefacilityshouldbe endorsedandtheirprinciplesappliedasnecessaryaccordingtolocalneedbytheIPCCommittee. Compliancewiththeserecommendationsmustbemonitored.Ataminimum,theserecommendationsform thebasisoftheinfectioncontrolpractitionersdirectives,whichshouldbeeasilyaccessibleinhardcopy, electronicorotherformats.Suggestedtopicstobeaddressed,dependingonthefacility,include: handhygiene; standardandtransmissionbasedprecautions,including: aseptictechniqueandpreventionofdevicerelatedinfectionsandotherhealthcareassociated infections(e.g.surgicalsiteinfections,IVDrelatedbloodstreaminfections); environmentalcleaninganddisinfection(withEnvironmentalServices); reprocessingofreusableequipmentandsupplies(withReprocessingServices); safemanagementofclinicalandrelatedwasteandsharps; healthcareassociatedinfectionsurveillance; communicablediseasepostexposuremanagementandfollowup; outbreakmanagement,includingsystemstodesignatepatientsknowntobecolonisedorinfectedwitha targetedMROandtonotifyreceivinghealthcarefacilitiesandpersonnelbeforetransferofsuchpatients withinorbetweenfacilities; criticalincidentmanagementandinvestigation; epidemiologicallysignificantorganisms(includingMROs); useofappropriateinfectioncontrolmeasures(includingtransmissionbasedprecautions)ofpotentially infectiouspersonsatinitialpointsofpatientencountersuchasatthetimeofadmissionandinthe outpatientsettings(triageareas,emergencydepartments,outpatientclinics,cliniciansoffices). preventionandmanagementofbloodbornepathogenexposure(withoccupationalhealthandsafety); surgecapacityfornovelrespiratoryandothercommunicablediseaseemergencies(withemergency responsecommitteesandoutbreakmanagementteams);and construction/refurbishment/engineering.
CONSULTATIONDRAFTJANUARY2010 C1.3.2 Infection prevention measures
Toimplementthemeasuresoutlinedininfectionpreventionandcontrolpoliciesandprocedures,thefacility musthaveaccesstoanaccredited(e.g.NationalAssociationofTestingAuthorities[NATA])laboratoryand pharmacystaff,aswellassystems,protocolsandresourcesto: implementtherecommendationsincludedinnationalandstate/territoryguidelines; performsurveillanceandauditing; provideregular,meaningfulfeedbackofHAIdatatoindividualclinicians,specificspecialty departments/units,qualityimprovement,seniormanagementandothersasstipulatedintheannualIPC programbusinessplan; implementandparticipateinperiodicintensivelocal,state,nationalorglobalHAIreductioncampaigns includingapplicationofrecommendationsforhealthcareassociatedinfectionsurveillanceand reporting; ensurecollaborationbetweentheinfectioncontrolpractitionerandotherstakeholderssuchasinfectious diseaseandpharmacydepartmentstosupportantibioticstewardship; collaboratewithproductanddevicecommitteestoassesstheinfectionpreventionimplicationsofnew devices,proceduresandtechnologies; provideeducationregardinginfectionpreventioncoreprinciplestoallnewstaffandtoexistingstaffat leastannually; provideadviceandinformationtostaffregardingnewandemerginginfectiousdiseasethreatsand trends;and haveaprocessforengagingpatientsinthesafetyoftheirhealthcarebyroutinely: providingadviceandeducationrelatedtospecificandgeneralhealthcareassociatedinfection preventiontopatientsandfamilies(e.g.brochures,pamphlets,facetofacediscussions,information sheets);and askingpatientsandfamiliesforfeedbackabouttheircare. C1.3.3 Quality improvement
Safeandhighqualityinfectioncontrolpracticescontributetocontinualimprovementsinthequalityof healthcareprovidedinanysetting.Thesepracticesoccurattheorganisational,staffandpatientlevels. IPCprogramsneedtoincorporatetheprinciplesofqualityimprovement,throughtheuseofapproaches suchasplandostudyactthatenableprocessestobeenhancedandimproved.Itisessentialtoperformance improvementthathealthcarestaffunderstandthevalueofmonitoringandevaluatingtheirownclinical practice.Examiningpatientandcarerexperiencescanprovideaninsightintotheirperspectivesandallow thesetobetakenintoaccountinimprovingthequalityofcare. Integratingmonitoringandreviewprocessesintopoliciesandprocedures(e.g.throughinfectioncontrol audits)enablesdatatobecollected.Performanceindicatorscanbedevelopedfromthis,suchassurveyson compliancewithprotocolsandmonitoringtheuseofinfectioncontrolproducts. Intheacutesetting,itisrecommendedthathospitalssupportlocalresearchregardingspecificcasesof infection,outbreaksorpreventativestrategies,andadoptrelevantresearchfindingsthatreduceorprevent healthcareassociatedinfections.Inaddition,comprehensiveandepidemiologicallysoundsystems, protocolsandresourcesshouldexistto: activelymanageallinfectionpreventioncomponentsofaccreditation; design,undertakeandrespondtoresultsofperiodicauditsandformalreviewsofrelevantclinical practiceandperformance(e.g.antibioticuse,handhygienecompliance,cleaning); collaboratewithClinicalRiskDepartmentsandExecutiveStafftodevelopappropriatemethodsfor rapidresponse,remediation,investigationandevaluationofinfectionpreventioncriticalincidents (e.g.sterilisationordisinfectionfailures);and providebasic,minimuminfectioncontroleducationtostaff,healthcareworkersandvolunteers appropriatetotheirroles,risksandtheservicesprovidedbythehospital;and
CONSULTATIONDRAFTJANUARY2010 includepatientfeedbackontheircareasanintegralpartofqualityimprovement.
Surveillanceandhealthcareassociatedinfectionmonitoringstrategiesshouldbedesignedanddriven accordingtolocalactivity,performanceandtrendsintheincidenceofepidemiologicallysignificant organisms. AusefulresourceistheACSQHCMeasurementforimprovementtoolkititprovidesasetofpracticalmethods tomeasurethesafetyandqualityofclinicalhealthcareservices. http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/CommissionPubs C1.3.4 Resource allocation
Healthcarefacilitymanagersshouldensurethattherearesufficienthumanandfiscalresourcesavailableto supportallaspectsoftheIPCprogram,including: providingspecificinfectioncontrolfulltimeequivalents,determinedaccordingtothescopeoftheIPC program,thecomplexityofthehealthcarefacility,thecharacteristicsofthepatientpopulationandthe needsofthefacilityandcommunity(officebasedpracticesmaychoosetoattributeresponsibilitiesand functionsrelatingtoinfectionpreventionandcontroltoaparticularstaffmember); meetingoccupationalhealthneedsrelatedtoinfectioncontrol(e.g.provisionofappropriatetechnologies andprotectivepersonalequipment,healthcareworkerimmunisation,postexposureevaluationand care,evaluationandmanagementofhealthcareworkerswithcommunicableinfections); inahospitalsetting,providingclinicalmicrobiologylaboratorysupport,includingasufficientnumber ofmedicaltechnologiststrainedinmicrobiology,appropriatetothehealthcaresetting,fordetecting endemicandemergingpathogens,monitoringtransmissionofmicroorganisms,planningand conductingepidemiologicinvestigations;and fundingsurveillancecultures,rapiddiagnostictestingforviralandotherselectedpathogens, preparationofantibioticsusceptibilitysummaryreportsandtrendanalysis. RISK MANAGEMENT
C1.4
RiskmanagementisthebasisforpreventingandreducingharmarisingfromHAIsandunderpinsthe approachtoinfectionpreventionandcontrolthroughouttheseguidelines.Withinahealthcarefacility,a successfulapproachtoriskmanagementincludesactionattheorganisationallevel(forexampleproviding supportforeffectiveriskmanagementthroughanorganisationalriskmanagementpolicy,stafftrainingand monitoringandreporting)aswellasinclinicalpractice. C1.4.1 Organisational support for risk management
Forriskmanagementwithinanorganisationtobeeffectivethereneedstobeappropriateinfrastructureand culture;alogicalandsystematicapproachtoimplementingtherequiredsteps(outlinedinC1.4.2);and embeddingofriskmanagementprinciplesintothephilosophy,practicesandbusinessprocessesofan organisation,ratherthanitbeingseparateactivityorfocus. Factorsthatsupportriskmanagementacrosstheorganisationincludedevelopmentofariskmanagement policy;stafftraininginriskmanagement;implementationofariskregister,risktreatmentscheduleand integratedactionplans;monitoringandaudit;andriskmanagementreporting. Aninfrastructureandenvironmentthatencouragestwowaycommunicationbetweenmanagementand healthcareworkersandamonghealthcareworkersisanimportantfactorinincreasingthelevelofsupport forandcompliancewithIPCprograms.Managementshould: providedirection(e.g.nominateissuesforattentionthatarerelevanttothecorebusinessofthe organisation,suchascoughetiquetteingeneralpractice,preventionofdiarrhoealdiseaseinpaediatrics, appropriatemanagementofurinarycathetersinspinalinjurycare); establishandevaluateperiodicgoals(i.e.nominatereducedratesforperformanceimprovement);
CONSULTATIONDRAFTJANUARY2010 seekfeedbackonpolicydirectivesparticularlyinregardstochangesinclinicalcareprotocolsornew technologies; provideinformationtoindividuals,selfdirectedworkgroups,patientsandotherstakeholders,withan emphasisoncontinuallyimprovingperformance. Healthcareworkerscancontributetothedevelopmentofriskmanagementstructures,andareintegralto thestrategieswithinthese.Strategiestoassistindividualhealthcareworkerstoreduceriskisincludedatthe endofeachsectionofPartB. C1.4.2 A stepwise approach to risk management
TheAustralian/NewZealandStandardonRiskManagementAS/NZS4360:2004outlinesastepwise approachtoriskmanagement: establishingthecontextidentifyingthebasicparametersinwhichriskmustbemanaged(e.g.thetypeof healthfacility,theextentofandsupportforthefacilitysinfectioncontrolprogram); avoidingriskestablishingwhetherthereisariskandwhetherpotentialriskcanbeaverted(e.g.by questioningwhetheraprocedureisnecessary); identifyingrisksasystematicandcomprehensiveprocessthatensuresthatnopotentialriskisexcluded fromfurtheranalysisandtreatment(e.g.usingrootcauseanalysis[seebelow]); analysingrisksconsideringthesourcesofrisk,theirconsequences,thelikelihoodthatthose consequencesmayoccur,andfactorsthataffectconsequencesandlikelihood(e.g.existingcontrols); evaluatingriskscomparingthelevelofriskfoundduringtheanalysisprocesswithpreviously establishedriskcriteria,resultinginaprioritisedlistofrisksforfurtheraction;and treatingrisksselectingandimplementingappropriatemanagementoptionsfordealingwithidentified risk(forexamplemodifyingprocedures,protocolsorworkpractices;providingeducation;and monitoringcompliancewithinfectioncontrolprocedures). C1.5 TAKING AN ORGANISATIONAL SYSTEMS APPROACH TO QUALITY AND SAFETY
Addressinginfectioncontrolissuesrequiresamulticomponent,facilitywideprogramandiseverybodys responsibility.Thissectiongivesanoutlineofasystematicapproachthathasbeenshowntobeeffective (carebundles),togetherwithexamplesoftheorganisationalsupportrequiredatfacilityleveltoaddresstwo crucialareasofinfectionpreventionandcontrolreducingsharpsinjuriestohealthcareworkersand loweringtheincidenceinpatientsofbloodstreaminfectionsassociatedwithintravasculardevices.C2toC6 discusstheseparateaspectsofasystemsapproachtoinfectionpreventionandcontrol. AgoodexampleistheQSAprogramwhichfocusesonthesystemsinorganisationswithintheNSWHealth systemforqualityandsafetyandnotonindividualperformance.MoreinfoisattheClinicalexcellence Commissionwebsite:http://www.cec.health.nsw.gov.au/programs/qsa.html C1.5.1 Care bundles
CarebundlingisanapproachdevelopedbytheUSInstituteofHealthcareImprovement(IHI)toimprove consistencyofpracticeinhealthcarefacilities,particularlyforconditionsandproceduresknowntoincrease patientsriskofhealthcareassociatedinfections.Whilelargestudieshavenotyetbeenundertaken,the approachhasbeenshowntoreducehealthcareassociatedinfectionswithinhospitals 16andisnowused widely,particularlyintheUSandUK. Acarebundleissetoffourorfiveevidencebasedprocessesthataimstotieroutineprocessestogetherinto acohesiveunitthatmustbeadheredtoforeverypatient.Thekeystothebundlestrategyssuccessarethe standardisedandunvaryingapplicationofbundlepractices,theuseofmultidisciplinaryrounds,anddaily trackingandauditingofcompliance.
16
Fordetailssee http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/BundleUpforSafety.htm
CONSULTATIONDRAFTJANUARY2010 Carebundlescanbeusedtomonitorcareandtofeedbackcarebundleresultstoclinicalstaffinorderto decreasetherateofhealthcareassociatedinfectionsrelatedtothatconditionorthatprocedure.Itis importantthatbundlesaredesigned,implementedandevaluatedwithmeasurementdesignedforquality improvementratherthanresearchorjudgement. ExamplesofsomeproceduralcarebundlesaregiveninSectionB4. C1.5.2 Reducing sharps injuries
SafehandlingofsharpsisdiscussedinmoredetailinSectionB1.3.Asystemsapproachcansupport reducingsharpsinjuriesbyaddressing(CDC2009): clinicalgovernancechampioningacultureofsafetyunderpinnedbyconceptsofpatientcentredcare; staffhealthandsafetyadoptingandevaluatingtheuseofsafetyengineereddevicesasalternativesto sharpswithoutsafetyengineeredfeatures,standardisingchangestoworkpracticesthatwillreducerisk (e.g.usinginstruments,ratherthanfingers,tograspneedles,retracttissue,andload/unloadneedles) (seeSectionC2); educationandtrainingprovidingeducationintheuseofnewdevicesandworkpractices(see SectionC3); surveillanceensuringcomprehensivereportingofinjuriesandfollowup;and facilitydesignapplyingengineeringcontrols(e.g.sharpsdisposalcontainersandsharpsdeviceswith integratedengineeredsharpsinjurypreventionfeatures). Lowering the incidence of IVD-related bloodstream infections
C1.5.3
SectionB4.2outlinesinfectioncontrolguidanceforhealthcareworkerstofollowwheninsertinga therapeuticdevicesuchasacentralvenouscatheter.Arangeofmeasuresarerequiredforsafeuseof devices,thefirstconsiderationbeingwhetherthedeviceisnecessaryorifasaferalternativecouldbeused. Facilitymanagementandtheinfectioncontrolteamhaveakeyroleinworkingwithclinicalstafftoimprove thesafetyofproceduressuchasIVDinsertion,byprovidingthenecessarysupportandinfrastructure. Thecarebundle(seealsoSectionB4.1)forcentralvenouscatheterinsertionstipulatestheuseofhand hygiene,maximalbarrierprotection,optimalintravascularcathetersiteselection,topicalchlorhexidinefor skindisinfection,anddailyreviewtoensurethatcathetersareremovedassoonastheyarenolonger necessary.Supportandinfrastructurerequirementstofacilitateimplementationofthesemeasuresinclude: clinicalgovernance:championingacultureofsafetyunderpinnedbyconceptsofpatientcentredcare educationandtraining: orientationprogramsforstaffincludingrigorousgroundinginfacilitypoliciesandproceduresfor standardprocedures,particularlyhandhygiene; developmentandpromotionofasupportingeducationprogramthataddressesIVDassociatedBSI; engagementofpatients,sotheyhavetheknowledgeandskillstobeactivelyinvolvedintheirown care; surveillance: implementationofatooltoquantifyadherencetopractice(e.g.checklists); measurementofbloodstreaminfectionrateswithfeedbacktorelevantstaff. facilitydesignandequipmentprovisionofappropriateequipment,suchasIVDinsertionkitswith standardisedcontentstoenableacompetenthealthprofessionaltoperformtheproceduresandadhereto acceptedtechniques.
CONSULTATIONDRAFTJANUARY2010 C2 STAFF HEALTH AND SAFETY
Summary Infection protection for healthcare workers should be an integral part of the infection control and occupational health and safety programs of every healthcare facility. This includes implementing a staff health screening policy, promoting immunisation, instituting extra protection for healthcare workers in specific circumstances (e.g. pregnant healthcare workers), and having processes for minimising and managing risk exposure. While the organisation has a duty of care to healthcare workers, staff members also have a responsibility to protect themselves and to not put others at risk.
C2.1
ROLES AND RESPONSIBILITIES
Inthecourseoftheirduties,healthcareworkerscanbeexposedtoinfectiousagents(e.g.throughdirect contactwithaninfectiouspatient,visitororcolleagueorindirectlythroughacontaminatedsurfaceor environment(ieair)orastheresultofasharpsinjury).Healthcareworkerscanalsoplacepatientsatriskof transmissionofinfection(e.g.ifthehealthcareworkerhasaninfectiousconditionthatiscapableofbeing transmittedastheyperformtheirduties). Toensurethesafetyofeveryoneinthefacility,bothemployersandemployeeshavearesponsibilityin relationtoinfectioncontrolandoccupationalhealthandsafety. C2.1.1 Responsibilities of healthcare facilities
AspartofitsIPCprogram,eachhealthcarefacilityshoulddevelop,implementanddocumenteffective policiesandproceduresrelatedtostaffhealthandsafety,includingstrategiestopreventoccupational exposuretoinfectionhazards;preventoccupationalrisksfromchemicalsorprocessesusedfor recommendedinfectioncontrolactivities;andimplementhealthcareworkerimmunisationprogramsfor infectiousagentstheymayencounteredinthecourseoftheirduties. Atthestartoftheiremployment,allhealthcareworkersshouldbeinformedofthefacilityspolicyonhealth screeningandcounselled,asappropriate,abouttheirworkplacementinaccordancewiththesepolicies.As personalandorganisationalcircumstanceschangeovertime,reassessmentandadditionaleducationmaybe necessary.Similarly,traininginstitutionsshouldinformhealthcarestudentsbeforetheircourseadmission aboutpoliciesandproceduresforstaffhealthandsafetyandtheirimplications,andprovidecounsellingfor studentsthatmaybeprohibitedfromcompletinganyrequirementsoftheircourseduetodisabilities, impairmentsortransmissibleinfections. Healthcareworkersprivacyandcivilrightsmustalwaysberespectedandnotbreached. Positivemeasuresshouldbeundertakentoimplementandsustainappropriateinfectioncontrol.Thereare fivemeasuresofprotection: healthstatusscreening(seeSectionC2.2.1); educationonsafeworkpracticesthatminimisethetransmissionofinfection(seeSectionC3); safesystemsofwork(seeSectionB4),withworkplacesdesignedtoallowclinicalpracticethatminimises transmissionofinfection(seeSectionandC6); physicalprotection,involvingtheuseofPPE(seeSectionB.1.2)andimmunisation(SectionC2.2.2);and reportingsystemsforcomplianceandidentifyingbreachesofinfectioncontrolprotocols. Responsibilities of healthcare workers
C2.1.2
Healthcareworkershaveanobligationtoalwaysfollowspecificestablishmentinfectioncontrolpoliciesas partoftheircontractofemployment.Thisincludesreportingtheirinfectiousstatusaswellasanyknown potentialexposurestobloodand/orbodysubstances.Failuretofollowinfectioncontrolpoliciesand

CONSULTATIONDRAFTJANUARY2010 proceduresmaybegroundsfordisciplinaryaction.Somestates/territorieshavestatutoryinfectioncontrol requirementsforhealthcareworkers. Healthcareworkerswithinfectionsshouldseekappropriatemedicalcarefromadoctorqualifiedtomanage thespecificinfectiousdiseases.Wherethereisariskofahealthcareworkertransmittinginfectiontoa patientorotherhealthcareworker(e.g.ifheorsheisinfectedwithanacuteinfectionorothertransmissible infection,carriesabloodbornevirus,orhasapredisposingskincondition),thehealthcareworkershouldbe counselledaboutworkoptionsandeitherrosteredappropriatelyorprovidedwithequipment,information andfacilitiestoenablehimorhertocontinuetoprovidesafecare. Theappropriateworkoptionwilldependonthespecificcircumstances: healthcareworkerswithsymptomsofacuteinfections(e.g.vomiting,diarrhoea,flusymptoms)should notcometoworkforthespecifiedexclusionperiod(seeSectionC2.3);and healthcareworkerswhocarryabloodbornevirus(e.g.hepatitisB,hepatitisC,HIV)mayneedtoaccept thattheirdutiesmaynotinvolvesignificantamountsofdirectpatientcareorexposureproneprocedures. Insomejurisdictions,healthcareworkerswhocarryabloodbornevirusarelegallyobligedtodeclare theirinfectiousstatus. Healthcareworkersshouldbeawareoftheirrequirementsforimmunisationagainstinfectiousdiseasesand maintainpersonalimmunisationrecords. Healthcareworkersinspecificcircumstances(e.g.pregnanthealthcareworkers)maybeparticularly susceptibletosomeinfectionsandshouldworkwithoccupationalhealthandsafetyofficerstoensuretheir safety(seeSectionC2.3) EducationaboutsafeworkpracticesisdiscussedinSectionC3. C2.2 C2.2.1 HEALTH STATUS SCREENING AND IMMUNISATION Staff health screening policies
Beforebeginningemployment,allstaffshouldbeassessedandofferedtestingand/orvaccinationforspecific infectiousdiseasesbeforebeingallowedtoworkinhighriskareas,withparticularattentionpaidtoimmune status,skinconditionsandpregnancyinstaff,aswellasriskfactorsforspecificgroupsofpatients.These conditionsmayvaryaccordingtostate/territoryspecificrequirementsandrecommendations.

Routine screening and assessment
Routinescreeningatthestartofemploymentoccursinthreeforms: personalassessmentofdiseaseandimmunestatusaquestionnaire(withrecordingofinformationgained) shouldcheckfordetailsofmedicalhistory,particularlyforrubella,measles,mumps,varicella (chickenpox),herpessimples,HepatitisB,immunedisordersandskinconditions,andforpriorexposure totuberculosis(includingworkinginhighrisksettingsandhighriskdemographicbackground); immunisation(seeSectionC2.2.2);and laboratoryandothertestingthisshouldincludearoutinetuberculinskintest.Routinescreeningfor streptococcusandsalmonellacarriersisnotrecommended,althoughthisformofscreeningmaybe institutedinthecaseofanoutbreak. Immunisation
C2.2.2
Thoughemployersarenotrequiredtovaccinatestaff,theyshouldtakeallreasonablestepstoensurethat staffmembersareprotectedagainstvaccinepreventablediseases.Insmallfacilities(e.g.officebased practices),nonimmuneworkersshouldbeencouragedtobevaccinated.Inlargerfacilities(where healthcareworkersmaybeatsignificantoccupationalriskofacquiringavaccinepreventabledisease)a comprehensiveoccupationalvaccinationprogramshouldbeimplementedthatincludes: avaccinationpolicy; maintenanceofcurrentstaffvaccinationrecords; provisionofinformationabouttherelevantvaccinepreventablediseases,and

C2 Staff health and safety 137
CONSULTATIONDRAFTJANUARY2010 themanagementofvaccinerefusal(whichshould,forexample,includereducingtheriskofahealthcare workertransmittingdiseasetoavulnerablepatient).
Healthcarefacilitiesshouldadvisehealthcareworkersofthepotentialconsequencesiftheyrefuse reasonablerequestsforimmunisation.Suchadviceandrefusaltocomplyshouldbedocumented.Should suchhealthcareworkerssubsequentlydevelopworkrelatedinfections,itismostlikelythatthehealthcare establishmentwouldnotbefoundtobeinbreachofitsdutyofcare. TraininginstitutionsshouldensurethathealthcarestudentsarevaccinatedaccordingtotheAustralian ImmunisationHandbookschedule,toprotectthemagainstinfectionsthattheymayencounterduringtheir training.

