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Healthcare Associated Infections

Canberra Hospital and Health Services

Clinical Procedure

Healthcare Associated Infections

Contents

Section 1. Contents 1

Section 2. Purpose 5

Section 3. Scope 5

Section 4. Governance and systems for infection prevention & control and surveillance 5

4.1 Procedure 5

Section 5. Infection prevention and control strategies 7

5.1 Standard precautions 7

5.2 Hand Hygiene 7

5.2.1 Procedure 7

5.2.2 Promoting patient, visitor and volunteer Hand Hygiene 8

5.2.3 Hand Hygiene auditing 8

5.2.4 Requirements for clinical glove use 9

5.2.5 Appropriate attire for healthcare workers in the healthcare setting 9

5.2.6 Skin care requirements 10

5.2.7 Placement of hand hygiene products 10

5.2.8 Contact tracing 12

5.3 Personal Protective Equipment 13

5.3.1 Gowns 13

5.3.2 Gloves 14

5.3.3 Face and eye protection 16

5.3.4 Masks 17

5.4 Aseptic technique 20

5.5 Single patient use equipment/items 20

5.6 Transmission based precautions 20

5.6.1 Contact precautions 21

5.6.2 Droplet precautions 22

5.6.3 Airborne precautions 23

5.6.4 Impact of transmission-based precautions on patients and their family 24

5.7 Notifiable diseases 24

5.7.1 Procedure 24

5.8 Exclusion periods for healthcare workers exposed to or with an infectious condition 29

5.8.1 Procedure 29

5.9 Code of dress or attire in restricted/semi restricted procedure areas 31

5.9.1 Scrub attire 31

5.9.2 Scrub attire outside of restricted/semi restricted area 31

5.9.3 Headwear 32

5.9.4 Footwear 32

5.9.5 Jewellery 32

5.9.6 Fingernails 32

5.9.7 Surgical masks 33

5.9.8 Protective eyewear 33

5.9.9 Radiation protection 33

5.10 Occupational Medicine Unit procedures 33

Section 6. Managing patients with infections or colonisation of pathogens 34

6.1 Multi-resistant Organism screening and clearance 34

6.1.1 MRO screening 34

6.1.2 MRO clearance 34

6.1.3 Healthcare facility transfer screening 34

6.2 Management of a patient suspected or identified with an MRO in Acute Care Settings 35

6.2.1 Equipment 35

6.2.2 Procedure 35

6.2.3 Core strategies 35

6.2.4 Additional requirements for the care of children with a MRO 37

6.2.5 Notification requirement 37

6.3 Management of a patient suspected or identified with an MRO in a multi bed room 38

6.3.1 Equipment 38

6.3.2 Procedure 38

6.3.3 Management of other patients in the room 38

6.3.4 Management of the vacated bed space 39

6.4 Management of patients suspected or identified with a MRO in the Subacute Unit 39

6.4.1 Procedure 39

6.4.2 Placement of patients 39

6.4.3 Movement of patients within the unit 39

6.4.4 Visitors 39

6.4.5 Screening of patients in a Subacute Unit 40

6.4.6 Transfer of MRO patients from Subacute to an Acute Care Unit 40

6.5 Vancomycin Resistant Enterococcus - probiotic treatment 40

6.5.1 Procedure 40

6.5.2 Duration of yoghurt therapy 40

6.5.3 If patient remains positive for VRE: 41

6.5.4 For a patient to be confirmed VRE negative post treatment 41

6.6 Management of patients suspected or identified with an infectious illness in outpatient settings 41

6.6.1 Procedure 41

6.6.2 Droplet precautions 41

6.6.3 Airborne precautions 42

6.6.4 Notification requirement 43

6.7 Negative Pressure or Positive Pressure rooms 43

6.7.1 Negative Pressure or Positive Pressure room features 44

6.7.2 Infection prevention and control 44

6.7.3 Property Management and Maintenance Unit, Infrastructure Support 44

6.7.4 Clinical Staff 45

6.7.5 Ward/Unit performance monitoring 45

6.8 Management of Multi–resistant Organisms in Operating Theatres 49

6.8.1 Preparation of Operating Theatre and surrounding area 49

6.8.2 Transport of the patient within Perioperative Unit 49

6.8.3 Management during and on completion of surgical procedure 49

6.8.4 Scrub nurse responsibilities 50

6.8.5 Caring for patients in Post Anaesthetic Care Unit that require infection control precautions 51

6.9 Outbreak management 51

6.9.1 Outbreak management team members 51

6.9.2 Preliminary phase 52

6.9.3 Control measures 52

6.9.4 Nursing care 52

6.9.5 Cohorting 53

6.9.6 Admission and discharges 53

6.9.7 Patient movements within the Health Care Facility 53

6.9.8 Documentation 53

6.9.9 Staff 53

6.9.10 Visitors 54

6.9.11 Environmental services 54

Section 7. Animals, toys and plants in the Health Care Setting (Acute and Community) 54

