INFECTION PREVENTION & CONTROL AT DUKE RALEIGH HOSPITAL

INFECTION PREVENTION & CONTROL AT DUKE RALEIGH HOSPITAL Annual Nursing Competency Updated 2013

How are Infections Prevented?Practices you Should Follow that can Prevent Spread of Infection: • Appropriate Hand Hygiene • Standard Precautions • Transmission-based Precautions • Wear PPE as appropriate • Respiratory Etiquette • Get recommended/required Vaccinations: includes Influenza • Environmental cleanliness & appropriate waste management • Proper cleaning, sterilization and disinfection of patient care equipment • Aseptic Practices to prevent device related infections • Utilize Resources which include Policies and Procedures

Hand Hygiene:Many Personnel Don’t Realize WhenThey Have Germs on Their Hands Casewell MW et al. Br Med J 1977;2:1315 Ojajarvi J J Hyg 1980;85:193 • Healthcare workers can get 100s to 1000s of bacteria on their hands by doing simple tasks like: • pulling patients up in bed • taking a blood pressure or pulse • touching a patient’s hand • rolling patients over in bed • touching the patient’s gown or bed sheets • touching equipment like bedside rails, over bed tables, IV pumps

Hand Hygiene Hand Hygiene is performed on ungloved hands using: • Hospital-approved hand sanitizer (foam or gel) OR • Water and soap at sinks located throughout the hospital. Use soap and water when hands are visibly dirty or contaminated with blood or body fluids. Alcohol foam or gel is appropriate if your hands are not visibly soiled.

Hand Hygiene Measurement: Standard Operating Procedure At DRaH, performance of hand hygiene is measured at TWO basic and important patient care moments. “Before Patient Interaction” immediately before or at the time of entering a patient room or area* & “After Patient Interaction” immediately after or at the time of exiting a patient room or area* * i.e. PACU, radiology or ambulatory area

Hand Hygiene: when? Clean your hands: • before • donning sterile gloves or exam gloves • inserting invasive devices into patients • moving from a contaminated body site to a clean body site • eating or drinking • touching your face • after • contact with patients’ intact skin • contact with patient equipment, linen, supplies • contact with body fluids, excretions, mucous membranes, non-intact skin, and soiled dressings • after removing gloves • using the restroom • coughing or blowing your nose

Hand Hygiene: How? • Soap & Water: • Apply hospital-approved soap to hands • Rub hands together vigorously, paying particular attention to between fingers, under fingernails, and backs of hands, for 15 seconds • Rinse hands in a stream of warm water (avoid extreme hot or cold water) • Dry hands with paper towel • Use towel to turn off water • Alcohol Foams, Gels, & Liquid Alcohol Hand Rub • Apply the manufacturer’s recommended amount of alcohol-based product to palm of one hand (for foam that’s about the size of a golf ball; for gels or liquids that’s one push on the dispenser lever) • Rub hands together, covering all surfaces of hands, fingers, & wrist until hands are dry.

Hand Hygiene Reminders & FINGERNAILS • Reminders : • Alcohol Hand Rubs Are Not Indicated: • If hands are visibly dirty or contaminated with blood, body fluids, or other material • After contact with patients with Clostridium difficile (C. diff) • After exposure to known or suspected Bacillus anthracis (anthrax) • The hands, including the nails and surrounding tissue should be free from infection and /or inflammation for personnel having patient contact. • Healthcare workers with dermatitis or areas of broken, non-intact skin or potential infection shall refrain from all patient care activities. Direct patient care providers must keep natural nail tips equal to ¼ inch long or less. No artificial nails, gels, overlays etc. for direct care givers.

Microbiology Culture Findings at DRAH What’s Growing Where: • Before & After Hand Hygiene:

Standard PrecautionsUtilize with all patients • Require that blood, body fluids, secretionsand excretions(excluding sweat), mucous membranes and non-intact skin of all patients be treated as potentially infectious. • Requires putting the appropriate barrier (i.e. gloves, gown, mask, eye protection) between the healthcare worker and the blood or body fluids of any patient. • “If it is wet and not yours, then use a barrier.”

STANDARD PRECAUTIONS Include: Utilize with all patients Standard Precautions are designed to reduce the risk of transmission • Handle all blood/body fluid as if infectious • Handle all items contaminated with blood or body fluid as if infectious • Follow appropriate Hand Hygiene Practices • Follow Cough/Respiratory Etiquette • Follow Safe Injection Practices • Use a surgical mask when performing spinal procedures(LP, epidural) • Handle all sharps with care • Discard sharps in rigid containers • Wear appropriate PPE • Report exposures ASAP • Enforce designated eating areas (in clinical setting to prevent contamination of food/beverages from blood or body fluids)

Standard Precautions and Personal Protective Equipment (PPE) Choose PPE appropriate for the activity to prevent exposure, PPE includes: • Gloves • Gowns • Face Masks • Eye Protection

Standard Precautions Include: Respiratory Etiquette • Instruct symptomatic persons to: • cover mouth/nose when sneezing/coughing • use tissues and dispose immediately after use • clean hands after contact with respiratory secretions • wear surgical mask if tolerated or maintain spatial separation, >3 feet if possible.