Recommended vaccinations
ThemostrecenteditionofTheAustralianImmunisationHandbook(currentlyNHMRC2008)providesdetailed informationonimmunisationschedulesandvaccines.Staffvaccinationprogramsshouldcomplyasmuchas possiblewiththeseschedules,whichacknowledgethatsomecircumstancesmayrequirespecial considerationbeforevaccination.

Table C1: Recommended vaccinations for all healthcare workers
Hepatitis B Influenza Booster dose of adult formulation diphtheria-tetanus-pertussis vaccine MMR (if non-immune) Varicella (if seronegative) Hepatitis A immunisation is recommended for healthcare workers in paediatric wards, ICUs and emergency departments that provide for substantial populations of Aboriginal and Torres Strait Islander children, and nursing and medical staff in rural and remote Indigenous communities Source: AustralianImmunisationHandbook Availableat:http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbookhome Pre-vaccination screening
PrevaccinationscreeningisoutlinedinSection1.3.4oftheAustralianImmunisationHandbook,includinga prevaccinationchecklist.Healthcarefacilitiesshouldhaveeducationprogramstosupporttheir immunisationpolicyandreinforcetheneedforcompliance. C2.2.3 Staff records
Healthcarefacilitiesshouldmaintainaregularlyupdatedrecordofhealthcareworkersimmunisation recordsoncommencementofemployment;anysubsequentvaccinationsreceivedaftercommencing employment;serologicalresults;andanycounsellingoreducationgivenregardinginfectiousdiseasesand theuseofstandardoradditionalprecautions. C2.3 EXCLUSION PERIODS FOR HEALTHCARE WORKERS WITH ACUTE INFECTIONS
Everyhealthcarefacilityshouldhavecomprehensivewrittenpoliciesregardingdiseasespecificwork restrictionandexclusion,whichincludeastatementofauthoritydefiningwhocanimplementsuchpolicies. Anyemployeewhohasaninfectiousdiseasehasaresponsibilityto: consultwithanappropriatemedicalpractitionertodeterminethattheyarecapableofperformingtheir taskswithoutputtingpatientsorotherworkersatrisk; undergoregularmedicalfollowupandtocomplywithallaspectsofinformedclinicalmanagement regardingtheircondition;and observestandardprecautionsatalltimes(andanyotherrecommendedinfectioncontrolpracticesand procedures).
CONSULTATIONDRAFTJANUARY2010 Thesepoliciesshouldencouragehealthcareworkerstoseekappropriatepreventiveandcurativecareand reporttheirillnesses,medicalconditions,ortreatmentsthatcanrenderthemmoresusceptibleto opportunisticinfectionorexposures.Theyshouldnotpenalisehealthcareworkerswithlossofwages, benefits,orjobstatus.

Table C2 Staff exclusion periods for infectious illnesses
Exclusion period Must not provide patient care for the duration of symptoms (i.e. while eye discharge is present). Must not come to work while symptomatic (e.g. diarrhoea and/or vomiting) or until 48 hours after symptoms have resolved (see GPP below)
Acute infection Conjunctivitis Gastro-enteritis (infectious diarrhoea) Glandular fever
NO need for exclusion, even if having direct patient contact, provided staff are well enough to return to work and employ standard precautions.
Herpes Simplex (cold sores)
Must not provide direct care to neonates, newborns, patients in delivery suites, severely immunocompromised patients, burns patients, patients with extensive eczema, or patients in operating room if there is an exposed herpetic lesion May provide direct patient care to other patients, do not need to wear a mask
Herpes Zoster (Shingles)
Must not provide ANY direct patient care if lesions cannot be covered (e.g. ophthalmic zoster) If active lesions can be covered, can provide care to all patients except for pregnant women, neonates, severely immunocompromised patients, burns patients and patients with extensive eczema.
Influenza
If treated with an antiviral within 2 days of the onset of the disease, may return to work following 2 days of treatment If they feel well enough. Employees who have had no treatment should remain off work for 56 days.
Pertussis (Whooping Cough) Scabies and Lice Staphylococcal infection
Remain away from work until at least 5 days after commencement of appropriate antibiotic therapy; or for 21 days after the onset of symptoms if not receiving antibiotic treatment. Remain off work until at least 24 hours after appropriate treatment has been completed. Any staphylococcal-infected lesions (e.g. boils, wound infections) must be covered while at work. If lesions cannot be covered, must not perform patient care or prepare hospital food until they have received appropriate antibiotic therapy and the infection has resolved
Streptococcal infection
Any employee with streptococcal infected lesions (e.g. impetigo, tonsillitis) must ensure that lesions are covered while at work. If lesions cannot be covered, employees must not provide direct patient care nor prepare hospital food until 24 hours after appropriate antibiotic therapy. Employees with pharyngitis/tonsillitis should avoid patient contact for at least 24 hours after starting appropriate antibiotic therapy.
Acute infection Tuberculosis (TB) Exclusion period If TB disease is suspected or is present, staff to be notified to TB Services and treated. Any personnel with pulmonary TB is to be excluded from the workplace until cleared by TB Services. Any active TB must be monitored by TB Services. Viral rashes Measles If suspected, must remain off of work until appropriate test results are known. May return to work if they have serological evidence of immunity (i.e. are IgG sero-positive and IgM seronegative); but must be excluded for 4 days after the appearance of the rash if they develop measles. Mumps If suspected, must remain off work until appropriate test results are known. May return to work if they have serological evidence of immunity (i.e. are IgG sero-positive and IgM seronegative). Must be excluded from work for 9 days after the onset of parotid gland swelling if they develop mumps. Rubella (German Measles) If suspected, must remain off of work until appropriate test results are known. May return to work if they have serological evidence of immunity (i.e. are IgG sero-positive and IgM sero-negative).Personnel must be excluded for 7 days after the appearance of the rash if they develop Rubella. Varicella (Chicken Pox) Before starting employment, personnel should be screened by completing a pre-employment health assessment; non immune staff should be offered vaccination unless contraindicated; personnel must be excluded for at least 5 days after the rash appears and all blisters have dried. Human Parvovirus B19 (Slapped Face) does not require exclusion from work, non-infectious once rash develops. Viral respiratory tract infections (e.g. common cold). Staff should be excluded from contact with susceptible persons, until they are no longer symptomatic. Staff with viral respiratory tract infections should stay at home until they feel well.
GOOD PRACTICE POINT

Norovirus exclusion periods Health care workers should not return to work until diarrhoea and vomiting have ceased for 2 days. It is extremely important that health care workers comply with appropriate hand hygiene methods and stringent infection control practices upon return to work, as some studies have shown prolonged viral shedding with this infection.
C2.4
HEALTHCARE WORKERS WITH SPECIFIC CIRCUMSTANCES
Healthcarefacilitiesshouldhavecomprehensiveoccupationalhealthprogramstomanagehealthcare workersinspecificcircumstancesthatputthematgreaterriskofinfection. Whereahealthcareworkerisknowntobeparticularlysusceptibletohealthcareassociatedinfections,work dutiesareassessedtoensurethatthewelfareofthatperson,patientsandotherhealthcareworkersis safeguarded.Thismayinvolveredeploymenttoaroleinvolvinglessrisk.Healthcareworkersinthis situationmayrequirecounsellingonwhattaskstheycanperform,whattheyshouldavoidandthepossible impactontheirworkontheirhealth. C2.4.1 Pregnant healthcare workers
Employersshouldprovideinformationontherisksassociatedwithpregnancyandshouldassistpregnant healthcareworkerstoavoidinfectiouscircumstancesthatmaypresentarisktothehealthcareworker (mother)orfoetus.Itistheresponsibilityofpregnanthealthcareworkerstoadvisetheirdoctorand employeroftheirpregnancy;thisinformationmustremainconfidential.

CONSULTATIONDRAFTJANUARY2010 Adherencetostandardandtransmissionbasedprecautionsandvaccinationshouldprotecthealthcare workers.However,pregnanthealthcareworkersshouldbegiventheopportunitytoavoidpatientswith specificinfections.Thosewithoutimmunitytorubella,varicella,cytomegalovirusorparvovirus,orwho havenothadcytomegalovirusinfection,shouldberedeployediftheyareatriskofcontractingthese diseasesthroughtheirwork. Formoreinformation,refertoSection2.3.2oftheAustralianImmunisationHandbook. C2.4.2 Immunocompromised healthcare workers
Healthcareworkerswithimmunedeficienciesaremoreatriskofacquiringinfections.Thetypeof employmenttheycanundertakeshouldincludeonlydutiesthatwillminimisetheirexposuretoinfections. Predisposingconditionsincludeneutropenia,disseminatedmalignancyandinfectionsthatproduce immunodeficiency(e.g.HIV). RefertoSection2.3.3oftheAustralianImmunisationHandbookforguidanceontheimmunisationof immunocompromisedhealthcareworkers. C2.4.3 Healthcare workers with skin conditions
Skinintegrityistheultimatebarriertotransmissionofinfectiousagents.Whenstaffmembershavedamaged skinorweepingskinconditions(e.g.allergiceczema,psoriasis,exfoliatingdermatitis),theymaybereadily colonisedbyhealthcareassociatedmicroorganismsandmaybecomeavehiclefordisseminatingthese organisms.Healthcareworkersinthissituationshouldbeidentifiedbypersonalhistoryscreeningwhen theystartemployment,andneedtobeinformedoftheriskstheymayposetopatients.Anydamagedskin mustbeappropriatelycoveredbeforehealthcareworkerscarryoutprocedures.Considerationmustbegiven toprovidingthesestaffmemberswithappropriate,individualPPEsuchasspecifictypesofgloves,hand hygieneproductandmoisturisinglotion. C2.5 EXPOSURE-PRONE PROCEDURES
Exposureproneprocedures(EPPs)areinvasiveprocedureswherethereispotentialfordirectcontact betweentheskin,usuallyfingerorthumbofthehealthcareworker,andsharpsurgicalinstruments,needles, orsharpbodyparts(e.g.fracturedbones),spiculesofboneorteethinbodycavitiesorinpoorlyvisualised orconfinedbodysites,includingthemouthofthepatient. DuringEPPs,thereisanincreasedriskoftransmittingbloodbornevirusesbetweenhealthcareworkersand patients(DoHA2004).AlistofEPPsisinAppendix3.ThenatureofEPPscanbecategorisedaccordingto levelofriskoftransmission,inincreasingorderofmagnitude.

Table C3
Category 1
Categories of exposure prone procedures

A procedure where the hands and fingertips of the healthcare worker are usually visible and outside the body most of the time and the possibility of injury to the workers gloved hands from sharp instruments and/or tissues is slight. This means that the risk of the healthcare worker bleeding into a patients open tissues should be remote (e.g. insertion of a chest drain).
Category 2
A procedure where the fingertips may not be visible at all times but injury to the healthcare workers gloved hands from sharp instruments and/or tissues is unlikely. If injury occurs it is likely to be noticed and acted upon quickly to avoid the healthcare workers blood contaminating a patients open tissues (e.g. appendectomy).
Category 3
A procedure where the fingertips are out of sight for a significant part of the procedure, or during certain critical stages, and in which there is a distinct risk of injury to the healthcare workers gloved hands from sharp instruments and/or tissues. In such circumstances it is possible that exposure of the patients open tissues to the healthcare workers blood may go unnoticed or would not be noticed immediately (e.g. hysterectomy).
Source: DH/HP/GHP3.HIVInfectedHealthCareWorkers:GuidanceonManagementandPatientNotification.London;2005
CONSULTATIONDRAFTJANUARY2010 C2.5.1
Employers
Responsibilities
EmployersmustensurethatemployeeswhoperformEPPshaveaccesstoappropriateinformation,testing, counsellingandvaccinationprograms.Serologicaltestingmaybeprovidedbythehealthcarefacilityor healthcareworkersmaychoosetoseektestingfromoutsidesources.Healthcarefacilitiesshouldaimto achievevoluntarycomplianceandselfdisclosurebyprovidinganenvironmentinwhichhealthcareworkers knowtheirconfidentialitywillbemaintained. Undercurrentnotificationrequirements,medicalpractitionersmustnotifythechiefmedicalofficeror state/territoryhealthdepartmentofcasesofHIV,HBVandHCV,byeithernameorcode.Amedical practitionermaybelegallyobligedtobringtotheattentionoftheappropriateregistrationboardany registeredprofessionalwhoisunabletopractisecompetentlyorwhoposesathreattopublicsafety. Healthcareworkerswhoneedtomodifytheirworkpracticesbecausetheyarecarriersofabloodbornevirus shouldbeprovidedwithcounsellingand,wherepractical,withopportunitiestocontinueappropriate patientcareactivities,eitherintheircurrentpositionorinaredeployedposition,ortoobtainalternative careertraining.
Healthcare workers
HealthcareworkerswhoundertakeEPPshavearesponsibilitytoknowtheirinfectiousstatuswithregardto bloodbornevirusessuchashepatitisBvirus,hepatitisCvirusandHIV,andshouldbegivenrelevant informationaboutthetestsavailableandencouragedtohavevoluntarytesting. Healthcareworkerswhocarryabloodbornevirushaveaclearresponsibilitytofollowthetreatment recommendedbytheirdoctorandmodifytheirinvolvementindirectpatientcare.Theymustnotperform EPPsiftheyare: 17 HIVantibodypositive; hepatitisBeantigen(HBeAg)positiveand/orHBVDNApositiveathightitres;or HCVRNApositive(bypolymerasechainreactionorsimilartest).
HealthcareworkerswhocarryabloodbornevirusandarenotinthesecategoriesmustnotperformEPPs untilspecialistmedicaladvicehasbeensought. HealthcareworkerswhoarecurrentlyHBsAgpositiveandHBVDNAnegativeorHCVantibodypositive andHCVRNAnegativemustobtainongoingmedicaladviceregardingtheirpotentialinfectiousnessand theappropriatenessoftheircontinuedperformanceofEPPs.

Healthcare students
Conditionalregistrationmayberequiredforstudentswhohavehadtoundertakemodifiedtraining programs.ThiswillrequireanundertakingthatindividualswhoareknowntocarryHIV,HCVorHBVwill reporttheirinfectiousstatusatthestartoftheiremploymentandagreenottoperformEPPs.Training coursesthatrequiretheperformanceofEPPsshouldincludeinformation,counselling,opportunitiesfor testingandcareeradvice. Traininginstitutionsshouldcounselstudenthealthcareworkerscarryingbloodborneillnesscapableofbeing transmittedthroughEPPs,againstacareerinanyprofessionwhichmayinvolvesuchprocedures. C2.6 OCCUPATIONAL HAZARDS FOR HEALTHCARE WORKERS
Needlestickandotherbloodorbodyfluidincidentsarethemaincausesofoccupationalhazardsfor healthcareworkers,includingHIV,HBVandHCV.
17
Theserequirementsmaychangewiththeendorsementofnationalguidelinescurrentlyunderreview.
CONSULTATIONDRAFTJANUARY2010 C2.6.1 Sharps injuries
Healthcareworkersfacetheriskofinjuryfromneedlesandothersharpinstrumentsduringmanyroutine procedures.Injuriesmostoftenoccurafteruseandbeforedisposalofasharpdevice,duringuseofasharp deviceonapatientandduringorafterdisposal(CDCunpublisheddata).Therearemanypossible mechanismsofinjuryduringeachoftheseperiods. Measurestohelpcombatneedlestickandothersharpsinjuriesincludetrainingandeducationontherisks associatedwithproceduresandontheuseofneedlestickdevices;andsaferworkingpractices(including adherencetoproperhandlinganddisposalproceduresandensuringthatdisposalcontainersarenot overfilled[seealsoSectionC1.5.1]). TheuseofdeviceswithsafetyengineeredprotectivefeatureswasmandatedintheUSin2000andhasbeen associatedwithreducedratesofincidenceofneedlestickinjuries(Jagger2008).Despitedifficultiesin determining,thedirectimpactofusingsafetyengineereddevicescomparedtostandarddevicessafety engineereddevicesareanimportantcomponentinpercutaneousinjuryprevention(Tuma&Sepkowitz 2006).Typicallyasharpsinjurycampaigninvolvesmultimodalstrategies.Asaresultmanystudiesthat showareductioninincidenceofneedlestickinjurieswiththeuseofsafetyengineereddeviceshavealso involvedacombinationofotherinterventionmeasuressuchastrainingandeducation,overarchinghospital policiesandothertechnologies(Whitby2008). Australiaistheonlycountrywithwelldevelopedsystemsofinfectioncontrolandoccupationalhealthand safetythathasnotyetmandatedtheuseofsafetyorretractabledevices.SuchmandatesexistintheUSA, CanadaandmostrecentlytheEuropeanUnion,includingtheUK.ThecurrentUKpolicyrecommendsthe provisionofmedicaldevicesthatincorporateasharpsprotectionmechanismwherethereareclear indicationsthattheywillprovidesafesystemsofworkingforhealthcareworkers.Considerationof economicandsocialcosts,staffpreferences,easeofuse,andtimerequiredtotrainstaffisnecessarybefore widespreadimplementationofsafetyengineereddevicesinAustralia.Inthemeantime,ifafacilitychooses tousesafetyengineereddevices,introductionofthedevicesmustbesupportedbyacomprehensivetraining andeducationprogram. Despitesystemsapproachestoimprovingsafetyandwithgrowingavailabilityofsafetydevices,healthcare workersarestillbeingexposedtobloodbornevirusinfections(Prattetal2007).Forexample,asurveyof occupationalexposuresinAustraliannurses(ASCC2008)foundthatinthe12monthspriortothesurvey, 11.2%ofnurseshadsustainedatleastoneneedlestickorothersharpsinjury.Aswellasindividualactions, safesystemsofworkandengineeringcontrolsmustbeinplacetominimiseanyidentifiedrisks(Prattetal 2007). C2.6.2 Managing risk of exposure
ExposuresthatmightplaceahealthcareworkeratriskofhepatitisBvirus,hepatitisCvirus,HIVorhuman TcelllymphotropicvirustypeI(HTLVI)arepercutaneousinjury(e.g.needlestickorcutwithasharp object)orcontactofmucousmembraneornonintactskin(e.g.exposedskinthatischapped,abraded,or affectedbydermatitis)withblood,tissueorotherpotentiallyinfectiousbodyfluids. Healthcarefacilitiesmusthavedocumented,readilyaccessibleprotocolsforprovidingimmediatepost exposureadviceforsharpsinjuriesandotherbloodorbodyfluidincidentsinvolvinghealthcareworkers: Treatmentprotocolsincluderemovalofcontaminatedclothing,thoroughwashingoftheinjuredarea withsoapandwater;andflushingofaffectedmucousmembraneswithlargeamountsofwater. Healthcareworkersshouldbeawarethattheymustreportoccupationalexposuresimmediately. Immediatepostexposureprophylaxis(PEP)shouldbeperformed,involving: ariskassessmentoftheexposure,takingintoaccountthetypeofexposure,thetypeandamountof fluidinvolved,theinfectiousstatusofthesource(ifknown),andthesusceptibilityoftheexposed healthcareworker(throughcollectionofinformationaboutmedicationstheyaretakingandany underlyingmedicalconditionsorcircumstances); testingthesource(ifknown)forHBVsurfaceantigen(HBsAg),HCVantibodyandHIVantibody; and
CONSULTATIONDRAFTJANUARY2010 baselinetestingoftheinjuredhealthcareworkerforHBVsurfaceantibody,andserumheldfor furthertesting(e.g.HIVantibody,HCVantibody,and/orbaselinealanineaminotransferasetesting), ifrequired. ContinuingPEPshouldbeofferedifthesourcepersonisfoundtobepositiveforHIV,HBVorHCV thenatureofthePEPwilldependonthevirusinvolved(seetheAustralianTherapeuticGuidelinesadvice onlongerterm,virusspecificPEP(availableat http://www.tg.org.au/etg_demo/tgc.htm#tgc/abg/7356.htm). postexposurecounsellingandfollowupshouldtakeplaceifthepersonhasbeenexposedtoa bloodbornevirus,theyshouldbeadvisedaboutprecautionstopreventsecondaryinfectionatworkand inthecommunityinthefollowupperiod(e.g.notsharingimplements,safesexandsafeinjecting,and otherrelevantmattersbasedonanindividualriskassessment)
Eachhealthcarefacilityrequiresapolicyonthemanagementofneedlestickinjuries,asgenericpoliciesmay notberelevanttoindividualsettings(e.g.accesstocare,especiallyafterhours).
CONSULTATIONDRAFTJANUARY2010 C3 EDUCATION AND TRAINING
Summary Education and training underpin efforts to integrate infection control practices into practice at all levels of every healthcare facility. Essential education for all healthcare workers should cover infection prevention and control work practices and their role in preventing the spread of infection, as part of undergraduate education, staff orientation and continuing professional development. Specific postgraduate education of infection control practitioners is strongly recommended. Engaging patients and carers in their own healthcare is integral to effective infection control. All healthcare workers should be informed about the rights and responsibilities of patients and learn how to apply this understanding in the way that they deliver care.
C3.1
TEACHING FACILITIES
Allhealthcareworkersneedtounderstandthebasisandimportanceofinfectioncontrol.Uptodate informationoninfectioncontrolbasics,policy,procedures,qualityassuranceandincidentmonitoring shouldbeincludedinthecurriculumofallundergraduateandpostgraduatecoursesinhealthrelatedareas. Universitiesandtrainingcollegesalsohaveanobligationtoinformprospectivestudentsabouttheimpact thatparticularinfectionsmayhaveontheirabilitytocompletethecourseandengageinthefullspectrumof clinicalpracticeaftergraduation(seeSectionC2).Thisinformationshouldincludeadviceaboutspecific measures,includingimmunisation,thatreducetheriskofacquiringinfection. C3.1.1 Education of infection control practitioners
WhilesomestatesinAustraliahavesomerequirementsforpractisingasaninfectioncontrolpractitioner, thereiscurrentlynominimumorstandardisededucationalrequirementtopracticeasaninfectioncontrol practitioner,ortocoordinateanorganisationalIPCprogram.Arangeofpostgraduateeducationprograms arecurrentlyavailablefornursesseekingorestablishingacareerininfectioncontrolinAustralia,although thecontentofthesecoursesisvariable. GOOD PRACTICE POINT