7.1 Animals or pets in Health Care Setting (Acute and Community) 54

7.1.1 Procedures 54

7.1.2 Patients and staff 55

7.1.3 Animals 55

7.1.4 Mandatory requirements for visiting animals 55

7.1.5 Environmental considerations 56

7.2 Toys in the workplace 57

7.2.1 Purchasing/obtaining toys 57

7.2.2 Cleaning of toys 58

7.2.3 Storage of toys 58

7.3 Flowers and pot plants 58

7.4 Mobile phones and electronic equipment 59

Section 8. Ward laundering and patient equipment cleaning 59

8.1 Laundering Practices 59

8.1.1 Machines and dryers 60

8.1.2 Powder 60

8.1.3 Laundry areas 60

Section 9. Antimicrobial Stewardship 60

Section 10. Cleaning Disinfection and Sterilisation Standard 60

10.1 Waste management – identification, streaming and safe handling 60

10.1.1 Basic principals - Personal Protective Equipment and Infection Control 60

10.1.2 Clinical and related wastes 61

10.2 Reprocessing reusable medical devices used in patient care 62

10.2.1 Procedure 62

10.2.2 Reprocessing of critical items 62

10.2.3 Reprocessing of semi-critical Items 63

10.2.4 Reprocessing of non-critical items: 63

10.2.5 Reprocessing of instruments where a risk of CJD transmission 63

10.2.6 Reprocessing of items designated as single use items MUST NOT occur 63

10.2.7 Spaulding Classification for reprocessing 64

10.2.8 Purchasing 65

Section 11. Facilities management 65

11.1 Contractors 65

11.2 Air conditioning units 65

11.3 Cooling towers 65

11.4 Sampling program protocol 66

11.5 Refrigeration units 67

11.6 Sterilisers, washer/disinfectors, ultrasonic cleaners, aeration cabinets & associated equipment 67

11.7 Negative Pressure isolation room 67

Section 12. Designing or refurbishing a new or existing building 68

12.1 Purchasing new product, equipment or other commodities 68

12.2 Purchasing contracted services 68

12.3 Pest control 68

12.4 Infection control during construction and renovation 68

12.4.1 Procedure 68

12.4.2 Construction and renovation assessment 69

12.4.3 Infection control activities 73

12.4.4 Engineering/major project activities 73

Section 13. Communication with patients and carers 73

13.1 Patient information pamphlets 73

Section 14. Implementation 74

Section 15. Related Policies, Procedures, Guidelines and Legislation 74

Section 16. References 75

Section 17. Definition of terms 77

Section 18. Search terms 79

Section 19. Attachments 79

Attachment A - Clearance requirements for microorganisms 80

Attachment B - Waste Streaming 86

Purpose

The purpose of the Healthcare Associated Infection (HAI) procedure is to outline systems and processes to ensure effective organisation wide evidence based strategies, to prevent staff and patients from acquiring preventable healthcare associated infections and effectively manage infections when they occur.

This document is a combination of all HAI related procedures and has been aligned against the National Safety and Quality Health Service (NSQHS) Standards actions list for HAI.

Scope

This procedure applies to all Canberra Hospital and Health Services (CHHS) staff, students and trainees undertaking clinical placement and all contracted agents working on CHHS premises, and where appropriate specific areas may be identified.

Governance and systems for infection prevention & control and surveillance

Procedure

The CHHS Infection Prevention and Control Unit (IPCU) will:

Provide promotion, education, support and assistance to staff to promote safe, high quality patient care and customer service.

Assist divisions and branches within CHHS to develop and maintain current best practice procedures specific to their field of expertise.

Assist staff members to:

Identify major infection risks in accordance with legislative requirements.

Ensure any responsibilities relating to notification of diseases are met.

Ensure staff are educated in and understand their infection prevention and control responsibilities through initial orientation training and other in-service education as appropriate and/or required, e.g. hand hygiene (HH), use of personal protective equipment (PPE), influenza and outbreak management, standard and additional precautions, staff health and vaccination and adherence to aseptic technique.

Liaise with other internal and external divisions to ensure external/contracted service providers, carers and volunteers, students and visitors comply with the organisation's infection prevention and control requirements, e.g. compliance with 5 Moments for Hand Hygiene across identified CHHS se

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