Standard Precautions include: Safe Injection Practices To prevent the transmission of infections in a healthcare setting Safe Injection Practices require: • Use a sterile, single-use, disposable needle and syringe for each injection given • Dispose of needle and syringe properly after one use • Whenever possible, use of single-dose vials is preferred over multiple-dose vials • Do not use single bags or bottles of IV solution as a common source for multiple patients

Standard Precautions and Needles and Sharps • Do not recap, bend, break, or hand-manipulate used needles. • If recapping is required, use a one-handed scoop technique only. • Use safety features when available and place used sharps in an OSHA approved puncture-resistant container.

Standard Precautions and Specimen Transport • All specimens of blood and body fluids should be placed in a well constructed DUHS approved container with a secure lid to prevent leaking during transport. • A clean outer container / bag must be utilized in transport to prevent exposure. • This container / bag should be labeled with a biohazard symbol for identification.

The Environment Can Facilitate Transmission of Infections

Standard Precautions and Environmental Control • Follow established procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient-care areas. • Only hospital approved cleaning products should be used • Follow manufacturer directions for cleaning equipment • Ensure all patient care items, bedside equipment, and frequently touched surfaces receive daily disinfection. • Privacy curtains are changed/cleaned when visibly soiled, and at discharge for Contact Isolation rooms. • Immediately clean spills of any blood or body fluids with approved DRaH disinfectant.

TRANSMISSION-BASED (ISOLATION) PRECAUTIONS • Transmission-based Precautions are designed for patients with suspected or documented infection with microorganisms that are highly transmissible. • Should be used in addition to Standard Precautions. • Refer to Standard & Transmission-based Precautions Policy located on the DRAH Intranet

Transmission-Based (Isolation) Precautions: Initiation/Communication/SignageUse in addition to Standard Precautions • In addition to the physician the RN can initiate transmission-based precautions • The patient’s physician is to be notified and an order written in the medical record • Contact Infection Prevention for assistance with isolation requirements • Educate the patient & their family on: • The reason for precautions • How to adhere to appropriate isolation practices • Don’t Forget…Document in the medical record that education was provided! • Place Signage on door or cubical entrance to patient’s environment • Enter order in Medical Record • Communicate isolation precaution at all levels of handoff between care givers • Signage should remain in place until room is cleaned at discharge or transfer

Transmission-Based (Isolation) Precautions:Isolation Documentation on Admission

Transmission-Based (Isolation) Precautions:How to Change Isolation Status

Transmission-Based Precautions: Education • Educate the patient & their family on: • The reason for precautions • How to adhere to appropriate isolation practices • Document in the medical record that education was provided • Patient Education is currently available on all units: • FAQs MRSA • FAQs VRE • FAQs Clostridium difficile • Understanding Isolation Precautions • Understanding Multi-drug Resistant Organisms • Hand Hygiene for Patients & Visitors

Transmission-based Precautions: Patient Transport or Ambulation of Patients • Patients on transmission-based (isolation) precautions should not leave their room unless medically necessary (i.e. part of plan of care). • Whenever feasible, the patient’s procedure shall be done in the patient’s room. • If a procedure cannot be done in the patient’s room, then it is preferred that the patient’s procedure be scheduled as the last patient. • PPE is not to be worn in transport unless: • healthcare worker transporting the patient is providing direct patient care during transport. • A second healthcare worker assists in transport, is considered “clean” and shall not wear PPE. • shall proceed ahead of patient and transport staff to open doors, press elevator buttons, etc.

Transmission-based Precautions: Patient Transport or Ambulation of Patients • When ambulation/transport is necessary: • Upon leaving room, patient to perform hand hygiene. • A clean gown should be placed on the patient. • Clean linens shall be placed over the patient on the stretcher or wheelchair to serve as a barrier. • Patients with draining wounds shall have a clean/dry dressing. • Patients on Droplet or Airborneprecautions shall wear a surgical mask when outside their room. • Personnel in the receiving area shall be notified of the isolation status of the patient prior to transport. • Isolation status shall be communicated in patient care handoff

Transmission-based Precautions: Visitors • Visitors who cannot comply with wearing of required PPE may not visit with patient(s) on transmission-based (isolation) precautions. • Children less than 12 years old should not visit patients on transmission-based (isolation) precautions due to potential inappropriate PPE use. • Exceptions may apply for special circumstances with Infection Prevention input and physician approval. • Visitors of patients on Airborne Precautions should be limited to immediate adult household members who have had recent contact with the patient • Visitors shall wear a N95 respirator while in the patient’s room. • Visitors are not fit-tested for the N95; however, healthcare staff shall demonstrate how to wear the N95 respirator. (Refer to Patient Care Manual: Tuberculosis Control Plan attachment for fitting a respirator). • Provide education and document completion