Education of infection control practitioners Postgraduate education gives infection control practitioners the necessary expertise to fulfil the role. Specific professional development should be supported at all levels.
CasestudyRequirementsforinfectioncontrolpractitionersinTasmania 18 Seniorinfectioncontrolpractitioners(e.g.atClinicalNurseConsultantorClinicalNurseManagerlevel)musthave adequateskillsincluding: formalpostgraduatequalificationsataDiplomalevelandworkingtowardsaMastersdegreeorhigherinanarea relevanttoinfectioncontrol; beingacredentialledinfectioncontrolpractitioner(AICAorCBIC);and participationinprofessionaldevelopmentopportunitiesincludingattendanceatrelevantstateand/ornational professionalorganisationmeetingsinaccordancewithAwardconditions. Infectioncontrolpractitionersatclinicalnurseorclinicalnursespecialistlevelmust: haveformalpostgraduatequalificationsataCertificatelevelorhigherinanarearelevanttoinfectioncontrol; haveregularaccesstoprofessionalandclinicalsupport; participateinprofessionaldevelopmentopportunities;and
18
AsoutlinedintheTasmanianHealthcareAssociatedInfectionPreventionStrategy200911
C3 Education and training 145
CONSULTATIONDRAFTJANUARY2010 becredentialled(AICAorCBIC).
CONSULTATIONDRAFTJANUARY2010 C3.2 HEALTHCARE FACILITIES
Healthcarefacilitiesshouldprovidespecificeducationandtrainingforallhealthcareworkersandstudents aboutinfectioncontrolprinciples,policesandproceduresthatarerelevanttothefacility.Theaimisto informandeducatehealthcareworkersabouttheinfectioushazardstheywillfaceduringtheiremployment, andtheirroleinminimisingthespreadofinfectiontoothers.Specialattentionshouldbegiventoadvice abouthandhygiene(seeSectionC3.4).Theroleofclinicaleducatorsinprovidingthiseducationneedstobe supported,astheyprovideavitallinkbetweenteachingandhealthcarefacilities Ataminimum,allstaff(bothclinicalandnonclinical)shouldbeeducatedabout: modesoftransmissionofinfectiousagents; riskidentification,assessmentandmanagementstrategiesincludingtransmissionbasedprecautions; orientationtothephysicalenvironment; safeworkprocedures; correctuseofstandardprecautions; correctchoiceanduseofPPE,includingdonninganddoffingproceduresandfitcheckingofmasks; appropriateattire(shoes/hair/nails/jewellery); handhygienepractices(seecasestudyinSectionC3.4); levelsofcleaningrequiredforclinicalareasandequipment; howtodealwithspills; safehandlinganddisposalofsharps; reportingrequirementsofincidentssuchassharpsinjuriesandexposures; wastemanagement; antibioticpolicyandpractice;and patientconfidentiality.
Thisinformationshouldbeprovidedinthecontextoftheirrolesintheorganisationorpractice,andwitha focusonrespectingandmaintainingpatientconfidentialityatalltimes.Itshouldbeprovidedaspartoftheir orientation,withperiodicupdatesandrefreshercoursesasrequiredfortheirspecificjobs. Healthcareworkersmayalsorequirejobortaskspecificeducationandtraining,suchas: instrumentcleaningandsterilisationcompetencytesting; insertionandmanagementofcentralandperipherallines;and risksandpreventionofMROtransmission.
Jobspecifictrainingshouldbeprovidedaspartoforientation,whennewproceduresaffecttheemployees occupationalexposure,beforerosteringtohazardousareas(e.g.caringforpatientswithhepatitisBina generalmedicalward);andataminimum,inannualrefreshercourses.Healthcareworkersshouldbe assessedtoensurethattheyarecompetentinusingandconsistentlyadheringtothespecificinfection controlpractice.Healthcarefacilitiesshouldmaintainrecordsofparticipationbyhealthcareworkersin infectioncontroleducationprograms.
CONSULTATIONDRAFTJANUARY2010 C3.3 EDUCATION STRATEGIES
Thetermeducationalstrategiesencompassesawiderangeofcommonlyappliedinterventionsthataimto bringaboutandsustainchangesinthepracticeofhealthcareworkers.Areviewwasundertakentoinform thedevelopmentoftheseguidelines,identifyingrelevantsystematicreviewsofeducationalinterventionsin generalhealthcaresettingsand,morespecifically,whereeducationhasbeenusedtoreducehealthcare associatedinfectionsandimprovehandhygieneintheworkplace. Examplesofeducationactivitiesinclude: educationalmeetings,eitherdidactic(e.g.lecture,presentation)orinteractive(e.g.workshopwithrole playandcasediscussion); educationalmaterials,eitherprintedoraudiovisual; educationaloutreach,whereaninterventionisdeliveredbyavisitinginfectioncontrolexpert; continuingmedicaleducation; multifaceted,tailoredinterventionstoaddressbarrierstogoodpractice;and interprofessionaleducation.
Whiletheoverallfindingsofthereviewswereinconclusive,theydididentifysomeconsistenttrends: Multifacetedstrategies,whichconsidertheneedsofthetargetgroup,potentialbarriersandfacilitators andthecontextinwhicheducationalstrategiesareapplied,arelikelytobemoreeffectivethansingle strategies,althoughitisnotknownwhatcombinationofinterventions,ifany,isoptimal. Activeeducationalinterventionsthatarerepeatedwithsomefrequencyhaveagreaterchanceof changingbehaviourthanasingle,didacticsession.Repetitionandinteractivityhavebothbeenshownto beimportantfactorsinachievingbehaviourchangethatissustained. Thedistributionofprintedmaterialsontheirownwasnotfoundtobeconsistentlyeffective,butmay contributewhenincludedinamultifacetedintervention.Theuseofmultipleformsofmediainan educationinterventionmaybemoreeffectivethantheuseofsinglemedia. Educationaloutreachvisitshavebeenfoundtobeaneffectivemethod,especiallywhencombinedwith otherstrategiessuchasinteractiveeducationandprintedmaterials,butarecostlytoimplement.They seemtobemosteffectivewhenrelatedtoprescribingpracticesofmoderatecomplexity.
Educationactivitiescanbeintegratedintostafforientationprograms,credentiallingpackages,annual trainingandcompetencytesting,implementationofpolicyandproceduremanuals,andindecisionsupport toolsavailableonthefacilityintranet.Theinfectioncontrolpractitionerscontactdetailsshouldbereadily availabletoallstaffandincludedinallresources. Elearning(e.g.interactivewebbasedtraining)isbeingusedinsomestates,andmaybeausefuladditionto othereducationstrategies.Forexample,theQueenslandHealthClinicianDevelopmentEducationService offersinteractiveflexibleonlinelearningprogramsacrossawiderangeoftopics,includinginfection control,whichareavailable24hoursadayfromworkorhome. C3.4 EXAMPLE OF EDUCATION IN PRACTICE HAND HYGIENE
Handhygieneisthemostimportantoftheinfectioncontrolstrategies.AccordingtotheHandHygiene AustraliaManual,healthcareworkersmustperformhandhygienebeforeandaftereverypatientcontactto preventpatientsbecomingcolonisedwithpathogensfromotherpatientsandthehospitalenvironment. Emphasismustalsobeplacedonpreventingthetransferoforganismsfromacontaminatedbodysitetoa cleanbodysiteduringpatientcare.Thelatestguidelinesalsorecommendhandhygieneaftercontactwith inanimateobjects,includingmedicalchartsandequipmentintheimmediatevicinityofthepatient. Handhygieneisagoodexampleoftheroleofeducationineffortstoimproveinfectioncontrolpractice. Althoughtheconceptofhandhygieneisstraightforward,improvinghandhygienepracticesinvolves changingattitudesandbehaviouramonghealthcareworkers.Numerousbarrierstoappropriatehand

CONSULTATIONDRAFTJANUARY2010 hygienehavebeenreported,severalofwhichreflectlackofunderstandingandknowledge(Graysonetal 2009): allhandhygieneagentsbeingthoughttocauseskinirritationanddryness; patientneedsbeingperceivedtotakepriorityoverhandhygiene; perceptionthatgloveusedispenseswiththeneedforadditionalhandhygiene; beliefthatthereisinsufficienttimeforhandhygiene,duetohighworkload; inadequateknowledgeofguidelinesorprotocolsforhandhygiene;

lackofrolemodels;and lackofrecognitionoftheriskofcrosstransmissionofmicrobialpathogens.
AsdiscussedinSectionB1.1,theuseofalcoholbasedhandrub,coupledwithchangesintherecommended indicationsforhandhygieneandachangeinattitudesandbehaviourofhealthcareworkersprovidesthe bestapproachtopreventingHCAItransmission. C3.4.1 National Hand Hygiene Initiative
RecenthandhygieneprogramsinVictorianhospitalshaveledtosignificantlyincreasedcompliancewith handhygiene(Graysonetal2008;Johnsonetal2005).Thesewerecomprehensiveculturechangeprograms involvingwidespreadavailabilityofalcoholbasedhandrubsinclinicalareasandtargetededucationof healthcareworkers. TheNationalHandHygieneInitiative(NHHI)coordinatedbyACSQHCisbasedontheabovestudiesand theWHO5momentsprogram.Itaimstoimplementanationalapproachtoimprovinghandhygieneand monitoringitseffectiveness.Intheinitiative,healthcareworkereducationisakeycomponentofamulti modalinterventionstrategy,involvingbasiceducationalsessionsforallhealthcareworkers,including: definition,impactandburdenofHAI; commonpathwaysfordiseasetransmission,specificallytheroleofhands; preventionofHAIandtheroleofhandhygiene; 5MomentsofHandHygienewithkeymessages; whentoperformhandhygiene; useofalcoholbasedhandrubs;and useatpointofcare. Aswellasintroductoryeducationalsessions,aprogramofformalregularsessionsandupdatesis recommended,takingtheformofspecificorientationprograms,inservicelecturesorspecialworkshops.All educationsessionsaresupportedbyanonlinetrainingpackage,DVD,videodemonstrationsofeachofthe fivemoments,andslidepresentations. Otheropportunitiesforeducationinclude: informaleducationopportunitiesindaytodayactivitiessuchasnursingwardrounds,clinicalunit meetings,increasedpresenceonthewardbyinfectioncontrolstaff,andpromptfeedbackofcompliance results;and promotionalactivitiestoraiseawareness,withpromotionalproducts(e.g.stickers)orincentivesforstaff whoattendeducationsessions.
Formedicalstaff,amultimodalapproachisalsorecommended,ledbyhandhygienechampionswho encouragemedicalstafftoactasrolemodelsforothers.Otheropportunitiesincluderegularscientific presentationsatsurgicalandmedicalmeetings,includingGrandRounds,andregularattendanceby infectioncontrolstaffatmedicalwardrounds.Aswithallhealthcareworkers,medicalstaffshouldbe regularlyassessedfortheirhandhygienecomplianceandbeprovidedwithrapidfeedbackofresults. OthermeasurestoincreasecompliancewithhandhygienearediscussedinSectionC6.
CONSULTATIONDRAFTJANUARY2010 C3.5 C3.5.1 COMPLIANCE AND ACCREDITATION Auditing
Auditingofhealthcareworkerbehaviourisimportantforsurveillanceandaccreditation,andtoreinforce positivesignsofculturechangewithinthefacility.Auditingtomeasurecompliancewithinfectioncontrol policiesandprocedurescanoccurthrough: directobservation; examininglogsandregisterofspecificactivities(e.g.sterilisers);and monitoringuseofPPEorhandhygieneproducts.
Timelyfeedbackisacriticalaspectofauditing.Inacutecaresettings,measurementandfeedbackgenerally occursatwardlevel. C3.5.2 Accreditation and credentialing
AICA(AustralianInfectionControlAssociation),thepeaknationalbodyrepresentingtheinterestsofthe specialistpracticeofinfectioncontrolwithinAustralia,recommendscertificatedcredentialingofinfection controlpractitioners.Thisisaselfregulatoryprocesstodetermineandacknowledgethatanindividualhas demonstratedprescribedcompetenceoftherelevantspecialistnursingrole. C3.5.3 Mentoring, support and networking
Whiletherearenoformalmentoringprogramsinplace,manyinfectioncontrolpractitionersprovide mentoringtolessexperiencedstaffaspartoftheirrole. MentoringofinfectioncontrolpractitionersinTasmania TheTasmanianInfectionPreventionandControlUnithasestablishedaforumforinfectioncontrolpractitionerstoget togethereverytwomonths.Allinfectioncontrolpractitionersworkinginacutehospitalsareencouragedtojoininvia videoconference.Eachforum,threetofourinfectioncontrolrelatedresearchpapersarepresentedanddiscussed.Each infectioncontrolpractitionerisexpectedtopresentonepaperina12monthperiod.Includedintheforumisdiscussion aroundcurrentissuesfacedornewdevelopmentsintheworldofinfectioncontrol. TherearenetworkingandsupportforumsavailablethroughAICAandtheAICAstateandterritory affiliatedassociations,aswellasregionbasedforums,andpractitionerscanalsouseotherinformal networksandcontactswithotherinfectioncontrolpractitioners. C3.6 PATIENT ENGAGEMENT
Informingpatientsandcarersaboutinfectionpreventionstrategiesandtakingtheirexperienceandfeedback intoaccountispivotaltosafeandeffectiveclinicalcare.Patientengagementisnotjustaboutgiving information,itisaprocessofinforming,listeningandinteractingthatgivespatientstheskillsand knowledgetobeactivelyinvolvedintheirownhealthcare,givefeedbackandparticipateinquality improvementprocedures. Throughopen,respectfulinteractionswithhealthcareworkers,patientsandcarerscanbegiveninformation andsupporttoensurethattheyareabletomaintainasafeenvironmentinwhichtheyreceivetheircare(e.g. informationoncaringforwounds,basicadviceonhandhygieneandspreadofinfection). Writtenmaterial(suchasbrochuresandposters)canbeusedtoreinforceverbaldiscussionswithpatientsas partoftheircare.Examplesofusefulinstructionalmaterialsforpatientsandvisitorsinclude: recommendedhandhygiene; respiratoryhygiene/coughetiquettepractices; theneedforandapplicationoftransmissionbasedprecautions;and informationaboutspecificMROs(e.g.MRSAorC.difficile)andhowtostopthemspreading.
CONSULTATIONDRAFTJANUARY2010 Patientengagementisespeciallyimportantintheeventofagastroenteritisorinfluenzaoutbreakorentry intoawardthathousesimmunosuppressedpatients.
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CONSULTATIONDRAFTJANUARY2010 C4 HEALTHCARE-ASSOCIATED INFECTION SURVEILLANCE 19
Summary Appropriate surveillance can substantially reduce healthcare-associated infections, morbidity and mortality. Both outcome and process measures are used for surveillance in large health facilities; process measures alone can provide a useful alternative, particularly in smaller facilities. Timely targeted feedback is critical for effective surveillance.
Manyinfectionscanbepreventedusingapproachesbasedonqualityandsafetytheoriessuchas: qualityimprovementmethodologies; creatingasafetyculture(individualstakingresponsibilityforensuringsafetyandqualityofthemselves andothers);and applicationofsystemsthinking(i.e.understandingthefactorsinthesystemthatallowerrorstooccur).
Tobesuccessful,alltheseapproachesneedtobebasedoncomprehensiveinformationobtainedthrough surveillancetheongoing,systematiccollection,analysis,interpretation,anddisseminationofdata regardingahealthrelatedeventforuseinpublichealthactiontoreducemorbidityandmortalityandto improvehealth(CDC2001). Allhealthcarefacilitiesrequirehealthcareassociatedinfectionsurveillancesystemslocaldatacollection thatresultsintimelyfeedbackhasbeenshowntoreduceinfectionrates. C4.1 ROLE OF SURVEILLANCE IN REDUCING HAI
Surveillanceisimportantforwidersystemsofqualitymanagement,butthemainpurposeofcollecting reliabledataistoimprovequalitywithinaserviceorfacility.Collectingsuchdatacanprovidetheimpetus forchangeandmakeitpossibletoevaluatetheeffectivenessofanintervention.Forexample,monitoring bothhandhygienecomplianceandtherateofbloodstreaminfections,anddisseminatingtheinformation withinthefacility,canimprovehandhygienepractices. Surveillanceofhealthcareassociatedinfectionsdrawsinformationabouttheagent,host,environmentand riskfactorsfromanumberofdatasources: providesbaselineinformationonthefrequencyandtypeofHAI; enablesbreakdownsininfectioncontroltobeidentified;and allowsfortimelyinvestigationandappropriateinfectioncontrolmeasurestobeinstituted.
Thereisasurveillancecycle,describedasdatacollectiondataanalysisandinterpretationdata dissemination(Rothmanetal1998). Allhealthcarefacilities,includingsmallacutecarefacilitiesandofficepractices,shouldcollectdataon healthcareassociatedinfections,infectioncontrolbreaches,outbreaksofinfectiousdiseaseandantibiotic resistance.Postdischargesurveillancebycommunitybasedhealthcarepracticesshouldalsobeconsidered. Thesurveillancesystemusedbyahealthcarefacilitydependsonthetypeandsizeofthefacility,itscase mix,andtheresourcesavailable.
19
Unlessotherwisespecified,thissectionisdrawnfromtheACSQHCreportReducingharmtopatientsfromhealth careassociatedinfection:theroleofsurveillance,availableatwww.safety.
CONSULTATIONDRAFTJANUARY2010 C4.2 TYPES OF SURVEILLANCE PROGRAMS
Itisnotfeasibletoconductfacilitywidesurveillanceforallevents;thereforesurveillanceisoftentargeted, withafocusonspecificevents,processes,organisms,medicaldevicesorhighriskpatientpopulations. Healthcareassociatedinfectionssurveillanceprogramsmayfocuson: specificsitesofinfection(e.g.bloodstream,surgicalsites); specificpopulations(e.g.neonates,healthcareworkeroccupationalexposuretobloodandbodyfluids); specificorganismsortypesoforganisms(e.g.MRO,C.difficile,RSV,rotavirus);or specificlocationsinthehospitalorcommunity(e.g.intensivecareunit,neonatalintensivecareunit, residentialcarefacility).
Therearetwomainmethodsofsurveillanceprocessandoutcome.Processmeasurementsareusually easiertomeasure,lessambiguousandmorewidelyapplicablethanoutcomeindicators.Processsurveillance maybeanadjuncttooutcomesurveillance;alternatively,itcanentirelyreplaceoutcomesurveillancefor practicesorlocationsthathavetoofewadverseoutcomesforstatisticalanalysis(e.g.smallhospitalswhere thenumberofpatientsatriskofinfectionmaybetoosmalltocalculatevalidinfectionrates). C4.2.1 Process surveillance
Processsurveillanceinvolvesauditingpracticeagainstacertainstandard,guidelineorpolicy.Asnosingle interventionwillpreventanyhealthcareassociatedinfection,packagesofevidencebasedinterventionshave beendevelopedandareincreasinglybeingusedinprocesssurveillance(e.g.carebundles,seealsoSections B4andC1.5). Processmeasuresthatarelinkedbyevidencetoimportantoutcomes(McKibbenetal2005): donotrequireriskadjustment; canpredictoutcomes; caneasilybeactedonbecausepotentialimprovementsareusuallytheresponsibilityoftheclinical service; canbecapturedquickly;and aresensitivebecausemanyepisodesofinappropriatecaredonotcauseharm.
Examplesofpublishedprocessindicatorsofhighvalueinclude: asepticinsertionandmanagementofperipheralorcentralintravasculardevices; healthcareworkerscompliancewithhandhygieneandthetechniquestheyused; perioperativeandintraoperativepracticesuchasantibioticprophylaxis,normothermia, normoglycaemiaandappropriatehairremoval;and healthcareworkersuptakeofimmunisation. Outcome surveillance
C4.2.2
Outcomesurveillanceinvolvesmeasuringadverseevents,aproportionofwhicharepreventable.The sensitivityandspecificityofeventdefinitionsandthereliabilityofdatacollectionneedtobeconsidered whendevelopingmethodstodetectadverseevents.Itisimportanttocreateabalancebetweenavoiding falsepositives(specificity)andpickinguptruepositives(sensitivity),giventhattruepositivesarerare eventsintheoverallpatientpopulation. Certainoutcomemeasuresforexample,theincidenceofhealthcareassociatedMRSAbacteraemia appeartobereliableandhavedrivenpracticechange,leadingtosignificantimprovementsinpatientsafety. Outcomesurveillancewithlaboratorybaseddataisusedinthesignaleventssystemthatwasdesignedby QueenslandandisimplementedinQueenslandandSouthAustralia(seealsoSectionC5.3).However, Australiacurrentlyhasnosystemwideapproachtomeasurementofpatientmortalitycausedbyor associatedwithHAI.Thesedeathsareunlikelytobereportedusingexistingmechanismssuchasadverse
CONSULTATIONDRAFTJANUARY2010 eventreportingsystems.Mortalityfrominfectionmaybeseenasanticipatedeventhoughtheoccurrenceof theinfectionthatledtothedeathwasunanticipated. Afurtherchallengeinmeasuringpatientdeathsisdifferentiatingbetweenpatientswhodiewitha healthcareassociatedinfectionandthosewhodiefromahealthcareassociatedinfectionorsufferserious injuryduetoahealthcareassociatedinfection(i.e.attributableinjuryordeath).Onenewapproachisto evaluatesuchpatientdeathstodeterminewhethermortalitywasunexpected,andthenanalysethe contributingfactorstodeterminepreventablerootcausesthatmightbemodifiedinfuture.Inthisapproach, infectionevents(usuallydeathsorBSI)areconsideredandinvestigatedindividually.Althoughmandated bytheUKsNationalHealthService,evidenceofthevalueofthisapproachislacking. C4.2.3 Critical incidents
Iftherehasbeenabreakdowninaninfectioncontrolprocedureorprotocol,alookbackinvestigationmay benecessarytoidentify,trace,recall,counselandtestpatientsorhealthcareworkerswhomayhavebeen exposedtoaninfection,usuallyabloodbornevirus. Lookbackinvestigationsmustbemanagedwithdueregardtoethicalandlegalconsiderations.Intheevent ofsuchanincident(e.g.failureofsterilisationordisinfection),thelocalpublichealthunitshouldbeadvised immediately. 20 Monitoringofcriticalincidentsandothersentineleventsisanimportantpartofsurveillance.Rootcause analysisofsentineleventsisastructuredprocessforidentifyingtheprocessandcontributingfactors, exploringandidentifyingriskreductionstrategiesandimplementingsolutions(seeSectionC1.4.2). C4.3 DATA COLLECTION AND MANAGEMENT
Surveillanceinvolves: definingsurveyedeventsprecisely; systematiccollectionofdata; analysisandinterpretation;and communicationoffindingstorelevantpeople.
Thefollowingepidemiologicprinciplesshouldbeappliedduringhealthcareassociatedinfection surveillance: usestandardiseddefinitionsofinfection; uselaboratorybaseddata(whenavailable); collectepidemiologicallyimportantvariables(e.g.clinicalserviceinhospitalsandotherlargefacilities, populationspecificriskfactors,underlyingconditionsthatpredisposetoseriousadverseoutcomes); analysedatatoidentifytrendsthatmayindicatedincreasedratesoftransmission;and feedbackinformationontrendsintheincidenceandprevalenceofhealthcareassociatedinfections, probableriskfactorsandpreventionstrategiesandtheirimpact,totheappropriatehealthcareworkers, administrators,andasrequiredbylocalandstate/territoryhealthauthorities.
Surveillancedataforqualityimprovementmustbeofhighquality.Thecharacteristicsthatqualifydataas evidenceforactioninclude(Booth1995): representativenessthedatafairlyrepresentthethingmeasured; accuracythedatareflectwhatisintendedtobemeasured; precisionthedataandthetargetofmeasurementcorrespondclosely; authoritativenessthedataareappropriatefordrawingameaningfulconclusion;and
20
TheNHMRCpublicationGuidelinesunderSection95ofthePrivacyAct1988providesfurtherinformationonthe protectionofprivacyinrelationtothecompilationoranalysisofstatisticsforhealthservicesmanagementormedical research.