DRaH Five Categories of Transmission-based Precautions Include: • Contact- Wear gown and gloves. Used for patients with known or suspected MRSA, VRE, ESBLs, RSV, Bedbugs, Shingles, etc. • Contact /Special Enteric- Wear gown and gloves. Used for patients with known or suspected Clostridium difficile, Norovirus, etc. (soap and water only for Hand Hygiene) • Droplet- Wear Surgical mask. Used with patients with known or suspected Meningitis, Influenza, Pertussis, etc. • Airborne- Wear N95 mask or PAPR. Used for patients with TB or r/o TB, active Chickenpox, Measles, etc. • Special Airborne/Contact-Wear gown, gloves, mask(N95 or PAPR). Used for patients with emerging infectious agent of unknown cause/origin

Contact Precautions (orange sign) Use in addition to Standard Precautions! • Contact Precautions are used for patients who are suspected or known to be infected with organisms that can be transmitted by: • direct contact with the patient (hand or skin-to-skin contact that occurs when performing patient care activities that require touching the patient’s dry skin) • indirect contact with environmental surfaces or patient-care items in the patient’s environment. • This isolation category requires the use of gloves and gown to enter the room regardless of patient contact. • Examples: • MRSA • VRE • Rashes • ESBLs (Extended-spectrum Beta-lactamase resistance) • KPC (KlebsiellapneumoniaeCarbapenem-resistance) • Varicella (Chicken Pox) • Scabies • Bedbugs • Draining Wounds • Shingles (non disseminated)

Contact /Special Enteric Precautions (orange & brown sign) • Special Enteric Precautions are designed to reduce transmission of organisms that can easily survive in the environment once shed from the human body. • Special Enteric Precautions include Contact Precautions plus hand hygiene by soap and water. • Hand hygiene with soap and water must be used when leaving the patient’s room / environment in order to remove the organism and/or spores. • Examples: • Clostridium difficile (C.diff) • Norovirus Use in addition to Standard Precautions!

Droplet Precautions (green sign) • Droplet Precautions are for known or suspected infections with microorganisms transmitted by droplets (large-particle droplets greater than 5 µm in size). • Droplets are generated by the patient during: • Coughing • Sneezing • Talking • Performance of procedures involving the respiratory tract. • Transmission can occur by: • direct contact with droplets • contact with objects recently contaminated with respiratory secretions. • Examples: • Meningitis • Influenza • Mumps • Pertussis Use in addition to Standard Precautions!

Airborne Precautions (bluesign) • Airborne Precautions are used for known or suspected infections with microorganisms transmitted by airborne droplet nuclei (small particle residue of 5 µm or less in size). • Place the patient in a private room that has monitored negative air pressure in relation to the surrounding areas. • If negative air pressure room in unavailable, portable HEPA filter units should be used. • HEPA should remain in use in the room for 40 minutes after patient discharge and before admitting another patient (CDC TB Guideline, 2005). • Keep the room door closed and the patient in the room. • Examples: • Mycobacterium Tuberculosis (TB) • Varicella (Chicken Pox) • Measles Use in addition to Standard Precautions!

Airborne Precautions (cont’) • This isolation category requires the use of respiratory protection: • Positive Air Purifying Respirator (PAPR) or • N95 mask that has been fit-tested on the user for entry into the patient’s room. • Remember, you must be fit-tested ANNUALLY for the N95 mask. • A Seal Check should be performed to ensure a proper fit once N95 applied). • If a proper fit cannot be achieved, do NOT enter the area requiring respiratory protection. • In the case of varicella or measles, the individual does not require a PAPR/N95 if immunity is documented.

Transmission-based Precautions: Discontinuation Criteria for Selected Pathogens (Overview) ***** Refer to DRAH Standard & Transmission Precautions Policy for complete list of discontinuation criteria.

Prevention of Device-associated & SurgicalInfections: • Central Line Associated Infections • (CLABSI) • Catheter Associated Urinary Tract Infections • (CAUTI) • Surgical Site Infections • (SSI)

CRUSH CLABSI

COUNTER CAUTI

SILENCE SSI

What is the most effective way to prevent the spread of infection? Perform proper HAND HYGIENE

Remember… Infection Prevention & Control Is In YOUR Hands Infection Prevention & Control Department: John Engemann, MD Connie Clark BSN, RN, CIC (x3166) Brittain Wood BSN, RN (x3076) Please feel free to contact us 24/7!

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DRAH_ICP

INFECTION PREVENTION & CONTROL AT DUKE RALEIGH HOSPITAL