CONSULTATIONDRAFTJANUARY2010 claritythedataarepresentedinaformthatthetargetaudiencecanunderstand.
Dataofthisnaturearemorelikelytoarisefromsurveillanceprocesses: thatinvolveallstakeholdersindesignandimplementation; forwhichthereareagreedorganisationalobjectives,andprocessesthatarerelevanttothepopulation served; thatusetrainedstafftocollectandmanagedata,andthatprovidethemwithappropriateinformation technologysupport; thatusedefinitionsofsurveillanceeventsthatareunambiguous,practical,specificandcanbevalidated; thathavereliableandpracticalmethodsfordetectingevents; forwhichtheprocessesthatdetermineanoutcomearethoroughlyunderstood; forwhichappropriatedenominatorsarecollectedforriskadjustment;and forwhichreportinglinksmeasurementtopreventionefforts,andmeetstheneedsofbothcliniciansand managers. OUTBREAK SURVEILLANCE
C4.4
Anoutbreakmaybedefinedas: occurrenceofmorecasesofdiseasethanexpectedinagivenareaamongaspecificgroupofpeopleover aparticularperiodoftime;or twoormorelinkedcasesofthesameillness.
Whenanoutbreakisdetected,thehealthcarefacilitysinfectioncontrolmanagementsystemshouldbe notifiedandanoutbreakcontrolteamformed.Asaminimum,thisshouldinclude: aseniorrepresentativefromtheaffectedclinicalservice; aninfectioncontrolpractitioner(orequivalent);and aninfectiousdiseasesphysician/microbiologistwithinfectioncontrolexperience.
Wherenecessary,therelevanthealthauthoritymayneedtobecontacted.Furtherdetailsonoutbreak managementareprovidedinSectionB3.2. Alloutbreaks,howeverminor,shouldbeinvestigatedthoroughlyandtheoutcomesoftheinvestigations documented.Thereforeallestablishmentsshouldhaveadequateresourcesforthedetectionandcontrolof outbreaks. Theobjectivesofoutbreakinvestigationsareto: controlongoingoutbreaks; preventfutureoutbreaks;and advanceknowledgeaboutadisease.
Theprinciplesforinvestigatingoutbreaksinhealthcarefacilitiesarethesameasforcommunitybased outbreaks;tostoptheoutbreakandpreventitrecurring,anepidemiologicalinvestigationisconductedto identifytheaetiologicalagent,theroute(s)oftransmission,exposurefactorsandthepopulationatrisk. C4.5 DISEASE SURVEILLANCE IN OFFICE-BASED PRACTICE
Allstaffmembersinofficebasedpracticesneedtobeawareofthepossibilitythatpatientswillpresentwith suspectedorconfirmedinfectiousdiseases. Forcertaindiseases,timelynotificationtotherelevantauthoritywillberequired,sometimesbytelephone. Systemsneedtobeinplacesothatauthoritiesareabletotracethosewithwhominfectiouspatientshave beenincontact.Astaffmembershouldberesponsibleforcheckingnationalandstatewebsitesforrelevant guidelines(RACGP2006).
CONSULTATIONDRAFTJANUARY2010 Inmostofficebasedpractices,therewillnotbeenoughproceduresperformedtoundertakeoutcome surveillance.Processsurveillancecanbeusedtoevaluateprocessesandproceduresandtomonitorsentinel events.Systemsshouldbeinplaceformonitoringforthreatsofoutbreaks(e.g.varicella,measles)and emergingdiseases(e.g.SARS,H1N1,CAMRSA). C4.6 C4.6.1 NOTIFIABLE DISEASES Notifiable diseases
NotifiablediseasesinAustraliaarelistedat: http://www.health.gov.au/internet/main/publishing.nsf/Content/cdasurveilnndsscasedefsdistype.htm. C4.6.2 State and territory health departments
Publichealthlegislationineachstateandterritorymandatesthereportingofcertaindiseasesbymedical practitioners,hospitals,and/orlaboratoriestotherelevantstateorterritoryCommunicableDiseasesUnit. Notificationsarecollectedatthestate/territorylevel,andcomputerised,deidentifiedrecordsaresenttothe AustralianGovernmentDepartmentofHealthandAgeingforcollationintotheNationalNotifiableDiseases SurveillanceSystem(NNDSS)foranalysisatanationallevel.NNDSSwasestablishedinconsultationwith theCommunicableDiseasesNetworkAustralia(CDNA). Linkstostateandterritorypublichealthlegislationcanbefoundat: http://www.health.gov.au/internet/main/publishing.nsf/Content/cdastatelegislationlinks.htm.
CONSULTATIONDRAFTJANUARY2010 C5 ANTIBIOTIC STEWARDSHIP 21
Summary Inappropriate antibiotic use hastens the emergence and amplification of resistant pathogens and subsequent transmission among hospital patients. This can result in a significant impact on morbidity, mortality and treatment costs. Antibiotic stewardship programs aim to change antibiotic prescribing to decrease unnecessary use, reserve so-called last-line agents, and promote the use of agents less likely to select resistant bacteria. All activities are informed guidelines and demonstrated incidence of antibiotic resistance. Surveillance data can be used to identify changes in usage that may be linked to development of resistance and to measure the impact of antibiotic stewardship programs.
C5.1
BACKGROUND
Thereisawelldocumentedrelationshipbetweenpriorantibioticusageandtheemergenceofbacterial resistance(McGowan1987).WHOandotherinternationalbodieshavenominatedantibioticresistanceasa majorpublichealthconcern,andtheACSQHChasestablishedanationalAntibioticStewardshipProgramto facilitatetheestablishmentofeffectiveantibioticstewardshipprogramsatnational,state,healthcarefacility andcommunitylevels. Theuseofparticularantibioticclassesislinkedwiththeemergenceandamplificationofspecificmulti resistantpathogens,particularlyC.difficile,MRSA,VREandmultiresistantGramnegativeorganisms.If unchecked,highlevelsofantibioticusageincreasethenumberofpatientswhoarecolonisedorinfectedwith resistantorganisms,bothinhospitalsandinthecommunity(Cosgrove&Carmeli2003;vandeSande Bruinsmaetal2008). C5.1.1 In hospitals
ComparisonwithinternationaldatashowsthatAustralianantibioticusageratesinhospitalsarehighfor someclassesofdrugs,andthereisconsiderableunexplainedvariationbetweenhospitalsintheuseof certainantibiotics,particularlybroadspectrumantibiotics(NAUSP2007).Monthtomonthvariationinuse ofspecificantibioticclasseshasbeenshowntocorrelatecloselywithsubsequentvariationinantibiotic resistance(e.g.changesinhospitalMRSAincidence)(LopezLozano2000). Problemsresultingfrominappropriateuseofantibioticsapplytobothcurrentandfuturehospitalpatients duetochangesinhospitalmicrobialecologyresultingfromtheresistance. Additionalcostsofinfectionscausedbyresistantorganismsinclude: theneedformoreexpensiveandbroaderspectrumantibioticstotreattheinfections;and theneedtoisolatepatientscolonisedwithresistantorganismsinordertominimisecrossinfection. In the community
C5.1.2
Inthe1990s,communityantibioticuseinAustraliawashighcomparedwithotherdevelopednations (McManusetal1997).Today,multiresistantbacteria,suchascommunitystrainsofMRSAandextended spectrumbetalactamaseproducingGramnegativebacteria,arecausingincreasinghumanmorbidityand thereisconcernthatpastexcessiveantibioticuseinthecommunityorinanimalproductionsystems(or both)isresponsible.
21
ThissectionisdrawnfromtheAustralianCommissionforSafetyandQualityinHealthCarereportReducingharmto patientsfromhealthcareassociatedinfection:theroleofsurveillance(availableat: http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/progHAI_Surveillance#report).For furtherinformationondefinitionsandreportingmechanismspleaserefertothisreport.

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CONSULTATIONDRAFTJANUARY2010 NationalPrescribingService(NPS)targetingofantibioticprescribingcontributedtoasignificantdeclinein antibioticprescribingbetween1999and2004(NAUSP2008),butthisdeclinehasnotbeensustained.Thereis currentlynocomprehensivesystemtomonitorchangesinresistanceprevalenceasaresultofaltered prescribingpatterns.Mostmonitoringisdoneattheinstitutionallevel,exceptinQueensland,whichhasa systemformonitoringresistanceinitspublichospitals. C5.1.3 What is antibiotic stewardship?
Antibioticstewardshipaimstooptimiseantimicrobialuseamongpatientsinordertoreduceantibiotic resistance,improvepatientoutcomesandsafety,andensurecosteffectivetherapy.Atthehealthcarefacility level,antibioticstewardshipinvolves: implementinganantibioticstewardshipprogram;and continualmonitoringandanalysisofantibioticusage,totrackchangesinantibioticresistanceandto monitoreffectsofcontainmentstrategies. ANTIBIOTIC STEWARDSHIP PROGRAMS
C5.2
Interventionprogramsthatrestricttheuseofbroadspectrumantibioticshaveshowndramaticeffectsin optimisingantibioticprescribing.Successfulantibioticstewardshipprogramshavebeenassociatedwith reducedfacilityresistanceratesaswellasmorbidity,mortalityandassociatedcostsoftheseandsome Australianhospitalshavealsodemonstratedsignificantcostsavingsthroughreductionindrugcosts. Thedensityofantibioticusewithinspecialisedunitssuchasintensivecareunits,haematologyandoncology units,andsolidorgantransplantunitsisseveralfoldhigherthaninotherhospitalsettings.Thisincreased usehasbeenshowntogeneratehighratesofantibioticresistance;therefore,theseareasshouldbea particularfocusforsurveillanceandintervention. KeyrequirementsofahospitalantibioticstewardshipprogramarelistedinTableC4.

Table C4: Key requirements of a hospital antibiotic stewardship program
Essential strategies for all hospitals Implementation of clinical guidelines that comply with Therapeutic Guidelines: Antibiotic and incorporate local microbiology and resistance patterns. Formulary restriction and approval systems that include restriction of broad spectrum antibiotics to those patients where use is clinically justified. Clinical microbiology services reporting patient-specific culture and sensitivity results to optimise individual antibiotic management. Review of antibiotic prescribing with intervention and direct feedback to the prescriber. Activities according to local priorities and resources Provision of effective education of prescribers and pharmacists about antibiotic usage, development of resistance and judicious prescribing. Point of care interventions including: streamlining or de-escalation of therapy, dose optimisation, parenteral to oral conversion Use of information technology such as electronic prescribing with clinical decision support, on-line approval systems Monitor antibiotic prescribing by measuring antibiotic consumption; drug use evaluations and using Quality Use of Medicine indicators. Annual publication of antibiograms validated by a clinical microbiologist.
Governance and Structure Support and collaboration of hospital administration including allocation of resources to provide education and measure and monitor antibiotic usage. A multidisciplinary antibiotic stewardship team with core membership of an infectious diseases physician (lead doctor) and a clinical pharmacist. A clinical microbiologist, and infection control practitioner may also be included. Antibiotic stewardship resides within the hospitals quality improvement and patient safety governance structure and there is collaboration between the stewardship team and drug and therapeutics and infection control committees.
Case study effect of an active antibiotic stewardship program AlargetertiaryteachinghospitalinNewSouthWaleshashadanactiveapproachtoantibioticstewardshipformany years.Itisunderpinnedbylocallyrelevantantibioticguidelinesandenthusiasticstaffintheareasofpharmacy, infectiousdiseasesandmicrobiology.Clinicalteamsareregularlyengagedinguidelinereview,developmentand implementationatlocalandnationallevels.Specificdiscussionsaboutpatientsarepromptedbyanonlineantiinfective registration(approval)system,whereclinicianswhoprescribebroadspectrumagentsregistertheindicationforuse andareadvisedoncorrectdosage.Twiceweeklyinfectiousdiseasesandmicrobiologypatientroundstakeplacein ICUs.Thesefrequentlyleadtochangesinantibiotictherapy,generallytoearlycessation. Adrugusageevaluationpharmacistregularlyauditsantibioticuseforparticularagentsorclinicalsyndromesor situations,mainlycommunityacquiredpneumoniaandsurgicalprophylaxis.Theseauditdataareusedtoprovide feedbacktoclinicianstoencouragemoreappropriateuse. MonthlydataonusagearesuppliedtotheNationalAntimicrobialUtilisationSurveillanceProgram.Thisallowsfor benchmarkingofintensivecarenitandnonintensivecareusageagainstotherlargeAustralianhospitals.Astudyof usageofselectedhighcost(predominantlybroadspectrum)antibioticsin2006indicatedthat,formostagents,usein intensivecareunitandnonintensivecaresituationsinthishospitalwasfarlowerthanthenationalaverage.Basedon purchasecostalone,thenetcostdifferencein2006was$278,000($59,000ofthiswasforintensivecareunituse). C5.3 C5.3.1 ANTIBIOTIC STEWARDSHIP SURVEILLANCE METHODS Hospitals
Therearetwomainmethodsofantibioticdatacollectioninhospitals:patientlevelsurveillanceand populationsurveillance. Patientlevelsurveillanceinvolvescollectingdataaboutthedose,dosageintervalanddurationof therapyforindividualpatients.Thisapproachgivesthemostaccurateinformation,particularlyifthe aimistolinkexcessiveantibioticusewithdevelopmentofresistanceinaparticularareaofpractice. Suchinformationisusuallyonlyavailablethroughreviewsofdrugusage,althoughelectronic prescribingandrecordingofdrugadministrationwillmakepatientlevelsurveillancemorepracticalin thefuture. Populationsurveillanceinvolvesaggregatingantibioticusedata,mostlysuppliedthroughpharmacy reports,andsummarisedatthelevelofahospitalorunit.Currently,thistypeofsurveillanceistheonly realisticalternativeforongoingandsystematicmonitoringofantibioticuse.Inmosthospitalsin Australia,aggregatedatafromissuestowardscombinedwithindividualpatientdispensingrecordsare used.Anotherdatacollectionmethodistousepharmacypurchasedata;however,thisisless representativethanaggregationofwardissuesandindividualinpatientsupplies.
SouthAustraliaandQueenslandhaveprogramsforstatewidemonitoringofantibioticusage.TheNational AntimicrobialUtilisationSurveillanceProgramprovidesbimonthlyreportsonhospitalinpatientantibiotic usagetocontributinghospitals,andbimonthlyreportstotheAustralianDepartmentofHealthandAgeing. Dataarecontributedby50%ofprincipalreferralhospitalsfromsixstates,whichiscurrently42%ofmajor cityprincipalreferralcentres.
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CONSULTATIONDRAFTJANUARY2010 C5.3.2 Community
Measurementofcommunityantibioticuseisgenerallybasedonprescriptiondata.InAustralia,thisis collectedfromtwosources:MedicareAustraliarecordsofprescriptionssubmittedforpaymentunderthe PharmaceuticalBenefitsScheme(PBS)andRepatriationPharmaceuticalBenefitsScheme(RPBS);andan estimateofnonsubsidisedmedicinesobtainedfromanongoingsurveyofarepresentativesampleof communitypharmacies.Thesedataalsoincludeantibioticsdispensedtooutpatientsanddischargedpatients inmoststates.
CONSULTATIONDRAFTJANUARY2010 C6 INFLUENCE OF FACILITY DESIGN ON HEALTHCARE-ASSOCIATED INFECTION
Summary The design of a healthcare facility can influence the transmission of healthcare-associated infections by air, water and contact with the physical environment. Key design features that minimise the transmission of infection include: surface finishes that are easy to maintain and clean; ventilation, air conditioning, cooling towers and water systems that meet Australian standards for the facility they are to service; the ability to isolate patients: in a single room (infectious patients) or negative pressure room (to prevent transmission of airborne pathogens) positive pressure rooms or use of laminar airflow filtration (LAF) for immunocompromised patients triaging of patients in waiting rooms with separation of infectious patients; appropriate work place design: separation of procedural and cleaning areas movement of work flow systems from clean to contaminated areas ready access to hand hygiene facilities adequate storage for clean and sterile items; adequate waste management procedures and linen handling; and involvement in demolition, construction and renovation projects of a multidisciplinary team that includes infection control staff to coordinate preventive measures.
C6.1
FACILITY DESIGN AND ITS IMPACT ON INFECTION CONTROL
Infectionpreventionandcontrolrequirementsarecriticaltotheplanningofahealthcarefacilityandneedto beincorporatedintoplansandspecifications.Allareasofahealthcarefacilityshouldbedesigned, constructed,furnishedandequippedtominimisetheriskoftransmissionofinfection.Inparticular,the designandlayoutofthefacilityshouldfacilitatetheapplicationofstandardandtransmissionbased precautionsbyallstaff. C6.1.1 Evidence on the influence of environmental design on healthcare-associated infection
Therearefewrandomisedcontrolledtrialsrelevanttotheeffectsofspecificdesignfeaturesorinterventions onhealthoutcomes.However,fromcasereports,publishedliteraturerelatingtooutbreaksandfroma theoreticalriskmanagementperspective,itisclearthatthedesignofbuildingscanhaveanimpactonrates ofHAIs.Reliablepatternsacrossseveralstudiesemerged,whichwerebroadlyconsistentwithpredictions basedonestablishedknowledgeandtheoryconcerningenvironmentandhealthcareoutcomes. However,itisdifficulttodistinguishtheindependenteffectofanyenvironmentalfactor,asmostchangesof thephysicalenvironmentinhealthcaresettingsalterseveralenvironmentalfactorssimultaneously.For example,renovatinganintensivecareunitwithtwobedpatientroomstocreatesinglebedroomswouldbe likelytoalternotonlythenumberofpatientsperroom,butalsotheratioofhandhygienesinksperbedand possiblytheroomventilationorairquality.
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CONSULTATIONDRAFTJANUARY2010 C6.2 MECHANISMS FOR INFLUENCING HEALTHCARE-ASSOCIATED INFECTION THROUGH ENVIRONMENTAL DESIGN
Manystudiesindicatethatinfectionratesarelowerwhenthereisverygoodairandwaterquality,greater physicalseparationofpatientsandgreaterspaceperpatient(withisolationwhereappropriate). C6.2.1 Reducing airborne transmission
Reservoirsforairbornepathogensinclude(Ulrich&Wilson2006): dust(e.g.sporesofC.difficileorAspergillus); aerosoldroplets(e.g.TB,severeacuterespiratorysyndrome[SARS],influenza,chickenpox),and skinscalesshedbypatientsinfectedwithMRSA.
AirbornetransmissionhasalsobeenimplicatedinoutbreaksofotherinfectionssuchasAcinetobacterand Pseudomonasspp.(Beggs2003;Beggsetal2008). Mostpathogensinhealthcaresettingsoriginatefrompatients,staffandvisitorswithinthebuildings.Other pathogenscanenterbuildingsfromoutsideairthroughdustthatharbourspathogenssuchasAspergillus, streptococciorstaphylococci(Beggs2003).Therearealsolesscommonsourcesofairborneinfections;for example,birddroppingsoraerosolsfromcontaminatedwaterinawarmwatertherapypool(Angenentetal 2005).

Approaches to airborne transmission
Approachestoreducingairbornetransmissioninclude: installationofeffectiveairfiltration; specifyingappropriateventilationsystemsandairchangerates; employingmonitoringandcontrolmeasuresduringconstructionorrenovation;and usingsinglebedroomsinsteadofmultibedroomstoincreaseisolationcapacity.
Indentalpractices,engineeringrulesstatetheremustbeseparationbetweeninletairforcompressorsand airconditioningoutlets(ADA2008). Filtration Aneffectivewaytopreventinfectionsistocontrolthesourceofpathogens.Filtration(thephysicalremoval ofparticulatesfromair)isessentialinensuringgoodairquality.Inacutehealthcaresettings,acommonly usedapproachistheHEPAfilter,whichcanbeatleast99.97%efficientinremovingparticulatesassmallas 0.3 micronsindiameter;thisisadequateformosthealthcaresettings,includingoperatingrooms(Sehulsteret al2004).Thereisevidencethatthereisalowerincidenceofinfectionwhenimmunocompromisedandother highacuitypatientsarehousedinHEPAfilteredisolationrooms. Ventilationsystemsandairflowcontrol. Optimalventilationrates,airflowpatternsandhumiditycanhelptominimisethespreadofinfection: Theventilationrateisameasureusedtocontrolindoorairquality,andinhealthcarefacilitiesisusually expressedasroomairchangesperhour(ACH).Thepeakefficiencyforparticleremovalintheairspace oftenoccursbetween12ACHand15ACHAustralianguidelinesrecommendthatisolationrooms haveaminimumof12ACHor145L/secwhicheverisgreater(NSWHealth2007),andotherroomsin AustralianhealthcarefacilitiesarerequiredtocomplywithAS1688.2(1991).However,thereisalackof consistencyintheminimumventilationrequirementsneededforeffectivepreventionofinfections. Astudyof17CanadianhospitalsfoundthattheriskofhealthcareworkersacquiringTBwasstrongly linkedwithexposuretoinfectedpatientsinroomswithlowACHrates,suchaswaitingareas(Menzieset al2000). Airflowdirectionisalsoimportant Negativeairflowpressureispreferredforroomshousinginfectiouspatientstopreventthe dispersionofpathogenladenaerosols,dustandskinscalesfromthelocusoftheinfectedpatientto
CONSULTATIONDRAFTJANUARY2010 otherspaces.Areviewof40studiesconcludedthatthereisstrongevidencetosupportand recommendtheuseofnegativelypressurisedisolationrooms(Lietal2007). Positiveairflowpressureisdesirabletosafeguardthemfromaerialpathogensenteringfrom adjacentspacesinthecareofimmunocompromisedpatients(e.g.,surgicalpatients,patientswith underlyingchroniclungdisease,ordialysispatients)orimmunosuppressedpatients(e.g.transplant patientsorcancerpatients), Laminarairflow(LAF)isHEPAfilteredairblownintoaroomatarateof273m/minina unidirectionalpatternwith100400ACH(Sehulsteretal2004).LAFcanreduceaircontaminationto thelowestpossiblelevelandisthereforerecommendedforoperatingroomsandareaswith ultracleanroomrequirements(e.g.immunocompromisedpatients)(Albertietal2001;Arletetal 1989;Dharan&Pittet2002;Fribergetal2003;Hahnetal2002;Sherertzetal1987). Maintenancesystems Ventilationandairflowcontrolsystemsneedtobemaintainedregularlybysuitablyqualifiedstaffaccording toanagreedmaintenanceplan,andaccuratedocumentedinamaintenancerecord. Maintainingairqualityduringconstructionorrenovation Effectivecontrolandpreventionmeasuresarenecessaryduringconstructionandrenovationwithina healthcarefacility,becausesuchactivitieshavebeenfrequentlyimplicatedinoutbreaksofairborneinfection. Thekeytoeliminatinginfectionsistominimisethedustgeneratedduringtheconstructionactivityandto preventdustinfiltrationintopatientcareareasneartheconstruction.Examplesofsuchmeasuresinclude installingbarriersbetweenpatientcareareasandconstruction/renovationareas,generatingnegativeair pressureforconstruction/renovationareasrelativetopatientcareareas,usingportableHEPAfiltersand sealingpatientwindows. Formoreinformation,refertoPublicHealthAgencyofCanadaguidelinesfrom2001,Constructionrelated NosocomialInfectionsinPatientsinHealthCareFacilities:DecreasingtheRiskofAspergillus,LegionellaandOther Infections,whichcontainariskassessmentandpreventivemeasureschecklist(availableat:http://www.phac aspc.gc.ca/publicat/ccdrrmtc/01vol27/27s2/27s2f_e.html). C6.2.2 Reducing infections spread through the physical environment
Thepreventionofcontactspreadinfectionsisofparamountimportanceinhealthcaresettings.Contact contaminationisgenerallyrecognisedastheprincipaltransmissionrouteofhealthcareacquiredinfections, includingpathogenssuchasMRSA,C.difficileandVRE,whichsurvivewellonenvironmentalsurfacesand otherreservoirs. Environmentalroutesofcontactspreadinfectionsincludedirectpersontopersoncontactandindirect transmissionviaenvironmentalsurfaces.

Reducing surface contamination through hand hygiene compliance
Healthcareworkershandsplayakeyroleinbothdirectandindirecttransmission(seeSectionsB1.1and C3.4).Giventheimportanceofmaximisinghandhygienecompliance,itisabsolutelyessentialthatallareas ofthefacilityaredesignedtofacilitatecompliancewithhandhygienerequirements.

Accessibility
Inconvenientlylocatedalcoholbasedproductdispensers,sinksandbasinsareamajorbarriertohealthcare workercompliancewithhandhygienerequirements(Graysonetal2009). Designfeaturescanincreasehandhygienecompliancebyprovidingagreaternumbersofalcoholbased productdispensers.Thisincreasedaccessibilityassistshealthcareworkersincomplyingwithhandhygiene requirements,particularlyifdispensersareplacedinappropriatelocations(whereclinicalcareisprovided [e.g.bedside]orwhereindirectcaretasksareperformed).Otheraspectsofdesignthatmayincrease complianceincludeautomateddispensersofhandhygieneproducts,electronicmonitoringand computerisedvoiceprompts.
CONSULTATIONDRAFTJANUARY2010 Aswellasbeinginstalledinallpatientcareareas,handhygienefacilitiesshouldbeplacedinallareaswhere carefulattentiontohygieneisessential,suchaskitchens,laundries,pharmacies,laboratoriesandstaff amenitiesareas(e.g.bathrooms,toiletsandchangerooms).

Staff preference
Healthcareworkeracceptanceofalcoholbasedhandrubisacrucialfactorinthesuccessofanyprogramto improvehandhygienecompliance.Thechoiceofhandhygieneproductsshouldcombinegoodantibiotic activitywithgooduseracceptability/skintolerability. TheHandHygieneAustraliaManual(Graysonetal2009)outlinesthefollowingalcoholbasedhandrub featuresasimportantininfluencingacceptability,aswellasreadyaccessibilityateachbedsideandinall patientcareareas: fragranceandcolourthesemayincreasetheinitialappealbutmaycauseallergenicreactions,andare thereforediscouraged; emollientagent(s)inthealcoholbasedhandrubtheseshouldpreventskindryingandirritantskin reactions,butnotleaveastickyresidueonhands; dryingcharacteristicsingeneral,solutionshavelowerviscositythangelsandthereforetendtodry morequickly;and riskofskinirritationanddrynessproactiveandsympatheticmanagementofthisproblemisvital.
Thereissomeevidencetosuggestthatgelsarepreferredtosolutions,howeveritisimportantforstaffto evaluateproductsthemselvesbeforeimplementationwherepossible.Evenwhereemollientagentsare presentintheproduct,readyaccesstoamoisturisingskincareproductisessential.Allhandhygiene productsshouldbechemicallycompatible.Itisadvisabletopurchasehandhygieneandhandcareproducts fromarangemadebyasinglemanufacturer,asthisensurescompatibilitybetweentheproducts. C6.2.3 Control of surface contamination through material selection
Easeofcleaningshouldbeakeyconsiderationinselectingappropriatefloorandfurniturecoverings.Several designrelatedfactorsshouldbeconsideredtominimisetheriskofinfectionstemmingfromcontaminated surfaces: thenatureandtypeofcontaminationthatislikelytooccur;and ifasuitablecleaningmethodforthatsurfacecanbeperformed.
Areasthatmaybeindirectcontactwithbloodandbodyfluids(e.g.surfacessuchasfloorsandbenchtops) needtobemadeofimperviousmaterialthatissmoothandeasytoclean. Floorcoverings Theuseofcarpetcanbecontroversialasitisperceivedtobedifficulttocleancomparedwithhardfloor coverings.Somestudieshaveidentifiedcarpetingassusceptibletocontaminationbyfungiandbacteria (Andersonetal1982;Boyceetal1997;Skoutelisetal1994;Beyer&Belsito2000). Intermsofinfectioncontrol,theadvantagesofhardfloorcoveringsinclude: beingeasiertoclean; beingeasiertodisinfectwhererequired; allowinguseofthemostappropriatedisinfectant,ratherthanaproductthatissuitableforuseoncarpet; costingless,asdisinfectantislessexpensivethansteamcleaning,andsteamcleaningmaynotbereadily available; thereislesssurfaceareasohardfloorcoveringsarelesslikelytoactaasreservoirthancarpet; theremaybeoccupationalhealthandsafetyissuesrelatingtostaffvacuumingcomparedwithmopping; and whenadditionalcleaningisrequired,hardfloorsurfacesareeasiertocleanthancarpet.
However,carpetingmayofferadvantagesunrelatedtoinfectioncontrol,includingnoisereduction(Philbin &Gray2002).
CONSULTATIONDRAFTJANUARY2010 Carpetingshouldbeavoidedinareaswhere(Sehulsteretal2004). spillsarelikelytooccur(e.g.aroundsinksorinisolationorsoiledutility/holdingareas); areaswherepatientsmayhavedirectcontactwithcontaminatedcarpets(e.g.children/babiescrawling onthefloor);and wherepatientsareatgreaterriskofairborneinfections.
Furnishings Noskinetal(2000)identifiedfabriccoveredfurnitureasasourceofVREinfectioninhospitalsand suggestedtheuseofeasilycleanable,nonporousmaterial. AstudycomparingtheperformanceofavarietyoffurnitureupholsterytypeswithrespecttoVREand Pseudomonasaeruginosa(PSAE)contamination(Lankfordetal2006)foundthatperformancewassimilar acrossdifferentfurniturecoveringsintermsofreductionsinVREandPSAEaftercleaningandthetransfer ofVREandPSAEtohandsthroughcontact.However,whiletherewerenodifferencesintheabilityof differentupholsterytypestoharbourPSAE,theVREpathogensurvivedlesswellorforshorterperiodson vinyl(Lankfordetal2006). TheCDC/HICPACguidelines(Sehulsteretal2004)recommendminimisingtheuseofupholsteredfurniture inareashousingimmunocompromisedpatients. Blindsandcurtainsshouldbeeasytocleanandalsodiscouragetheaccumulationofdust. C.6.2.4 Reducing water-borne transmission
Comparedwithairborneandcontacttransmissionofinfection,fewerstudieswereidentifiedonwaterborne transmissioninrelationtohospitaldesignfactors.Theliteraturenonethelessisclearthatwaterborne infectionscanbeaseriousthreattopatientsafety.Manybacterialandsomeprotozoalmicroorganismscan proliferateorremainviableinmoistenvironmentsoraqueoussolutionsinhealthcaresettings(Sehulsteret al2004). Contaminatedwatersystemsinhealthcaresettings(suchasinadequatelytreatedwastewater)mayleadto thepollutionofmunicipalwatersystems,entersurfaceorgroundwater,andaffectpeopleinthecommunity (Iversenetal2004).

Sources of water contamination
TheCDC/HICPACguidelines(Sehulsteretal2004)identifythefollowingcategoriesofenvironmentalroutes orsourcesofwaterbornetransmission: directcontact,suchashydrotherapy(Angenentetal2005); ingestionofwater,suchasdrinkingwater(Congeretal2004;Squieretal2000); inhalationofaerosolsdispersedfromcontaminatedwatersources,suchasimproperlycleanedor maintainedcoolingtowers,showers(Mineshitaetal2005),respiratorytherapyequipmentandroomair humidifiers;and aspirationofcontaminatedwater.
Approaches to reducing waterborne transmission
Watersupplysystem Thewatersupplysystemshouldbedesignedandmaintainedwithpropertemperatureandadequate pressure;stagnationandbackflowshouldbeminimisedanddeadendpipesshouldbeavoided. TopreventthegrowthofLegionellaandotherbacteria,theCDC/HICPACguidelinesrecommendthat healthcarefacilitiesmaintaincoldwateratatemperaturebelow20C,storehotwaterabove60C,and circulatehotwaterwithaminimumreturntemperatureof51C(Sehulsteretal2004). Whentherecommendedstandardscannotbeachievedbecauseofinadequatefacilitiesthatareunabletobe renovated,othermeasuressuchaschlorinetreatment,coppersilverionization,orultravioletlightsare recommendedtoensurewaterqualityandpreventinfection(Sehulsteretal2004).

CONSULTATIONDRAFTJANUARY2010 Pointofusefixtures Waterfixturessuchassinks,faucets,aerators,showers,andtoiletshavebeenidentifiedaspotential reservoirsforpathogenicmicroorganisms(Blancetal2004;Congeretal2004;Mineshitaetal2005;Squieret al2000).Suchfixturesproduceaerosolsthatcandispersemicrobesandtheyhavewetsurfacesonwhich mouldsandothermicroorganismscanproliferate.However,empiricalevidencelinkingthesefixturesto HAIsisstilllimited;noconsensushasbeenreachedregardingthedisinfectionorremovalofthesedevices forgeneraluse(Sehulsteretal2004). Regularcleaning,disinfectionandpreventativemaintenanceprogramsshouldbeprovided,especiallyin areashousingimmunocompromisedpatients. Icemachines Icestoragereceptaclesandicemakingmachinesshouldbeproperlymaintainedandregularlycleaned.Ice andicemakingmachinesmaybecontaminatedthroughimproperhandlingoficebypatientsand/orstaff. Suggestedstepstoavoidthisincludeminimisingoravoidingdirecthandcontactwithiceintendedfor consumption;usingahardsurfacescooptodispenseice,andinstallingmachinesthatdispenseicedirectly intoportablecontainersatthetouchofacontrol(Sehulsteretal2004). Waterfeatures Despitetheabsenceofempiricaldocumentationlinkingproperlymaintainedfountainstohospitalacquired infections,theAIA&FGIGuidelines(2006)recommendthatfountainsnotbeinstalledinenclosedspacesin hospitals. C6.3 THE BENEFITS OF SINGLE-BED ROOMS FOR PATIENT ISOLATION
Thethreeroutesoftransmissionoftenoverlap,andenvironmentalapproachesmayinfluencemorethanone transmissionroute.Forexample,singleroomsplayakeyroleinpreventingapatientwithacontagiousor aerialspreadinfectionfrominfectingothers,andalsoprotectimmunocompromisedpatientsinnearby patientcareareasfromairbornepathogens. Studiesofcrossinfectionforcontagiousairbornediseases(suchasTB,measles,andchickenpox) indicatethatplacingpatientsinsinglerooms,singlebedcubicleswithpartitions,isolationrooms,or roomswithfewerbedsandmorespacebetweenpatients,issaferthanhousingtheminmultibedspaces withmorepatients. Surfacesnearinfectedpatientsquicklybecomecontaminated,creatingnumerousreservoirsthatcan transferpathogenstopatientsandstaff. ScreeningforMROsorspecificpathogensiseffectivebutresultsmaynotbeavailableonadmission; cohabitingMROcolonised/infectedpatientswithnoncolonised/infectedpatientsinmultibedrooms increasesthespreadofMROs. Singlebedroomscanfacilitategreaterfrequencyofcleaninganddecontaminationasthereislimited impactonneighbouringpatients. Handhygienecomplianceislikelytobeimprovedthroughgreaterprominenceofsinksorhandhygiene dispensers. PrivatetoiletsareakeyfactorthatpreventcontributedtothespreadofC.difficileandotherinfectious agentsthatspreadviaentericandcontactmechanisms.
InternationalbodiesincludingtheAmericanInstituteofArchitectsrecommendthatacutecarefacilitieshave 80%singlebedrooms.Thisrecommendationisbeingimplementedinanumberofcurrenthospital redevelopments(e.g.RoyalCanberraHospital,RoyalPerthHospital)andshouldbeconsideredduring planningforredevelopmentofanyacutehealthcarefacility.
CONSULTATIONDRAFTJANUARY2010 C6.4 CONSTRUCTION AND RENOVATION
Infectioncontrolprecautionsduringconstructionandrenovationshouldbeintegratedintothedesignand documentationofthefacilityfromthebeginningofthedesignstage.Itisimportantthatthedustcontroland infectioncontrolprinciplesdevelopedduringthepredesignstageareintegratedfromtheinitialstagesof designdevelopmentuntilthecompletionoftheactivity. Identificationoftheatriskpopulation,knowledgeofthetransmissionrouteofalikelypathogenand locationoftheatriskpopulationallneedtobetakenintoaccountintheplanningstages. C6.4.1 Risk management
Theriskprofileshouldcontainasaminimum: identifythelocationofhighriskpatientsinrelationtothesite; identifyventilationsystemtypesandpotentialimpact; determineairmonitoringrequirements,methodologyandfrequency; takeairqualitysamplestoestablishabaseline; identifypossiblecontaminantsandtheirlocations(contaminantsmaybepresentinceilingdust,service shafts(especiallyifdampnessispresent),sprayedonfireretardantsandbirddroppings.
RefertoSectionDoftheAustralasianHealthFacilityGuidelines(AusHFG)forfurtherguidanceandthe definitionofinfectioncontrolrisklocation/areatableandinfectionpreventionandcontrolstrategies. C6.5 GUIDANCE DOCUMENTS
Moredetailedinformationonfacilitydesignisavailablefrom: AustralasianHealthFacilityGuidelines;
HB260HospitalacquiredinfectionsEngineeringDowntheRiskHandbook; Sehulsteretal(2004)CDC/HICPACguidelinesforenvironmentalinfectioncontrolinhealthcare facilities; AmericanInstituteofArchitectsandFacilitiesGuidelinesInstitute; AmericanSocietyofHeating,RefrigeratingandAirconditioningEngineers;and CDCguidelinesontuberculosis,SARsandpandemicinfluenza.
PART D
STANDARDS, LEGISLATION AND OTHER RESOURCES
Many other resources exist that support and add to these guidelines: Australian Standards and legislation that regulate many infection control work practices; international and local guidelines that give more detailed guidance on specific areas of infection control; and published and web-based tools which can be used to assist implementation of guidelines recommendations.
This Part lists a range of these relevant resources. The information presented in this Part is relevant to everybody employed by a healthcare facility, including management, healthcare workers and support service staff.
PartDincludessectionscorrespondingtoeachsectionoftheguidelinesinPartBlistingrelevant Australianstandards,nationallegislationandexamplesofjurisdictionallegislation,guidelines(Australian andinternational)andalsotoolsandotherwebbasedresources.ThePartwillbefurtherdeveloped followingconsultation.
Part D Standards, legislation and other resources 168
CONSULTATIONDRAFTJANUARY2010 D1 GENERAL INFECTION CONTROL RESOURCES
International guidelines on infection control
CentersforDiseaseControlandPreventionGuidelineforIsolationPrecautions:PreventingTransmissionof InfectiousAgentsinHealthcareSettings2007. epic2:NationalEvidenceBasedGuidelinesforPreventingHealthcareAssociatedInfectionsinNHSHospitalsin Englandhttp://www.epic.tvu.ac.uk/PDF%20Files/epic2/epic2final.pdf NationalInstituteforClinicalExcellenceInfectionControl:PreventionofHealthcareassociatedInfectionsin PrimaryandCommunityCare2003http://www.nice.org.uk/guidance/index.jsp?action=byID&o=10922
Policies on infection control
NSWHealthDepartmentPolicyDirective2007_036.InfectionControlPolicy http://www.health.nsw.gov.au/policies/pd/2007/PD2007_036.html NSWHealthDepartmentGuideline2005_037InfectionControlGuidelinesforOralHealthCareSettings http://www.health.nsw.gov.au/policies/GL/2005/GL2005_037.html DepartmentofHealthVictoria.InfectionControlandCleaninginHospitals http://www.health.vic.gov.au/ideas/infcon NTDeptofHealthandFamiliesInfectionControl http://www.health.nt.gov.au/Remote_Health_Atlas/Contents/Infection_Control/index.aspx QueenslandHealthInfectionControlGuidelinesandassociatedpolicies,recommendedpracticesand advisories.http://www.health.qld.gov.au/chrisp/
Legislation/codes of practice
Healthcareworkersregistrationboardscontainstandardsofhealthcareprofessionalstandardsof practicethatincludeinfectioncontrolstandards(e.g.RegistrationBoardsforMedicalPractitioners; NursesandMidwives;Physiotherapists;Dentists;DentalTechnicians,andPodiatrists). PublicHealthActsforthevariousstatesandterritoriesaimtoprovidedbasicsafeguardsnecessaryto protectpublichealththroughcooperationbetweenthestateGovernment,localgovernments,healthcare providers(e.g.ACTThePublicHealth(InfectionControl)CodeofPractice2005(No1),NSWPublic HealthAct,1991,QLDThePublicHealthAct2005).
Commonwealth legislation
TherapeuticGoodsAct1989 TherapeuticGoodsAmendmentAct(No.1)2003 QuarantineAct1908
Resources
HealthCareInfectionControlSpecialInterestGroup http://www.asid.net.au/hicsigwiki/index.php?title=Main_Page AustraliaInfectionControlAssociationhttp://www.aica.org.au/
Creutzfeldt-Jakob disease
ThevariantCreutzfeldtJakobdisease(vCJD)contingencyplan http://www.health.gov.au/internet/main/publishing.nsf/content/healthpubhlthstrategbsefamily.htm DHSVictoria(2005).GuidelinesfortheControlofInfectiousDiseases.TheBlueBook http://www.health.vic.gov.au/ideas/bluebook
CONSULTATIONDRAFTJANUARY2010 D2 STANDARD PRECAUTIONS
Hand hygiene
Standards
StandardsAustralia.HB2602003.HospitalacquiredinfectionsEngineeringdowntherisk.Sydney: StandardsAustraliaInternationalLtd.2003.
NationalOccupationalHealthandSafetyCommission.NationalCodeofPracticefortheControlofWork relatedExposuretoHepatitisandHIV(bloodborne)Viruses[NOHSC2010(2003)2nded.]Canberra: AustralianGovernmentNationalOccupationalHealthandSafetyCommission.2003. AustralianInfectionControlAssociation.Standard13HandHygiene.Brisbane:AICA.2006
Guidelines
WHOGuidelinesonHandHygieneinHealthcare2009 http://www.who.int/patientsafety/information_centre/documents/en/index.html HandHygieneAustraliaManual(availableathttp://www.hha.org.au/)
Tools and web-based resources
HandHygieneAustraliaswebsitecontainsnumerouseducationalresources,tools,andinformationon implementinghandhygieneprograms(availableathttp://www.hha.org.au/)

Standards
Gloves StandardsAustralia/StandardsNewZealand.AS/NZS4011:1997/Amdt1:1998.Singleuseexamination glovesSpecification.Sydney:StandardsAustraliaInternationalLtd. StandardsAustralia/StandardsNewZealand.AS/NZS4179:1997/Amdt1:1998.Singleusesterilesurgical rubberglovesSpecification.Sydney:StandardsAustraliaInternationalLtd. Masks Australia/NewZealandStandards,2002,AS/NZS4381:Singleusefacemasksforuseinhealthcare. Australia/NewZealandStandards,2003,AS/NZS1716Respiratoryprotectivedevices Australia/NewZealandStandards,1994.AS/NZS1715:Selection,useandmaintenanceofrespiratory protectiondevices Eyewear/goggles Australia/NewZealandStandards,2002,AS/NZS4381:Singleusefacemasksforuseinhealthcare
Gowns Australia/NewZealandStandards3789.2andAustralia/NewZealandStandards3789.3
State/territoryworkplace/occupationalhealthandsafetylegislation/regulationoutlinetherequirement forPPE(e.g.QueenslandWorkplaceHealthandSafetyAct1995,andassociatedregulationsandWA WorksafeCommissionCodeofPracticePersonalProtectiveClothingandEquipment2002). AustralianInfectionControlAssociation.AICAStandard14.PersonalProtectiveEquipment.Brisbane: AICA.2006
DepartmentofHealthandAgeingPuttingonandRemovingPPEPandemicInfluenza http://www.healthemergency.gov.au/internet/healthemergency/publishing.nsf/content/safeuse dvd.htm CentersforDiseaseControlandPreventionDecisionAidonChoosingPPE http://www.cdc.gov/ncidod/dhqp/ppe.html
Handling and disposing of sharps

Standards
AustralianstandardsAS4031Nonreusablecontainersforthecollectionofsharpmedicalitemsusedin healthcareareas1992/AMDT11996 AS/NZS4261Reusablecontainersforthecollectionofsharpitemsusedinhumanandanimalmedical applications1994/AMDT1:1997
NationalOccupationalHealthandSafetyCommission.NationalCodeofPracticefortheControlofWork RelatedExposuretoHepatitisandHIV(BloodBorne)Viruses[NOHSC2010(2003)2nded.]Canberra: AustralianGovernmentNationalOccupationalHealthandSafetyCommission.2003. State/territoryworkplace/occupationalhealthandsafetylegislation/regulation
CDCWorkbookforDesigning,Implementing,andEvaluatingaSharpsInjuryPreventionProgram UniversityofVirginiaHealthSystemInternalworkersafetycentreprovidesnumerousresourceson safetydevicesandtheapplicationoftheiruse. http://www.healthsystem.virginia.edu/internet/epinet/about_center.cfm QueenslandHealthSharpsSafetyPrograms http://www.health.qld.gov.au/chrisp/resources/sharps_safety.asp
Routine management of the physical environment

Standards
VictorianDepartmentofHumanServicesCleaningstandardsforVictorianpublichospitals http://www.health.vic.gov.au/ideas/infcon/publications
TherapeuticGoodsOrderNo54StandardforDisinfectantsandSterilants(TGO54), AustralianRegisterofTherapeuticGoods(ARTG)ClassBfordisinfectants NationalOccupationalHealthandSafetyCommission.NationalCodeofPracticeforthepreparationof materialsafetydatasheets.[NOHSC:2100(1994)].Canberra:AustralianGovernmentPublishing Services.
Guidelines
TheRevisedHealthcareCleaningManualJune2009 CentersforDiseaseControlandPreventionGuidelineforEnvironmentalInfectionControlinHealthCare Facilities2003http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html
LittleYellowInfectionControlBook.Availableat http://www.health.vic.gov.au/__data/assets/pdf_file/0018/37350/lyicb_original.pdf HealthProtectionScotlandControloftheEnvironmentStandardInfectionControlPrecautions(SICP) http://www.hps.scot.nhs.uk/haiic/ic/guidelinedetail.aspx?id=31229

CONSULTATIONDRAFTJANUARY2010 Processing of instruments and equipment

Standards
AS1079.11993Packagingofitems(sterile)forpatientcareselectionofpackagingmaterialsforgoods undergoingsterilization AS14102003SterilizersSteamPrevacuum AS2182SterilizerSteamBenchtop AS21921991SterilisersSteamdownwarddisplacement AS24371987Flusher/sterilizersforbedpansandurinebottles AS2487:Dryheatsterilizers. AS25141999Dryingcabinetsformedicalequipment AS2773.11998UltrasoniccleanersforhealthcarefacilitiesNonportable AS2773.21999UltrasoniccleanersforhealthcarefacilitiesBenchtop AS27741985Dryingcabinetsforrespiratoryapparatus AS2945(Int)2002Batchtypewashes/disinfectorsforhealthcarefacilities AS3789.21991TextilesforhealthcarefacilitiesandinstitutionsTheatrelinenandprepacks AS38361998Rackconveyorwashesforhealthcarefacilities AS/NZ4146:2000LaundryPractice AS/NZS4187:Cleaning,DisinfectingandSterilizingReusableMedicalandSurgicalInstrumentsand Equipment,andMaintenanceofAssociatedEnvironmentsinHealthCareFacilities; AS/NZS4815:OfficebasedhealthcarefacilitiesReprocessingofreusablemedicalandsurgical instrumentsandequipment,andmaintenanceoftheassociatedenvironment; TherapeuticGoods(MedicalDevices)2007Regulations(seePD2005_399SingleUseMedicalDevices (SUDs)Remanufacture).
Guidelines
DepartmentofHealthandAgeingInfectioncontrolguidelines(2007)Section31CreutzfeltdJakob Diseasehttp://www.health.gov.au/internet/main/publishing.nsf/Content/icgguidelinesindex.htm NSWHealth,HealthProcurement,GuidelinesforStorageandHandlingofPreSterilizedConsumables CentersforDiseaseControlandPreventionGuidelineforDisinfectionandSterilizationinHealthcare Facilities,2008http://www.cdc.gov/ncidod/dhqp/guidelines.html
D3
SterilizingResearchAdvisoryCouncilofAustraliahttp://www.sraca.org.au/ TheAustralianCollegeofOperatingRoomNursesStandardshttp://www.acorn.org.au/ QueenslandHealthSterilizingServicesresourcesavailableat:EndoscopeReprocessing,Queensland Healthhttp://www.health.qld.gov.au/EndoscopeReprocessing/default.asp Prionsandreprocessinghttp://www.dh.gov.uk/ab/ACDP/TSEguidance/index.htm TRANSMISSION-BASED PRECAUTIONS
Transmission-based precautions
Guidelines
DepartmentofHealthandAgeingSafeuseofPersonalProtectiveEquipmentforPandemicInfluenzaDVD availableontheDOHAwebsitepandemicinfluenzaresourcepage http://www.health.gov.au/internet/panflu/publishing.nsf/Content/safeusetranscript1 State/territoryinfectioncontrolpoliciesprovideguidanceontheimplementationoftransmissionbased precautions

CONSULTATIONDRAFTJANUARY2010 WHOstrategicactionplanforpandemicinfluenza2006
Multi-resistant organisms
Guidelines
SouthAustralianGuidelinesForTheManagementOfPatientsWithVancomycinResistantEnterococci(VRE) Colonisation/Infectionwww.health.sa.gov.au/infectioncontrol/guidelinestabStateInfectionControl guidelines DHSVictoriaGuidelinesfortheManagementofPatientswithVancomycinResistantEnterococci(VRE) Colonisation/Infection(1996) NSWHealthDepartmentPolicyDirective2007_084.InfectionControlPolicy:Prevention&Managementof MultiResistantOrganisms(MRO)http://www.health.nsw.gov.au/policies/pd/2007/PD2007_084.html QueenslandHealthInfectionControlGuidelineshttp://www.health.qld.gov.au/chrisp/ CentersforDiseaseControlandPreventionManagementofMultidrugResistantOrganismsinHealthcare Settings,2006.http://www.cdc.gov/ncidod/dhqp/guidelines.html SHEAGuidelinesforPreventingNosocomialTransmissionofMultiresistantStrainsofStaphlylococcusaureus andEnterococci2003 APICGuidetotheEliminationofMethicillinResistantStaphylococcusaureus(MRSA)TransmissioninHospital Settings,March2007
Outbreak management
Guidelines
CDNAGuidelinesfortheControlofMeaslesOutbreaksinAustraliaandNewZealand.July2000. CDNAGuidelinesfortheEarlyClinicalandPublicHealthManagementofMeningococcalDiseaseinAustralia 2001 QueenslandHealthOutbreakManagementGuidelines http://www.health.qld.gov.au/chrisp/ic_guidelines/contents.asp DEVICE MANAGEMENT
D4
Intravascular devices
Guidelines
InstituteforHealthcareImprovementCVCBundleofinterventionsproventobeeffectivePart5 CentralVenousCatheters CentersforDiseaseControlandPreventionGuidelinesforthePreventionofIntravascularCatheterRelated Infections,2002http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html HealthProtectionScotland.BundlesInfectioncontrol http://www.hps.scot.nhs.uk/haiic/ic/bundles.aspx QueenslandHealthICareProgramhttp://www.health.qld.gov.au/chrisp/icare/about.asp NationalKidneyFoundationIncDOQIClinicalPracticeGuidelinesforHaemodialysisAdequacy:Update2000 CaringforAustralianswithRenalImpairment(CARI)http://www.cari.org.au/
Indwelling urinary catheters

Guidelines
CentersforDiseaseControlandPreventionPrevention&ControlofCatheterAssociatedUrinaryTract Infections(UTI)http://www.cdc.gov/ncidod/dhqp/dpac_uti_pc.html HealthProtectionScotland.CAUTIpreventionbundle http://www.hps.scot.nhs.uk/haiic/ic/CAUTIPreventionBundle.aspx

CONSULTATIONDRAFTJANUARY2010 NICEInfectionControl:PreventionofHealthcareassociatedInfectionsinPrimaryandCommunityCare.2003 Section3http://guidance.nice.org.uk/CG2/Guidance/pdf/English.html
Ventilation Associated Pneumonia

Guidelines
CanadianCriticalCareSocietyEvidenceBasedClinicalPracticeGuidelineforthePreventionofVentilator AssociatedPneumoniahttp://www.canadiancriticalcare.org/bestpractices_guidelines.htm MastertonRG,GallowayA,FrenchGetal.Guidelinesforthemanagementofhospitalacquired pneumoniaintheUK:ReportoftheWorkingPartyonHospitalAcquiredPneumoniaoftheBritish SocietyforAntimicrobialChemotherapy,JAntimicrobialChemotherapy(2008)62,534 http://jac.oxfordjournals.org/cgi/content/full/dkn162 HealthProtectionScotland.VAPpreventionbundlehttp://www.hps.scot.nhs.uk/haiic/ic/bundles.aspx
Enteral feeding
Guidelines
NICEInfectionControl:PreventionofHealthcareassociatedInfectionsinPrimaryandCommunityCare.2003 Section4EnteralFeedinghttp://guidance.nice.org.uk/CG2/Guidance/pdf/English QueenslandHealthFactSheetTubeFeedingatHome http://www.health.qld.gov.au/nutrition/resources/etf_tfah.pdf
Surgical site infection

Guidelines
NICEPreventionandTreatmentofSurgicalSiteInfection2007http://guidance.nice.org.uk/CG74 HealthProtectionScotland.SSIpreventionbundle http://www.hps.scot.nhs.uk/haiic/ic/ssipreventionbundle.aspx CentersforDiseaseControlandPreventionPreventionofSurgicalSiteInfections1999 http://www.cdc.gov/ncidod/dhqp/guidelines.html InstituteforHealthcareImprovementPreventSurgicalSiteInfectionsbundle http://www.ihi.org/IHI/Programs/Campaign/SSI.htm
2006ACORNStandardsforPerioperativeNursesincludingNursingRoles,Guidelines,PositionStatementsand CompetencyStandardshttp://www.acorn.org.au/
Patient Education Tools and resources on devices TheSocietyforHealthcareEpidemiologyofAmerica(SHEA)andtheInfectiousDiseasesSocietyof America(IDSA)FAQsheetonintravasculardevices,indwellingurinarycatheters http://www.cdc.gov/ncidod/dhqp/HAI_shea_idsa FrequentlyAskedQuestionsSurgicalSiteInfection(SSI) http://www.cdc.gov/ncidod/dhqp/FAQ_SSI.html INVOLVING PATIENTS IN THEIR CARE
D5
TheAustralianCharterofhealthcarerightsdescribestherightsofpatientsandotherpeopleusingthe Australianhealthsystem.http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/content/com pubs_achr Eachstateandterritoryhaslegislationregardingtheresponsiblecollectionandhandlingofpersonal informationwithinthepublicsectoraswellasprovideindividualswithrightsofaccesstoinformatione.g. InformationPrivacyAct

CONSULTATIONDRAFTJANUARY2010 D6 STAFF HEALTH AND SAFETY
Occupational health and safety

Legislation/ policy
Eachstateandterritoryhasnumerouslegislation/Actsrelatingtooccupationalhealthandsafety,workers compensationandtheemployersresponsibilitytoprovideasafeworkenvironment. Immunisationofhealthcareworkersisanaspectofoccupationalhealthandsafetyinthehealthcaresetting. Eachstatehasitsownpolicies,examplesareprovidedbelow: ImmunisationforHealthCareWorkers(RevisedOctober2007)DHSVictoria http://www.health.vic.gov.au/immunisation/general/guide_hcw HealthDepartmentPolicyDirective2007_006OccupationalAssessment,Screening&VaccinationAgainst SpecifiedInfectiousDiseaseshttp://www.health.nsw.gov.au/policies/pd/2007/PD2007_006.html NSWHealthDepartmentPolicyDirective2005_203.InfectionControlManagementofReportableIncidents ImmunisationforHCWsinSouthAustraliawww.health.sa.gov.au/infectioncontrol/
Guidelines
NationalImmunisationProgramSchedule2007DoHA AustralianImmunisationHandbook9thEdition2008(NHMRC)
Exposure to blood and blood products

NationalOccupationalHealthandSafetyCommission.NationalCodeofPracticefortheControlofWork relatedExposuretoHepatitisandHIV(bloodborne)Viruses[NOHSC2010(2003)2nded.]Canberra: AustralianGovernmentNationalOccupationalHealthandSafetyCommission.2003.
Eachstatehasitsownpolicies,examplesareprovidedbelow: NSW NSWHealthDepartmentPolicyDirective2008_021OccupationalExposurestoBloodBornePathogens:NSW HealthNotificationRequirementstoWorkCover http://www.health.nsw.gov.au/policies/pd/2008/PD2008_021.html NSWHealthDepartmentPolicyDirective2005_311HIV,HepatitisBandHepatitisCManagementof HealthCareWorkersPotentiallyExposed http://www.health.nsw.gov.au/policies/PD/2005/PD2005_311.html WAWorksafeCommissionCodeofPracticePersonalProtectiveClothingandEquipment(2002). http://www.docep.wa.gov.au/WorkSafe/PDF/Codes_of_Practice/Code_first_aid.pdf QueenslandHealthInfectionControlGuidelinesandassociatedpolicies,recommendedpracticesand advisorieshttp://www.health.qld.gov.au/chrisp/ QueenslandHealthSharpsSafetyPrograms http://www.health.qld.gov.au/chrisp/resources/sharps_safety.asp SURVEILLANCE
WA
QLD
D7
Policies
Reducingharmtopatientsfromhealthcareassociatedinfection:theroleofsurveillance http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/progHAI_Surveillance
Notifiable diseases
DepartmentofHealthandAgeingAustralianNotifiablediseases http://www.health.gov.au/internet/main/publishing.nsf/Content/cdasurveilnndsscasedefsdistype.htm LinkspagetostateandterritoryPublicHealthLegislation,theQuarantineAct,andtheNationalHealth SecurityAct2007http://www.health.gov.au/internet/main/publishing.nsf/Content/cdastatelegislation links.htm FACILITY DESIGN
D8 General
Standards
StandardsAustralia.HB2602003.HospitalacquiredinfectionsEngineeringdowntherisk.Sydney: StandardsAustraliaInternationalLtd.2003 AS1668.22002 TheuseofventilationandairconditioninginbuildingsVentilationdesignforindooraircontaminant control AS1668.22002/Amdt12002 TheuseofventilationandairconditioninginbuildingsVentilationdesignforindooraircontaminant control AS1668.22002/Amdt22003 TheuseofventilationandairconditioninginbuildingsVentilationdesignforindooraircontaminant control
Guidelines
AustralasianHealthFacilityGuidelines(AusHFG) http://www.healthfacilityguidelines.com.au/guidelines.htm NSWHealthDepartmentGuidelineGL2007_003HealthFacilityGuidelinesUseofAustralasianHealth FacilityGuidelines(AUSHFG)http://www.health.nsw.gov.au/policies/gl/2007/GL2007_003.html GuidelinesDHS,VictoriaGuidelinesfortheClassificationandDesignofIsolationRoomsinHealthCare FacilitiesVictorianAdvisoryCommitteeonInfectionControl2007 VictorianDHSDesignGuidelinesforHospitalsandDayProcedureUnits2005 http://www.healthdesign.com.au/vic.dghdp/guidelines.htm
APPENDICES
CONSULTATIONDRAFTJANUARY2010 1 MEMBERSHIP AND TERMS OF REFERENCE OF THE WORKING COMMITTEE
Members
Affiliation
Dr Ann Koehler (Chair) Director, Communicable Disease Control Branch, SA Health Prof Chris Baggoley Chief Executive Officer of the Australian Commission on Safety and Quality in Healthcare Clinical Prof Keryn Christiansen Dr Liz Coates Clinical Microbiologist, PathWest Laboratory Medicine, Royal Perth Hospital WA Senior Consultant, Adelaide Dental Hospital. ADA representative Professor Peter Collignon Infectious diseases physician and microbiologist Director, Infectious Diseases Unit and Microbiology Department, The Canberra Hospital. Professor, School of Clinical Medicine, Australian National University, ACT Dr Celia Cooper Director, Microbiology and Infectious Diseases, Childrens, Youth and Womens Health Service, Adelaide Dr Nick Demediuk General Practitioner, Royal Australian College of General Practitioners Dr Sylvia Gandossi Vice President, Australian Infection Control Association. Infection Control Consultant A/Prof Tom Gottlieb Senior specialist in microbiology and infectious diseases Department of Microbiology and Infectious Diseases, Concord Hospital, NSW Mr Brett Mitchell Director, Tasmanian Infection Prevention and Control Unit, Department of Health and Human Services Assoc Prof Peter Morris Paediatrician, NT Clinical Studies School, Royal Darwin Hospital and Menzies School of Health Research, Darwin Indigenous health, evidence-based medicine Infection prevention and control in Australia and internationally General practice, infection control in office based practice Infection control practice in both the public and private health sectors Microbiology, infectious diseases Infectious diseases, public health, and medicine Antibiotic resistance and infection control in hospitals Microbiology, infectious diseases, antimicrobial resistance and surveillance Infection control in dental settings
Area of expertise
Clinical microbiology, communicable disease control, epidemiology Safety and quality in healthcare
Appendices 178
CONSULTATIONDRAFTJANUARY2010 Terms of Reference TheInfectionControlSteeringCommittee(theCommittee)willoverseeandprovideexpertiseintherevision oftheInfectioncontrolguidelinesforthepreventionoftransmissionofinfectiousdiseaseinthehealthcaresetting (2004)(theGuidelines). 1 Therevisionwilltakeintoaccountbutnotbelimitedto: ThecurrentInfectioncontrolguidelinesforthepreventionoftransmissionofinfectiousdiseaseinthehealth caresetting(2004)producedbytheCDNA. Thebestavailablecurrentscientificevidence. NHMRCrecommendedstandardsonguidelinedevelopment. Commentsprovidedbythebroadercommunityandhealthcaresectorthroughfeedbackfromthe projectsstakeholdergroup,targetedconsultationsandpublicconsultation. 2 TheCommitteewillprovideadviceonthefollowingareasoftheGuidelinesrevision: Thescopeandrequirementsofthesystematicreview; Theformulationofrecommendationsfromtheresultsofthesystematicreview; ThecontentoftheGuidelines; Thedevelopmentofeducationalmaterialsandcompaniondocuments; Identificationofindicatorsforthepurposeofevaluationandmonitoringtheguidelines implementation; Thedevelopmentofanimplementationstrategy;and Keystakeholderstoundertakeliaison/consultation. 3 TheCommitteewillprovideregularreportsontheprogressofguidelinedevelopmenttotheCEOofthe NHMRC. 4 TheCommitteewillprovidetheNHMRCCEOwithadraftreportfortheCEOtoseekadvicefrom Council.
Appendix 1 179
CONSULTATIONDRAFTJANUARY2010 2 PROCESS REPORT
TheNHMRCwasapproachedbytheAustralianCommissiononSafetyandQualityinHealthCare(the Commission)inNovember2007toreviewandupdatetheInfectioncontrolguidelinesforthepreventionof transmissionofinfectiousdiseasesinthehealthcaresetting.Theseguidelineswereproducedbythe CommunicableDiseasesNetworkAustralia(CDNA)andreleasedin2004. TheNHMRCrevisedguideline(theGuideline)aimedtoprovideacoordinatedapproachtothe managementofhealthcareassociatedinfection(HAI)inAustraliabysupportingtheCommissionsother HAIpriorityprograminitiativesincludingthe: NationalHAISurveillanceStrategy; HandHygieneInitiative;and AntibioticStewardship.
TheNHMRCdevelopedarangeofpartnershipstosupportandassistintheguidelinedevelopmentprocess includingtheNHMRCsNationalInstituteofClinicalStudies,CDNA,theOfficeofHealthProtectioninthe AustralianGovernmentDepartmentofHealthandAgeing,theCommissionandguidelineusers. TheprojectplanfortherevisionoftheguidelineswasapprovedbytheNHMRCActingChiefKnowledge Developmentofficeron25January2008.TheInfectionControlGuidelinesSteeringCommittee(the Committee)wasestablishedundertheNHMRCAct(1992)asaSection39committee,andwaschairedbyDr AnnKoehler,theSouthAustralianrepresentativeoftheCDNA.Thecommitteewasfirstestablishedwith eightmembers,comprisingofexpertsinmicrobiologyandinfectiousdisease,publichealth,Indigenous healthaswellasjurisdictionalrepresentativesandinfectioncontrolpractitioners.During2008,two CommitteemembersresignedfromtheCommittee(MsDollyOlesonandMsClaireBoardman)butan additionalfivememberswereappointedtobroadentheexpertiseoftheCommittee.TheCommitteefrom November2008untilthecompletionoftheprojectisoutlinedinAppendix1.
Appointment of technical writers
AmpersandHealthScienceWritingwasselectedthroughaRequestforQuoteprocessfromtheNHMRC TechnicalWritersandEditorsPanel.ThetwokeypersonnelfromAmpersandworkingonthisprojectwere MsElizabethHallandMsJennyRamson,whoparticipatedintheforumsandSteeringCommitteemeetings togainanunderstandingoftheissuesandthecontextoftheinfectioncontrolguidelines. Scope TheGuidelinetargetsclinicians,ancillarystaffandadministratorsacrossAustraliasvarioushealthcare settings.Initialfeedbackindicatedthatthefollowinghealthcaresettingsshouldbeconsideredwhen developingtheGuidelines: privateandpublicacutecare; residentialagedcare; communityhealthincludinghomecare; Aboriginalmedicalservices;and officebasedpracticesinvolvedininvasiveproceduressuchasdental,obstetricsandgynaecology, ophthalmology,surgicalandgeneralpractice.
AsameansofaddressingthisbroadscopeofpracticeitwasdecidedthattheGuidelineswouldbe structuredtoaddressthecoreprinciplesofinfectioncontrolandpreventionandtheunderpinningkey practiceprinciples.Thecoreprincipleofinfectioncontrolistopreventthetransmissionofinfectious organismsandmanageinfectionsiftheyoccur.Theunderpinningkeypracticeprinciplesinclude: 1. 2. anunderstandingofthemodesoftransmissionofinfectiousagentsandanoverviewofrisk management; effectiveworkpracticesthatminimisetheriskofselectionandtransmissionofinfectiousagents;

Appendices 180
CONSULTATIONDRAFTJANUARY2010 3. 4. governancestructuresthatsupporttheimplementation,monitoringandreportingofinfectioncontrol workpractices;and compliancewithlegislation,regulationsandstandardsrelevanttoinfectioncontrol.
Itisacknowledgedtheremaybevariationinsomecurrentpracticesduetodifferencesintechnology, resourcesandsystemssupportingahealthcarefacility.Toaddressthis,ariskmanagementapproachwas adoptedthatconsidershowfactorsassociatedwiththetransmissionofinfectiousagentscanbeidentified andmanagedwithinvarioushealthcaresettings.Thisapproachensuresthatcommoninfectionssuchas gastrointestinalvirusesandevolvinginfectiousagentssuchasinfluenzaorantibioticresistantbacteriacan bemanagedeffectivelyusingtheprinciplesofinfectioncontrol. Preliminary scoping Theinitialfocusoftheprojectwastoliaisewithstakeholdersacrossabroadrangeofhealthcaresettingsto identifytheusefulnessandapplicabilityofthe2004Guidelines.Thiswasmanagedthroughstakeholder surveysandaseriesoforganisedforums.Thestakeholdersurveywasdevelopedtoallowparticipantsand theorganisationstheyrepresentedtoconsidertheissuespriortoattendingtheforums.Thesurveywas targetedtowardsstatebasedinfectioncontrolpractitionerassociations,publichealthmedicalofficersand theagedcareaccreditationalliance.Thissurveywascirculatedtostakeholdersparticipatinginforumsto gatherfeedbackontheguidelinesandtoorganisationswishingtoprovidefeedbackbutunabletoattendthe forums.
Stakeholder forums
StakeholderforumswereconductedinSydney,CanberraandMelbourneinearlyMarch2008,andwere facilitatedbyCarlaCranny&Associates.Inall,59representativesfromvarioushealthcaresettings,the medicaldeviceindustry,professionalassociations,healthcarefundersandgovernmentagenciesattended. Thepurposeoftheforumswastogainfeedbackfromstakeholdersinthehealthcaresettingonthe usefulnessandapplicabilityofthe2004guidelinesaswellasidentifygapsandareasofambiguityinthe guidelines. Theforumsidentified: currentgapsinthe2004guidelines,inparticulartheneedforbetterguidanceon: healthcareworkerinfectioncontrolissues pandemicplanning sterilisationandreprocessingofequipment environmentalcleaningandwastemanagement MROsmanagementofpatientsinthevarioushealthcaresettings theimpactofhealthcarefacilitydesignoninfectioncontrol thescopeofpracticeofinfectioncontrolprofessionalsandguidanceonstaffingprofilesacrossthe rangeofservicesettings; areasofuncertaintyorclinicalvariationininfectioncontrolpractice; barrierstoimplementationoftheguidelinesincludingcrossreferencestoguidancethatisnotfreely available;healthcareworkerattitudesandbehavioursandthelackofaccountabilityofhealthcare managers; additionaltoolsrequiredtosupportimplementation;and Optionsonformattingandpresentation.
Priority setting ThestakeholderforumsidentifiedseveralkeyareastheGuidelinesneedtoaddress.Theseissuesrelateto: emergingpathogens;screeningandclearanceofpatientswithMROinfections;areaswheregapsinevidence resultedinvariationinclinicalpractice;andmedicaldevicetechnology. Usingthefeedbackfromtheforums,theCommitteeactivelyengagedwithstakeholdersacrossthe healthcaresettingtoseekfeedbackonthepriorityareastherevisedinfectioncontrolguidelinesshould

Appendix 2 181
CONSULTATIONDRAFTJANUARY2010 address.WithsignificantinputfromtheAustralianInfectionControlAssociation,theCommitteecarefully consideredandsystematicallyidentifiedthepriorityareasofinfectioncontrolthatneedtobeaddressedby theGuidelines.TheCommitteedevelopedaframeworkencompassingthebroadscopeofinfectioncontrol activitiesacrossthehealthcaresetting.PriorityareasidentifiedattheforumsandbytheCommitteewere placedintheframeworkandthenrankedaccordingtowhichissueshavethegreatestimpactoninfection control. Fromthisprioritysettingexercise,theCommitteeidentifiedthekeyissuesthatrequiredfurtherresearch. Theseissuesformedthebasisforthedevelopmentoftheclinicalquestionsforsystematicreview. Systematic review of the evidence TherecommendationsfortheGuidelineweredevelopedusingatwofoldapproach. Forareaswhereclinicalvariationexistsoritisconsideredthereareemergingissuesininfectioncontrol, systematicreviewsoftheliteraturewereconductedtogathertheevidenceforthespecificguideline section.TheNHMRClevelandgradespilotprogramwasimplementedinreviewingandsynthesising theevidence. Forareasofestablishedpractice,recommendationsfromcurrentnationalandinternationalguidelines wereadaptedforanAustraliancontextbytheCommittee.Guidelineswereselectedaccordingtotheir currencyandclinicalrelevanceandwereappraisedusingtheAppraisalofGuidelinesforResearchand Evaluation(AGREE)instrumenttoassesstherigorwithwhichtheyhadbeendeveloped.
Drafting of clinical questions for systematic review
DrAdeleWeston,amemberoftheNHMRCevidencebasedmedicineexpertpanel,attendedthe12May committeemeetingtoinformthemembersontheNHMRCsystematicreviewprocessincludinghow recommendationsaredraftedfromtheevidence.Theclinicalquestionscommencedbeingdraftedatthat meetingusingthepopulation,intervention,comparator,outcome,time(PICOT)approach.Theywere furtherrefined,circulatedanddiscussedviaaseriesofteleconferencesbeforebeingreleasedinaRequestfor TenderinJuly2008.Thequestionsareoutlinedbelow.
Appendices 182
Table App2.1:
QUESTION Environmental cleaning 1. Which environmental cleaning/disinfection agents have the greatest efficacy against: Bacteria (specifically MRSA, C. difficile, VRE and Acinetobacter spp Enveloped and non enveloped viruses (specifically blood-borne viruses, rotavirus, norovirus and respiratory viruses). This information should be presented in a matrix that demonstrates what cleaning agent should be used dependent on what organisms considering its mode of transmission (droplet, contact, respiratory). 2. Considering the information above, what is the frequency of cleaning required to limit the survival of these organisms considering their survival rates in the environment. MROs 3. What is the most effective method to demonstrate effective decolonisation of MRSA, VRE and MRGNs in patients: 4. previously colonised with the above? currently colonised with the above? Does this decolonisation reduce the rate of transmission of these pathogens? 5. Does detection of MROs (listed below) through systematic patient screening (and in the case of MRSA with staff) reduce the rate of transmission to other patients: VRE (in high risk areas such as bone marrow transplant ward, ICUs and haemodialysis units) MRSA MRGN Patients Staff (in the instance of MRSA) Screening for MROs Not screening Reduced transmission Transmission outcomes Patients currently with MRSA, VRE or MRGN Population Patients with previously MRSA, VRE or MRGN Intervention Screening / clearance methods Comparator Other screening / clearance methods Outcome Decolonisation Bacteria, nonenveloped and enveloped viruses Cleaning agent Frequency of agent use considering survival rates of the organisms
Clinical questions for systematic review

POPULATION Population Bacteria, nonenveloped and enveloped viruses INTERVENTION Intervention Environmental cleaning agent COMPARATOR Comparator Alternative environmental cleaning agents and mode of transmission of organisms OUTCOME Outcome Reduced levels of surface agents
Appendix 2 183
6. Does isolation in managing patients with VRE or MRGN reduce the patients length of stay / spread of infection to other patients? 7. Does personal protective equipment reduce the transmission of MRSA or VRE? Device management 8. What methods of management have the best efficacy for preventing infection associated with the insertion and maintenance of: Intravascular devices Haemodialysis access devices Population Patients neonates adults Intervention Device insertion and management Comparator Comparisons of one form of skin antisepsis with others, e.g. alcoholic vs aqueous products including chlorhexidine, povidone iodine, betadine Stick injuries 9. Is there a decreased incidence of stick injuries for health care workers using automated cleaning practices compared to manual cleaning practices? 10. Does the use of retractable devices show a decreased rate in the incidence of sharps injuries for health care workers? Facility design 11. Can the risk factors for nosocomial infections in health care facilities be identified and ranked according to relative risk? Risk factors could include bed occupancy levels, staffing ratios and building design 12. Do negative pressure rooms reduce transmission of airborne pathogens to non infected patients compared to standard rooms? This is inclusive of tuberculosis, multi resistant tuberculosis, varicella zoster virus, measles and viral haemorrhagic fevers. Patients Population Healthcare facilities Intervention bed occupancy levels, staffing ratios and building design Infection control program management Isolation in negative pressure room Normal pressure room isolation Reduced infection transmission to other patients Comparator Rates in other facilities, clinical areas Outcome Reduced acquisition rates Healthcare Workers Safety devices etc Non retractable devices sharps injuries Population Healthcare Workers Intervention Automated cleaning Comparator Manual cleaning Outcome Reduced stick injuries Patients Gloves, gowns, aprons No gloves, gowns PPE, Reduced acquisition rates of MRSA or VRE Outcome Reduced post procedural infection Patients Isolation Shared bays Reduced acquisition rates of pathogen in other patients
Appendices 184
13. Do positive pressure rooms reduce the transmission of infection to immuno-compromised patients compared to normal pressure rooms? Staff Health 14. What is the evidence supporting the length of time a health care worker should remain excluded from work post the resolution of symptoms of gastroenteritis? Population Healthcare Workers Intervention Exclusion period Comparator Different periods of time Patients Isolation in positive pressure room Single room isolation Reduced infection rates of immunocompromised patients Outcome Rates of transmission of infection to healthcare worker or patients Hand hygiene (Level 1 evidence only) 15. What concentrations of which alcohols are adequate for hand hygiene to decontaminate specific organisms? Population Healthcare Workers Intervention Hand hygiene comparing different concentrations of alcohol, and of different alcohols e.g. ethyl, methyl, isopropyl 16. What is the efficacy of alcohol based products compared to non alcohol based, e.g. soap and water and other hand hygiene products, in reducing the risk of transmission of: Clostridium difficile non-enveloped viruses? Population Health Care Workers Intervention Education programs Comparator Other education programs Outcome Changes in clinician behaviour Healthcare Workers Hand hygiene Comparator Washing with water and soap/ detergent/ chlorhexidine, Other concentrations of same alcohol Other alcohols Non alcohol based products Decontamination Outcome Decontamination of hands
Education (Level 1 evidence only) 17. What is the effectiveness of education program changing healthcare worker behaviour
Appendix 2 185
CONSULTATIONDRAFTJANUARY2010 TheRequestforTenderprocesswasultimatelyunsuccessfulandsystematicreviewerswereapproached usingaRequestforQuoteorDirectSourcingapproach.Thesystematicreviewswereconductedbythe following:

Contractor Joanna Briggs Institute Topic Griffith University Royal Darwin Hospital NHMRC Effectiveness of environmental cleaning agents, Decolonisation of MDRO Patient screening for MDRO Effectiveness of isolation for VRE and MRGN Effectiveness of PPE in reducing VRE and MRSA transmission.
Intravascular device management Hand hygiene products Staff exclusion periods for Norovirus Efficacy of positive pressure rooms Efficacy of negative pressure rooms Educational strategies to improve hand hygiene compliance
Anumberofclinicalquestionsthatwereidentifiedasaprioritywereunabletobeconductedduetoresource constraints.Theseincluded: 9. Doestheuseofretractabledevicesshowadecreasedrateintheincidenceofsharpsinjuriesforhealth careworkers?
10. Isthereadecreasedincidenceofstickinjuriesforhealthcareworkersusingautomatedcleaning practicescomparedtomanualcleaningpractices? 11. Cantheriskfactorsfornosocomialinfectionsinhealthcarefacilitiesbeidentifiedandrankedaccording torelativerisk?Riskfactorscouldincludebedoccupancylevels,staffingratiosandbuildingdesign Duetoapaucityofevidenceorlowqualityevidencesomesystematicreviewswerenotusedtodraft recommendations.Theseinclude: effectivenessofenvironmentalcleaningagents; decolonisationofMROs; patientscreeningforMROs;and efficacyofnegativepressurerooms.
Recommendationsfortheseareasweredrawnfromexistingguidelinesandsupportedbyexpertopinion. Theeducationreviewtoidentifystrategiestoimprovehandhygienecompliancewasincorporatedinto SectionCGovernancestructureswhichcontainsnogradedrecommendationsforpractice. Thesystematicreviewsfor: intravasculardevicemanagement(Attachment2a(i)); handhygieneproducts(Attachment2a(ii)); effectivenessofisolationforVREandMRGN(Attachment2a(iii)); effectivenessofPPEinreducingVREandMRSAtransmission(Attachment2a(iv)); staffexclusionperiodsforNorovirus(Attachment2a(v));and efficacyofpositivepressurerooms(Attachment2a(vi))
wereconductedaccordingtoapprovedNHMRCprocessesandsystematicreviewmethodologywitha documentedsearchstrategy,inclusionandexclusioncriteria,criticalappraisalmethodologyandsummary oftheevidence.Thesesystematicreviewsareprovidedinthefullreport,whichisavailablefromthe NHMRConrequest.ThesystematicreviewersummarisedthequestionsandsubquestionsintotheNHMRC

Appendices 186
CONSULTATIONDRAFTJANUARY2010 template,whichdocumentstheevidencebase(numberofstudies,levelofevidenceandriskofbiasinthe includedstudies),consistency,clinicalimpact,generalisabilityandapplicability. TheNHMRCtemplatewasusedbytheSteeringCommitteetodraftevidencestatementsand recommendationscorrespondingtothesummaryofevidenceprovidedbythesystematicreviewer.These evidencestatementsandrecommendationsaresummarisedinAttachment2bofthefullreport.Thegrades assignedbythesystematicreviewersaredocumentedwiththecorrespondinggradesassignedbythe Committee.ThegradeswereassignedbytheCommitteeviateleconferencesandmeetingswiththefinal recommendationsandgradingoutlinedinAttachment2cofthefullreport.Dissentingopinionswerenoted.

Development of recommendations from guidelines and standards
Asapartoftheprioritisationprocessamappingexercisewasconductedtoidentifyrelevantguidelinesand standardsthatexistednationallyandinternationallyoninfectioncontrolinthehealthcaresetting.Linksto standardsandlegislationrelevanttoinfectioncontrolthatwereidentifiedwillbeincludedinSectionD: Compliancewithlegislationandstandards.Itisenvisagedthattargetedandpublicconsultationwillprovide morefeedbackinthissection. Forareasofestablishedpracticenotcoveredbythesystematicreview,guidelinesdevelopedusingrigorous methodologywereusedtoadaptrecommendationsfromforanAustraliancontext.Guidelineswere identifiedbyacombinationofliteraturesearches,currentuseinpracticeandbytheICGCommittee. Guidelineswereselectedaccordingtotheircurrencyandclinicalrelevanceandwereappraisedusingthe AppraisalofGuidelinesforResearchandEvaluation(AGREE)instrumenttoassesstherigorwithwhichtheyhad beendeveloped.TheAGREEscoreswerecalculatedacrossthesixdomainsandusedtoidentifywhich guidelinestouse.TheNHMRCengagednumerousstakeholdersidentifiedduringtheforumsandthrough theCommissiontoassistwiththeappraisaloftheguidelines. Threereviewersperguidelinewithappropriateclinicalexperienceininfectioncontrol,infectiousdiseasesor guidelinedevelopmentreviewedeachguideline.ThereviewersincludedCommitteemembers,the CommissionsHealthCareassociatedInfectionImplementationAdvisoryCommitteeandmembersofthe AustralianDentalAssociation. Reviewerswereaskedtorateanitemonascaleof1to4,with1beingstronglydisagreeand4being stronglyagree.Domainscoreswerecalculatedbysummingupallthescoresoftheindividualitemsina domainandbystandardisingthetotalasapercentageofthemaximumpossiblescoreforthatdomain. Generally,ahigherscoreindicatestheguidelineratedwellagainsttheAGREEcriteria. Thesixdomainswere: scopeandpurpose; stakeholderinvolvement; rigourofdevelopment; clarityandpresentation; applicability;and editorialindependence.
Anoverallassessmentandrecommendationwasprovidedbyeachreviewer.Guidelinesselectedtodraft recommendationsfromwere: UnitedStatesCentreforDiseaseControlandPrevention(CDC) GuidelineforIsolationPrecautions:PreventingTransmissionofInfectiousAgentsinHealthcareSettings (2007); ManagementofMultidrugResistantOrganismsinHealthcareSettings(2006); Guidelinesforinfectioncontrolinthedentalsetting(2003); Guidelinesforenvironmentalinfectioncontrolinhealthcarefacilities(2003); WorkbookforDesigning,Implementing,andEvaluatingaSharpsInjuryPreventionProgram(2008) GuidelinesforthePreventionofIntravascularCatheterRelatedInfections,(2009)
Appendix 2 187
CONSULTATIONDRAFTJANUARY2010 Prattetal(2007)Epic2:NationalEvidenceBasedGuidelinesforPreventingHealthcareAssociatedInfections inNHSHospitalsinEngland; WHOGuidelinesonHandHygieneinHealthCare(2009) NationalInstituteofClinicalExcellenceSurgicalsiteinfectionpreventionandtreatmentofsurgicalsite infection(2008); USgovernmentwebsitepandemicflu.gov(2006)InterimGuidanceonPlanningfortheUseofSurgical MasksandRespiratorsinHealthCareSettingsduringanInfluenzaPandemic; MuscedereJetalfortheVAPGuidelinesCommitteeandtheCanadianCriticalCareTrialsGroup(2008) Comprehensiveevidencebasedclinicalpracticeguidelinesforventilatorassociatedpneumonia: Prevention.JournalofCriticalCare23:12637; EuropeanandAsianguidelinesonmanagementandpreventionofcatheterassociatedurinarytract infections_PeterTenkea,,BelaKovacsa,TrulsE.BjerklundJohansenb,TetsuroMatsumotoc,PaulA. Tambyahd,KurtG.NaberInternationalJournalofAntimicrobialAgents 31S (2008) S68S78 NICE(2003)PreventionofHealthcareassociatedInfectioninPrimaryandCommunityCare;and GuidelinesforthemanagementofhospitalacquiredpneumoniaintheUK:ReportoftheWorkingParty onHospitalAcquiredPneumoniaoftheBritishSocietyforAntimicrobialChemotherapyR.G.Asterton, A.Galloway,G.French,M.Street,J.Armstrong,E.Brown,J.Cleverley,P.Dilworth,C.Fry,A.D. Gascoigne,AlanKnox,DilipNathwani,RobertSpencerandMarkWilcoxJournalofAntimicrobial Chemotherapy(2008)62,534
Relevantrecommendationsweredrawnoutofeachapprovedguidelineandcategorisedappropriatelyby thetechnicalwriters.Theserecommendationswerecirculatedtocommitteemembersandadditional infectioncontrolrepresentativesintopicsubgroups,toprioritisewhatshouldbeusedintheguidelines. CommentswerecollatedbytheNHMRCandthetechnicalwritersandtherecommendationschosenforthe guidelinewererefinedatafacetofacemeeting.Theapproachtakentoconsensussettingwasdevelopedin consultationwithNICSandcomprisedattributesoftheDelphiandRAND/UCLAprocesses. Theserecommendationswereprioritisedandthenregradedfromtheiroriginalguidelinegradingtoan NHMRCgradingbasedonmatchingcriteriafromtheoriginalguidelinedevelopers.TheCommittee consideredthesegradesanddissentingcommentswerenoted.Therecommendationswiththeiroriginal gradingandtheassignedNHMRCgradingaresummarisedinAttachment2cofthefullreport. ApreliminarydraftwasprovidedtojurisdictionsforfeedbackinOctober2009.Asummaryofthefeedback andNHMRCresponsesisprovidedinAttachment2dofthefullreport.
Appendices 188
CONSULTATIONDRAFTJANUARY2010 3 EXPOSURE PRONE PROCEDURES (EPP)
Exposureproneprocedures(EPPs)areinvasiveprocedureswherethereispotentialfordirectcontact betweentheskin,usuallyfingerorthumbofthehealthcareworker,andsharpsurgicalinstruments,needles, orsharptissues(e.g.fracturedbones),spiculesofboneorteethinbodycavitiesorinpoorlyvisualisedor confinedbodysites,includingthemouthofthepatient. DuringEPPs,thereisanincreasedriskoftransmittingbloodbornevirusesbetweenhealthcareworkersand patients. EPP categories ThenatureoftheEPPperformedbythehealthcareworkercanbecategorisedaccordingtolevelofriskof transmission,inincreasingorderofmagnitude.
Category 1 A procedure where the hands and fingertips of the healthcare worker are usually visible and outside the body most of the time and the possibility of injury to the workers gloved hands from sharp instruments and/or tissues is slight. This means that the risk of the healthcare worker bleeding into a patients open tissues should be remote, e.g. insertion of a chest drain. Category 2 A procedure where the fingertips may not be visible at all times but injury to the healthcare workers gloved hands from sharp instruments and/or tissues is unlikely. If injury occurs it is likely to be noticed and acted upon quickly to avoid the healthcare workers blood contaminating a patients open tissues, e.g. appendicectomy. Category 3 A procedure where the fingertips are out of sight for a significant part of the procedure, or during certain critical stages and in which there is a distinct risk of injury to the healthcare workers gloved hands from sharp instruments and/or tissues. In such circumstances it is possible that exposure of the patients open tissues to the healthcare workers blood may go unnoticed or would not be noticed immediately, e.g. hysterectomy.
Source: DH/HP/GHP3.HIVInfectedHealthCareWorkers:GuidanceonManagementandPatientNotification.London;2005
Advice on EPPs in specific areas of clinical care

Accident and emergency (A&E)
A&EstaffmemberswhoarerestrictedfromperformingEPPsshouldnotprovideprehospitaltraumacare. Thesestaffshouldnotphysicallyexamineorotherwisehandleacutetraumapatientswithopentissues becauseoftheunpredictableriskofinjuryfromsharptissues.Coverfromcolleagueswhoareallowedto performEPPswouldbeneededatalltimestoavoidthiseventuality. OtherEPPswhichmayariseinanA&Esettingwouldinclude: rectalexaminationinpresenceofsuspectedpelvicfracture; deepsuturingtoarresthaemorrhage;and internalcardiacmassage. (SeealsoAnaesthetics,Biting,ParamedicsandResuscitation)

Anaesthetics
Endotrachealintubation,useofalaryngealmaskandproceduresperformedpurelypercutaneouslyarenot exposureprone.TheonlyprocedurescurrentlyperformedbyanaesthetistswhichwouldconstituteEPPs are: theplacementofportacaths(veryrarelydone)whichinvolvesexcavatingasmallpouchundertheskin andmaysometimesrequiremanoeuvreswhicharenotunderdirectvision; theinsertionofchestdrainsinaccidentandemergencytraumacasessuchaspatientswithmultiplerib fractures.

Appendix 3 189
CONSULTATIONDRAFTJANUARY2010 Theinsertionofachestdrainmayormaynotbeconsideredtobeexposurepronedependingonhowitis performed.Procedureswhere,followingasmallinitialincision,thechestdrainwithitsinternaltrocharis passeddirectlythroughthechestwall(asmayhappene.g.withapneumothoraxorpleuraleffusion)and wherethelungiswellclearofthechestwall,wouldnotbeconsideredtobeexposureprone.However, wherealargerincisionismade,andafingerisinsertedintothechestcavity(e.g.withaflailchest)and wherethehealthcareworkercouldbeinjuredbythebrokenribs,theprocedureshouldbeconsidered exposureprone. Moderntechniquesforskintunnellinginvolvewireguidedtechniquesandputtingsteelorplastictrochars fromtheentrysitetotheexitsitewheretheyareretrievedinfullvision.Thereforeskintunnellingisno longerconsideredtobeexposureprone(seealsoArterialcutdown).
Arterial cutdown
Althoughtheuseofmorepercutaneoustechniqueshasmadearterialorvenouscutdowntoobtainaccessto bloodvesselsanunusualprocedure,itmaystillbeusedinrarecases.However,astheoperatorshandsare alwaysvisible,itshouldnolongerbeconsideredexposureprone.

Biting
StaffworkinginareasposingasignificantriskofbitingshouldnotbetreatedasperformingEPPs.
Bone marrow transplants
Notexposureprone.
Cardiology
Percutaneousproceduresincludingangiography/cardiaccatheterisationarenotexposureprone. Implantationofpermanentpacemakers(forwhichaskintunnellingtechniqueisusedtositethepacemaker devicesubcutaneously)mayormaynotbeexposureprone.Thiswilldependonwhethertheoperators fingersareorarenotconcealedfromviewinthepatientstissuesinthepresenceofsharpinstruments duringtheprocedure(seealsoArterialcutdown).

Ear, nose and throat surgery (otolaryngology)
ENTsurgicalproceduresgenerallyshouldberegardedasexposurepronewiththeexceptionofsimpleear ornasalprocedures,andproceduresperformedusingendoscopes(flexibleandrigid)providedfingertips arealwaysvisible.Nonexposureproneearproceduresincludestapedectomy/stapedotomy,insertionof ventilationtubesandinsertionofatitaniumscrewforaboneanchoredhearingaid.

Endoscopy
Simpleendoscopicprocedures(e.g.gastroscopy,bronchoscopy)havenotbeenconsideredexposureprone. Ingeneralthereisariskthatsurgicalendoscopicprocedures(e.g.cystoscopy,laparoscopyseebelow)may escalateduetocomplicationswhichmaynothavebeenforeseenandmaynecessitateanopenEPP.Theneed forcoverfromacolleaguewhoisallowedtoperformEPPsshouldbeconsideredasacontingency (seealsoBiting).

General practice
SeeAccidentandEmergency,Biting,MinorSurgery,Midwifery/Obstetrics,Resuscitation
Gynaecology (see also laparoscopy)
Opensurgicalproceduresareexposureprone.Manyminorgynaecologicalproceduresarenotconsidered exposureprone,examplesincludedilatation&curettage(D&C),suctionterminationofpregnancy, colposcopy,surgicalinsertionofdepotcontraceptiveimplants/devices,fittingintrauterinecontraceptive devices(coils),andvaginaleggcollectionprovidedfingersremainvisibleatalltimeswhensharp instrumentsareinuse.Performingconebiopsieswithascalpel(andwiththenecessarysuturingofthe cervix)wouldbeexposureprone.Conebiopsiesperformedwithalooporlaserwouldnotinthemselvesbe
Appendices 190
CONSULTATIONDRAFTJANUARY2010 classifiedasexposureprone,butiflocalanaestheticwasadministeredtothecervixotherthanunderdirect visioni.e.withfingersconcealedinthevagina,thenthelatterwouldbeanEPP(category1).

Haemodialysis/Haemofiltration
SeeRenalMedicine
Intensive care
IntensivecaredoesnotgenerallyinvolveEPPsonthepartofmedicalornursingstaff
Laparoscopy
Thesearemostlynonexposurepronebecausefingersareneverconcealedinthepatientstissues.Exceptions are:ifmaintrocharinsertedusinganopenprocedure,asforexampleinapatientwhohashadprevious abdominalsurgery.AlsoexposureproneifrectussheathclosedatportsitesusingJneedle,andfingers ratherthanneedleholdersandforcepsareused.Ingeneralthereisariskthatatherapeutic,ratherthana diagnostic,laparoscopymayescalateduetocomplicationswhichmaynothavebeenforeseennecessitating anopenEPP.CoverfromcolleagueswhoareallowedtoperformEPPswouldbeneededatalltimestoavoid thiseventuality.

Midwifery/obstetrics
Simplevaginaldelivery,amniotomyusingaplasticdevice,attachmentoffoetalscalpelectrodes,infiltration oflocalanaestheticpriortoanepisiotomyandtheuseofscissorstomakeanepisiotomycutarenotexposure prone.TheonlyEPPsroutinelyundertakenbymidwivesarerepairsfollowingepisiotomiesandperineal tears:category1inthecaseoffirstdegreelacerations;category2inthecaseofsecond,thirdandfourth degreelacerations.Repairsofthirdandfourthdegreetearsarenormallyundertakenbymedicalstaff memberswhomayincludegeneralpractitionersassistingatbirthsinacommunitysetting.

Minor surgery
Inthecontextofgeneralpractice,minorsurgicalproceduressuchasexcisionofsebaceouscysts,skinlesions, cauterizationofskinwarts,aspirationofbursae,cortisoneinjectionsintojointsandvasectomiesdonot usuallyconstituteEPPs.

Sharps occupational exposure
HealthcareworkersneednotrefrainfromperformingEPPspendingfollowupofoccupationalexposureto aBBVinfectedsource.ThecombinedrisksofcontractingaBBVfromthesourcepatientandthen transmittingthistoanotherpatientduringanEPPissolowastobeconsiderednegligible.Howeverinthe eventoftheworkerbeingdiagnosedwithaBBV,suchproceduresshouldceaseinaccordancewiththis guidance.

Nursing
GeneralnursingproceduresdonotincludeEPPs.Thedutiesofoperatingroomnursesshouldbeconsidered individually.InstrumentnursesdonotgenerallyundertakeEPPs.However,itispossiblethatnursesacting asfirstassistantmayperformEPPs(seealsoAccidentandEmergency,RenalMedicine/Nursing,and Resuscitation).

Obstetrics/Midwifery
SeeMidwifery/Obstetrics.Obstetriciansperformsurgicalprocedures,manyofwhichwillbeexposure proneaccordingtothecriteria.
Operating room technicians
GeneraldutiesdonotnormallyincludeEPPs.
Ophthalmology
Withtheexceptionoforbitalsurgery,whichisusuallyperformedbymaxillofacialsurgeons(whoperform manyotherEPPs),routineophthalmologicalsurgicalproceduresarenotexposureproneastheoperators
Appendix 3 191
CONSULTATIONDRAFTJANUARY2010 fingersarenotconcealedinthepatientstissues.Exceptionsmayoccurinsomeacutetraumacases,which shouldbeavoidedbyEPPrestrictedsurgeons.

Optometry
ThetrainingandpracticeofoptometrydoesnotrequiretheperformanceofEPPs.
Orthodontics
See Dentistry and orthodontics (including hygienists)

Orthopaedics EPPs
Opensurgicalprocedures; Proceduresinvolvingthecuttingorfixationofbones,includingtheuseofKwirefixationand osteotomies; Proceduresinvolvingthedistanttransferoftissuesfromasecondsite(suchasinathumb reconstruction); Acutehandtrauma; NailavulsionofthetoesforingrowingtoenailsandZadeksprocedure.

Non-EPPs
Manipulationofjointswiththeskinintact; Arthroscopy,providedthatifthereisanypossibilitythatanopenproceduremightbecomenecessary, theprocedureisundertakenbyacolleagueabletoperformtheappropriateopensurgicalprocedure; Superficialsurgeryinvolvingthesofttissuesofthehand; Workontendonsusingpurelyinstrumentaltunnellingtechniquesthatdonotinvolvefingersandsharp instrumentstogetherinthetunnel; Proceduresforsecondaryreconstructionofthehand,providedthattheoperatorsfingersareinfullview; Carpaltunneldecompressionprovidedfingersandsharpinstrumentsarenottogetherinthewound; Closedreductionsoffracturesandotherpercutaneousprocedures.

Paediatrics
Neithergeneralnorneonatal/specialcarepaediatricshasbeenconsideredlikelytoinvolveanyEPPs. PaediatricsurgeonsdoperformEPPs(seealsoArterialcutdown).
Paramedics
Incontrasttootheremergencyworkers,aparamedicsprimaryfunctionistoprovidecaretopatients. ParamedicsdonotnormallyperformEPPs.However,paramedicswhowouldberestrictedfromperforming EPPsshouldnotprovideprehospitaltraumacare.Thisadviceissubjecttoreviewastheworkundertaken byparamedicscontinuestodevelop(seealsoAccident&Emergency,BitingandResuscitation).

Pathology
IntheeventofinjurytoanEPPrestrictedpathologistperformingapostmortemexamination,theriskto otherworkershandlingthesamebodysubsequentlyissoremotethatnorestrictionisrecommended.
Podiatrists
Routineproceduresundertakenbypodiatristswhoarenottrainedinanddonotperformsurgical techniquesarenotexposureprone.Proceduresundertakenbypodiatricsurgeonsincludesurgeryonnails, bonesandsofttissueofthefootandlowerleg,andjointreplacements.Inaproportionoftheseprocedures, partoftheoperatorsfingerswillbeinsidethewoundandoutofview,makingthemEPPs(seealso Orthopaedics).
Appendices 192
Radiology
Allpercutaneousprocedures,includingimagingofthevasculartree,biliarysystemandrenalsystem, drainageproceduresandbiopsiesasappropriate,arenotEPPs(seealsoArterialcutdown).
Renal medicine
TheseproceduresarenotexposureproneandneitherhaemofiltrationnorhaemodialysisconstituteEPPs. Theworkingpracticesofthosestaffwhosupervisehaemofiltrationandhaemodialysiscircuitsdonot includeEPPs.

Resuscitation
ResuscitationperformedwearingappropriateprotectiveequipmentdoesnotconstituteanEPP.
Surgery
Opensurgicalproceduresareexposureprone.Thisappliesequallytomajororganretrievalbecausethereis averysmall,thoughremote,riskthatmajororgansretrievedfortransplantcouldbecontaminatedbya healthcareworkersbloodduringwhatarelongretrievaloperationswhilethepatientscirculationremains intact.Itispossibleforsomecontaminatedbloodcellstoremainfollowingpretransplantationpreparatory proceduresandforanyvirustoremainintactsinceorgansarechilledtoonly10C(seealsoLaparoscopy, MinorSurgery).

Volunteer health care workers (including first aid)
TheimportantissueiswhetherornotaninfectedhealthcareworkerundertakesEPPs.
Appendix 3 193
CONSULTATIONDRAFTJANUARY2010 GLOSSARY Thissectionoutlinesthewayinwhichcertaintermsareusedintheseguidelines. Tobeexpandedfollowingconsultation.

Acinetobacter An aerobic Gram-negative bacillus commonly isolated from the hospital environment (especially intensive care units) and hospitalised patients; can cause healthcare-associated infections, especially wound infections and pneumonia. Aerosols Microscopic particles < 5 m in size that are the residue of evaporated droplets and are produced when a person coughs, sneezes, shouts, or sings. These particles can remain suspended in the air for prolonged periods of time and can be carried on normal air currents in a room or beyond, to adjacent spaces or areas receiving exhaust air. Airborne precautions A set of practices used for patients known or suspected to be infected with agents transmitted person-to-person by the airborne route. Alcohol-based hand rub An alcohol-containing preparation designed for reducing the number of viable microorganisms on the hands. Anteroom A small room leading from a corridor into a room. Antibiotic A substance that kills or inhibits the growth of bacteria, fungi or parasites. Antisepsis The use of chemical or physical methods to prevent infection by destroying or inhibiting the growth of harmful microorganisms. Aseptic technique Aseptic technique is analogous to clean technique but introduces extra practices to prevent infectious agents from entering a patients bloodstream, particularly during invasive procedures performed outside a controlled sterile environment (e.g. intravenous therapy on the ward or in a community healthcare setting). This involves creating a sterile field around susceptible sites, and ensuring there is no direct or indirect contact between sterile products (e.g. syringe) and any nonsterile surface. Bloodstream infection The presence of live pathogens in the blood, causing an infection. Bundle A set of evidence-based practices that have been shown to improve outcomes when performed collectively and consistently. The concept was developed by the Institute for Healthcare Improvement in the United States to improve the care process and patient outcomes. Catheter A thin, flexible, hollow tube used to add or remove fluids from the body. Clean technique Clean technique refers to practices that reduce the number of infectious agents, and should be considered the minimum level of infection control for non-invasive patient care activities. Practices include: personal hygiene, particularly hand hygiene, to reduce the number of infectious agents on the skin; use of barriers to reduce transmission of infectious agents (including proper handling and disposal of sharps); environmental cleaning; and reprocessing of equipment between patient uses.
Glossary 194
Clinical waste Waste material that consists wholly or partly of human or animal tissue, blood or body fluids, excretions, drugs or other pharmaceutical products, swabs/ dressings, syringes, needles or other sharp instruments. Cohorting Placing together in the same room patients who are infected with the same pathogen and are suitable roommates. Colonisation The sustained presence of replicating infectious agents on or in the body without the production of an immune response or disease. Contact The touching of any patient or their immediate surroundings or performing any procedure. Contact point The area of direct contact of skin to equipment. Contact Precautions A set of practices used to prevent transmission of infectious agents that are spread by direct or indirect contact with the patient or the patients environment. Cough etiquette A combination of measures designed to minimize the transmission of respiratory pathogens via droplet or airborne routes in healthcare settings. Decontamination Use of physical or chemical means to remove, inactivate, or destroy pathogens on a surface or item so that they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal. Detergent solution Detergent diluted with water as per manufacturers instructions. Disinfectant A chemical agent used on inanimate objects and surfaces (e.g., floors, walls, or sinks) to destroy virtually all recognised pathogenic microorganisms, but not necessarily all microbial forms (e.g. bacterial endospores). Disinfection Destruction of pathogenic and other kinds of microorganisms by physical or chemical means. Droplet precautions A set of practices used for patients known or suspected to be infected with agents transmitted by respiratory droplets. Droplets Small particles of moisture generated when a person coughs or sneezes, or when water is converted to a fine mist by an aerator or shower head. These particles, intermediate in size between drops and droplet nuclei, can contain infectious microorganisms and tend to quickly settle from the air such that risk of disease transmission is usually limited to persons in close proximity (e.g. less than 1 metre) to the droplet source. Engineering controls Removal or isolation of a workplace hazard through technology. Epidemic A widespread outbreak of an infectious disease. Many people are infected at the same time. Hand hygiene A general term applying to processes aiming to reduce the number of micro-organisms on hands. This includes use of soap/solution (plain or antimicrobial) and water (if hands are visibly soiled), and application of a waterless antimicrobial agent (e.g. alcohol-based hand rub) to the surface of the hands. Glossary 195
Healthcare facility Any facility that delivers healthcare services. Healthcare facilities could be hospitals, general practice surgeries, dentistry practices, other community-based office practices, day surgery centres, emergency services, domiciliary nursing services, residential aged care facilities, Aboriginal medical services, alternative health provider facilities and other community service facilities, such as needle exchanges. Healthcare workers All people delivering healthcare services, including students and trainees, who have contact with patients or with blood or body substances. Healthcare-associated infections Infections acquired in healthcare facilities (nosocomial infections) and infections that occur as a result of healthcare interventions (iatrogenic infections), and which may manifest after people leave the healthcare facility. High-risk patients Patients with an increased probability of infection due to their underlying medical condition. Often refers to patients in intensive care units, those receiving total parenteral nutrition, and immunocompromised patients. High-efficiency particulate air (HEPA) filter An air filter that removes >99.97% of particles > 0.3 microns (the most penetrating particle size) at a specified flow rate of air. High level disinfection Minimum treatment recommended for reprocessing instruments and devices that cannot be sterilised for use in semicritical sites Hypochlorite A chlorine-based disinfectant. Immunocompromised Having an immune system that has been impaired by disease or treatment. Incidence The number of new events (e.g. cases of disease) occurring in a population over defined period of time. Infectious agent An infectious agent (also called a pathogen or germ) is a biological agent that causes disease or illness to its host. Most infectious agents are microorganisms, such as bacteria, viruses, fungi, parasites and prions. Invasive procedure Entry into tissues, cavities or organs or repair of traumatic injuries. Intermediate level disinfection Minimum treatment recommended for reprocessing instruments and devices for use in non-critical sites, or where there are specific concerns regarding contamination of surfaces with species of myobacteria (e.g. Mycobacterium tuberculosis) Klebsiella pneumoniae Gram-negative bacteria frequently responsible for healthcare associated infections of wounds and urinary tract, particularly in immunocompromised patients; may also cause pneumonia. Long-term care facilities A range of residential and outpatient facilities designed to meet the bio-psychosocial needs of persons with sustained selfcare deficits.
Glossary 196
Low-level disinfection An alternative treatment to cleaning alone when devices for use in non-critical sites are reprocessed and when only vegetative bactericidal activity is needed. Masks Loose-fitting, single-use items that cover the nose and mouth. These include products labelled as surgical, dental, medical procedure, isolation and laser masks. Methicillin-resistant Staphylococcus aureus (MRSA) Strains of Staphylococcus aureus that are resistant to many of the antibiotics commonly used to treat infections. Epidemic strains also have a capacity to spread easily from person-to-person. Multi-drug resistant organisms (MROs) In general, bacteria that are resistant to one or more classes of antimicrobial agents and usually are resistant to all but one or two commercially available antimicrobial agents. Needle-free devices (also needleless intravascular catheter connectors) Intravascular connector systems developed to help reduce the incidence of needlestick injury while facilitating medication delivery through intravascular catheters. There are three types of needle-free connectors: blunt cannula (two-piece) systems, one-piece needle-free systems, and one-piece needle-free systems with positive pressure. Negative pressure room A single-occupancy patient care room used to isolate persons with a suspected or confirmed airborne infectious disease. Environmental factors are controlled in negative pressure rooms to minimise the transmission of infectious agents that are usually transmitted from person to person by droplet nuclei associated with coughing or aerosolisation of contaminated fluids. P2 (N95) respirator A personal protective device worn by healthcare personnel to protect them from inhalation exposure to airborne infectious agents that are < 5 microns in size. Pandemic An epidemic that is geographically widespread, occurring throughout a region or even throughout the world. Patient contact Involves touching the patient and their immediate surroundings, or performing any procedure on the patient. Patient surroundings All inanimate surfaces that are touched by or in physical contact with the patient (such as bed rails, bedside table, bed linen, invasive devices, dressings, personal belongings and food) and surfaces frequently touched by healthcare workers while caring for the patient (such as monitors, knobs and buttons). Patient care area The room or area in which patient care takes place. Percutaneous injury An injury that results in a sharp instrument/object, e.g. needle, scalpel, cutting or puncturing the skin. Personal protective equipment (PPE) A variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with infectious agents. PPE includes gloves, masks, respirators, goggles, face shields, and gowns. Phlebitis Inflammation of the wall of a vein. Prevalence The number of events (e.g. cases of disease) present in a defined population at one point in time.
Glossary 197
Procedure An act of care for a patient where there is a risk of direct introduction of a pathogen to the patient. Randomised controlled trial (RCT) A clinical trial where at least two treatment groups are compared, and non-randomised control trial (NRCT) one of them serving as the control group, and treatment allocation is carried out using a random, unbiased method. A non-randomised controlled trial compares a control and treatment group but allocation to each group is not random. Bias is more likely to occur in NRCT. Routine Performed as part of usual practice (as opposed to the use of additional measures in specific circumstances e.g. where invasive procedures are conducted or in the event of an outbreak). Sharps Instruments used in delivering healthcare that can inflict a penetrating injury, e.g. needles, lancets and scalpels. Standard precautions Work practices that constitute the first-line approach to infection control in the healthcare environment. These are recommended for the treatment and care of all patients. Sterile technique Sterile technique aims to eliminate microorganisms from areas and objects, and should be undertaken by all healthcare workers undertaking invasive medical procedures. This includes: ensuring that everything within a defined radius is clean and sterile, or as a minimum subject to high level chemical or thermal disinfection; use of skin antisepsis and sterile personal protective equipment; and reprocessing of instruments between patient uses. Sterile Free from all living microorganisms; usually described as a probability (e.g. the probability of a surviving microorganism being 1 in 1 million). Sterilisation Use of a physical or chemical procedure to destroy all microorganisms including substantial numbers of resistant bacterial spores. Strain A strain is a genetic variant or subtype of a microorganism (e.g. a virus, bacterium or fungus). Some strains may be more dangerous or difficult to treat than others. Surface barrier Barriers (e.g. clear plastic wrap, bags, sheets, tubing or other materials impervious to moisture) designed to help prevent contamination of surfaces and equipment. Surgical site infection An infection at the site of a surgical operation that is caused by the operation. Surveillance Disease surveillance is an epidemiological practice by which the spread of disease is monitored in order to establish patterns of progression. The main role of disease surveillance is to predict, observe and minimise the harm caused by outbreak, epidemic and pandemic situations, as well as increase knowledge as to what factors might contribute to such circumstances. Targeted surveillance A process in which data are collated on the susceptibilities and resistances of disease-causing microbes to various antimicrobial treatments. Targeted surveillance gathers data that is not generated by routine testing: specific species or groups of species are examined in detail to answer important questions that cannot be addressed by passive surveillance.
Glossary 198
Transmission-based precautions (formerly additional precautions) Extra work practices in situations where standard precautions alone may be insufficient to prevent infection (e.g. for patients known or suspected to be infected or colonised with infectious agents that may not be contained with standard precautions alone). Vancomycin resistant enterococci (VRE) Enterococci are Gram-positive bacteria that are naturally present in the intestinal tract of all people. Vancomycin is an antibiotic to which some strains of enterococci have become resistant. These resistant strains are referred to as VRE and are frequently resistant to other antibiotics generally used to treat enterococcal infections.
Glossary 199
CONSULTATIONDRAFTJANUARY2010 ABBREVIATIONS AND ACRONYMS ACH ACSQHC ADEC AGREE AICA AusHFG BCG BSI CAUTI CBIC cCJD CDC CDNA CEO CHG EPP ESBL GPP HAI HBeAg HBsAg HBV HCV HEPA HIV HTLVI IHI IPC IVD LAS MMR MRGN MRO MRSA NaOH airchangesperhour AustralianCommissiononSafetyandQualityinHealthCare AustralianDrugEvaluationCommittee Appraisalofguidelinesresearchandevaluation AustralianInfectionControlAssociation AustralasianHealthFacilityGuidelines BacillusCalmetteGurin bloodstreaminfection catheterassociatedurinarytractinfection CertificationBoardofInfectionControl classicalCreuzfeldtJakobdisease CentersforDiseaseControlandPrevention(US) CommunicableDiseasesNetworkAustralia chiefexecutiveofficer chlorhexidineimpregnated exposureproneprocedures extendedspectrumbetalactamase goodpracticepoint healthcareassociatedinfection hepatitisBeantigen HBVsurfaceantigen hepatitisBvirus hepatitisCvirus highefficiencyparticulateair humanimmunodeficiencyvirus humanTcelllymphotropicvirustypeI InstituteforHealthcareImprovement(US) infectionpreventionandcontrol intravasculardevice laminarairflowfiltration measlesmumpsrubellavaccine multiresistantGramnegative multiresistantorganism methicillinresistantStaphylococcusaureus sodiumhydroxide
Glossary 200
CONSULTATIONDRAFTJANUARY2010 NATA NHHI NHIG NHMRC NICE NNDSS NPS NRL NRL PAPR PBS PEG PEP PICC PPE PPE PSAE PVL RPBS RSV SAL SARS SSI TB TGA VAP VRE WHO NationalAssociationofTestingAuthorities NationalHandHygieneInitiative normalhumanimmunoglobulin NationalHealthandMedicalResearchCouncil NationalInstituteforHealthandClinicalExcellence(NICE) NationalNotifiableDiseasesSurveillanceSystem NationalPrescribingService naturalrubberlatex naturalrubberlatex poweredairpurifyingrespirator PharmaceuticalBenefitsScheme percutaneousendoscopicgastrostomies postexposureprophylaxis peripherallyinsertedcentralvenouscatheter personalprotectiveequipment personalprotectiveequipment Pseudomonasaeruginosa pantonvalentineleukocidin RepatriationPharmaceuticalBenefitsScheme respiratorysyncytialvirus sterilityassurancelevel severeacuterespiratorysyndrome surgicalsiteinfection tuberculosis TherapeuticGoodsAdministration ventilatorassociatedpneumonia vancomycinresistantenterococci WorldHealthOrganization
Acronyms and abbreviations 201
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AUSTRALIAN GUIDELINES FOR THE PREVENTION AND CONTROL OF INFECTION IN HEALTHCARE

CONSULTATION DRAFT 7 JANUARY 2010

Table1: Table2: Table3: Table4: Table5:

TableApp2.1:Clinicalquestionsforsystematicreview ......................................................................................... 183

CONSULTATIONDRAFTJANUARY2010 FigureB1.3: Processesforroutinecleaning ............................................................................................................... 51

Section B1.1.3 Page 32

Section B1.2.4 Page 38

Section B1.2.5 Page 40

Section B2.2.3 Page 71

Section B2.2.3 Page 72

Section B2.3.3 Page 74

Section B2.3.3 Page 75

Section B2.4.2 Page 77

Section B2.4.3 Page 77

CONSULTATIONDRAFTJANUARY2010 Finding information Theserecommendationsprovidethebasisforappropriateinfectioncontrolpracticeinthehealthcaresetting. PracticalguidanceontheirimplementationisgiveninPartBoftheseguidelines.Thefollowingtable providesadirectoryforthisguidance.

How to apply the process of risk management

CONSULTATIONDRAFTJANUARY2010 INTRODUCTION Effectiveinfectioncontrolpreventingthetransmissionofinfectiousorganismsandmanaginginfectionsif theyoccuriscentraltoprovidinghighqualityhealthcareforpatientsandasafeworkingenvironmentfor thosethatworkinhealthcaresettings.

Duetoapaucityofevidenceorlowqualityevidencesomesystematicreviewswerenotusedtodraft recommendations. MembershipoftheInfectionControlSteeringCommitteeisgiveninAppendix1.

NHMRC grades of evidence

Casestudiesillustratetheapplicationofriskmanagementprinciples(SectionsB1,B2andB3)andmeasuresto supportgoodpractice(PartC) Thefollowingtablesummarisesthekeytopicsdiscussedinthedocument.

BASICS OF INFECTION CONTROL

CONSULTATIONDRAFTJANUARY2010 A1 INFECTION CONTROL IN THE HEALTHCARE SETTING

RISKS OF CONTRACTING A HEALTHCARE-ASSOCIATED INFECTION

Transmissionofinfectioncanalsooccurviacommonsourcessuchascontaminatedfood,water, medications,devicesorequipment. A1.2 STANDARD AND TRANSMISSION-BASED PRECAUTIONS

Part A Basics of infection control 22

CONSULTATIONDRAFTJANUARY2010 A1.2.2 Transmission-based precautions

Section A1 Infection control in the healthcare setting 23

CONSULTATIONDRAFTJANUARY2010 A2 OVERVIEW OF RISK MANAGEMENT IN INFECTION PREVENTION AND CONTROL

RISK MANAGEMENT BASICS

Communicate and consult

Monitor and review

A2 Overview of risk management in infection prevention and control 25

CONSULTATIONDRAFTJANUARY2010 A3 A PATIENT-CENTRED APPROACH

PATIENT-CENTRED HEALTH CARE

PART B STANDARD AND TRANSMISSION-BASED PRECAUTIONS

CONSULTATIONDRAFTJANUARY2010 B1 STANDARD PRECAUTIONS

Standard precautions consist of the appropriate use of four distinct interventions:

Evidence supporting practice

Handhygienepracticesalonearenotsufficienttopreventandcontrolinfectionandneedtobeusedaspart ofamultifactorialapproachtoinfectioncontrol. B1.1.2 When should hand hygiene be performed?

CONSULTATIONDRAFTJANUARY2010 contact(includingbetweencaringfordifferentpatientsandbetweendifferentcareactivitiesforthesame patient)andafteranyactivityorcontactthatpotentiallyresultsinhandsbecomingcontaminated(including removalofgloves)reducestheriskofcrosscontamination.

Figure B1.2: The 5 moments of hand hygiene

Note: Handhygieneisalsoperformedaftertheremovalofgloves. Source: Graysonetal2009.

Coveringsneezesandcoughspreventsinfectedpersonsfromdispersingrespiratorysecretionsintotheair. Practisinghandhygieneaftercontactwithrespiratorysecretionsandcontaminatedobjectsormaterialsisan essentialelementofcoughetiquette.

What product should be used?

Table B1.2: Use of alcohol-based hand rub

Table B1.3: Using soap (including antimicrobial soap) and water

Other aspects of hand hygiene

B1.1 Hand hygiene 33

Use of hand cream

Individual actions for reducing the risk

Risk management case study

CONSULTATIONDRAFTJANUARY2010 B1.2.3 Aprons and gowns

Singleuseplasticapronsarerecommendedforgeneralusewhenthereisthepossibilityofspraysorspills, toprotectclothesthatcannotbetakenoff(Garner1996;Prattetal2001;Clarketal2002;Prattetal2007). Unusedapronsshouldbestoredinanappropriateareaawayfrompotentialcontamination(Callaghan 1998).

Removing aprons and gowns

B1.2 Personal protective equipment 37

Face and eye protection

Removalofafaceshield,protectiveeyewearandmaskcanbeperformedsafelyaftergloveshavebeen removedandhandhygieneperformed.Theties,earpiecesand/orheadbandusedtosecuretheequipmentto theheadareconsideredcleanandthereforesafetotouchwithbarehands.Thefrontofamask,gogglesor faceshieldisconsideredcontaminated.

B1.2 Personal protective equipment 41

Sources: DerivedfromKotilainenetal1989;Korniewiczetal1989;Korniewiczetal1993;Rego&Roley1999;Prattetal 2001;Korniewiczetal2002;CDC2003;Siegeletal2007. Removing and disposing of gloves

Other items of clothing

CONSULTATIONDRAFTJANUARY2010 B1.2.7 Sequence for putting on and removing PPE

2. MASK Secure ties or elastic bands at middle of head and neck

4. GLOVES Extend to cover wrist of isolation gown

B1.2 Personal protective equipment 43