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MODULE 2ISOLATION PRECAUTIONS & INFECTION PREVENTION

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In this module, we will …

• Describe standard precautions

• Describe transmission-based precautions including:

– Contact precautions

– Droplet precautions

– Respiratory precautions

• Describe the hierarchy of controls for infection

prevention, including

– Engineering Controls

– Administrative Controls

– Personal Protective Equipment (PPE)

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This course is intended to be applicable to all infectious diseases. However, the Ebola Virus Disease (EVD) will be used as an example throughout this course.

COURSE REMINDER:

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ISOLATION PRECAUTIONS

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What are Standard Precautions?

• Standard Precautions represent the minimum infection prevention measures that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered.

(CDC, 2011)

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Standard Precautions include…1) hand hygiene

2) use of personal protective equipment (e.g., gloves, gowns, facemasks)

3) respiratory hygiene and cough etiquette

4) safe injection practices

5) safe handling of potentially contaminated equipment or surfaces in the patient environment

(CDC, 2011)

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Transmission-Based Precautions

• Three categories include:1) Contact Precautions

2) Droplet Precautions

3) Airborne Precautions

• For diseases that have multiple routes of transmission, a combination of Transmission-Based Precautions may be used.

• Whether used singly or in combination, they are always used in addition to Standard Precautions.

(CDC, 2011)

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INFECTION PREVENTION

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In this section, we will…• Describe site specific engineering controls to

reduce exposure to specific infectious agents present in the workplace

• Describe selected work practices to reduce exposure

• Describe limitations of administrative/work practice controls

• Describe specific work practice controls to reduce potential exposure to Ebola Virus Disease (EVD)

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Engineering Controls

Examples:

• Isolation rooms

• Ventilation (special air handling systems, HEPA filtration)

• Ultra-violet lights

• Plastic to contain contamination

• Sharps management

• Disinfectants

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Administrative Controls

Examples

• Written policies and procedures

• Signs and postings

• Staffing and training

• Work practice controls

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Work Practice Controls

Examples

• Handwashing

• Personal hygiene practices

• Housekeeping

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PERSONAL PROTECTIVE EQUIPMENT

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In this section, we will…

• Describe appropriate selection of PPE for use

with potentially infectious materials

– Describe limitations of PPE

– Describe specific PPE to prevent potential exposure to EVD

• Describe selection of respiratory protection

– Explain the limitations of respiratory protection

– Describe respirator use for EVD

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Infection Prevention - Overview

• Personal Protective Equipment

– Gloves

– Gowns

– Masks/face shields

– Respirators

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Use of PPE: Gloves

• Wear gloves when there is potential contact with blood (e.g., during phlebotomy), body fluids, mucous membranes, non-intact skin or contaminated equipment.

– Wear gloves that fit (select according to hand size).

– Do not wear the same pair of gloves for the care of

more than one patient.

– Do not wash gloves for the purpose of reuse.

• Perform hand hygiene before and immediately after removing gloves.

(CDC, 2011)

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Use of PPE: Gowns

• Wear a gown to protect skin and clothing

during procedures or activities where contact

with blood or body fluids is anticipated.

– Do not wear the same gown for the care of more

than one patient.

• Remove gown and perform hand hygiene

before leaving the patient’s environment.

(CDC, 2011)

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Use of PPE: Facemasks, Goggles/Face Shields

Facemask:

Use when there is potential contact with respiratory

secretions and sprays of blood or body fluids (as defined

in Standard Precautions and/or Droplet Precautions).

Goggles or Face Shields:

Wear eye protection for potential splash or spray of

blood, respiratory secretions, or other body fluids.

Personal eyeglasses and contact lenses are not considered adequate eye protection

(CDC, 2011)

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Use of PPE: Respirators

• If available, wear N95-or higher respirators for

potential exposure to infectious agents

transmitted via the airborne route (e.g.,

tuberculosis).

• All healthcare personnel that use N95-or

higher respirator are fit tested at least

annually and according to OSHA

requirements.

(CDC, 2011)

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Respirators

• Include either N95 respirators, elastomeric or powered air purifying respirators.

Elastomeric Half-Face Respirator

with HEPA Cartridge

N95 Disposable Respirator

Elastomeric Full-Face Respirator

with HEPA Cartridge

Powered Air Purifying Respirator

(PAPR)

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Respirators can be divided based on facial coverage

Full Face Half Face

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Powered Air Purifying Respirators

PAPRs with tight fitting facepiece PAPR with loose fitting hood

PAPRs provide air directly to the wearer.

Additional benefits include: 1) Provide splash protection 2) Greater protection from contaminants3) No fit testing4) Wearer can have a beard5) Are more comfortable 6) Allow for longer working time

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If respirator requires a seal test, complete checks before each use

Negative Pressure Check Positive Pressure Check

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HIERARCHY OF CONTROLEBOLA VIRUS DISEASE EXAMPLE

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The Hierarchy of Controls

Substitution

Engineering

Administrative Work Practices

PPE

More reliance on workers

Why is Personal Protective Equipment at the bottom?

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Engineering Controls for EVD

Nebraska Biocontainment Unit recommends using 6 mil plastic liner inside ambulances.

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Administrative Controls

• Selection of administrative controls should be industry, task, and site specific.

• These controls will vary depending on whether they are used in healthcare, mortuary/death care, environmental services, or transportation.

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Administrative Controls for EVDExamples:

• Signage and checklists

• Training plan that ensures competency

• PPE observers and a buddy system for donning, doffing, and decontamination

• Limit the number of people who are exposed

• Limit movement between pre-hospital environment and isolation room

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Administrative Controls Example: Rapid Identification and Isolation

• Procedures for rapid identification/isolation of infectious disease cases, such as EVD, are key to prevention.

• Hospital procedures to ensure symptomatic patients are not in waiting rooms, reception areas, emergency departments, or other common areas.– Collect a travel history for patients presenting with

fever.

– Immediately isolate (using standard, contact and droplet precautions) for suspect or confirmed cases.

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Administrative Controls Example: Evaluating Patients for EVD

• CDC encourages all healthcare providers to:– Ask patients with symptoms about a history of travel

to West Africa in the 21 days before illness onset.

– Know the signs and symptoms of EVD.

– Know the initial steps to take if a diagnosis of EVD is suspected.

• CDC has developed documents to facilitate these evaluations including:– An EVD algorithm for the evaluation of a returned

traveler, and

– A poster title “Think Ebola’ for evaluation of a patient.

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CDC Guidelines for Healthcare Workers

• Updated Guidance from October 2014

• Three principles:

1. Rigorous and repeated training

2. No skin exposure

3. Trained monitor who watches each worker don (put on) and doff (take off) PPE

– http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html

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Training and Drills

• Must be hands on and frequent

• Should not be primarily computer-based or lecture

• Must include an opportunity to drill the actual process of donning and doffing PPE and respirators

– Must include a trained observer and decontamination

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No Skin Exposure Summary• Goggles no longer recommended

• Double gloves

• Boot covers that are waterproof, go up to mid-calf or leg covers

• Single-use fluid resistant or impermeable gown, mid-calf or coverall without integrated hood

• Single-use, full-face shield that is disposable

• Surgical hoods, complete coverage of head and neck

• Apron that is waterproof if patients have vomiting or diarrhea

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PPE for EVD

• Selection of PPE should be based on risk

assessment.

– If there is a potential for blood and body fluids

exposure, high risk protection is needed.

– If exposure does not include blood and body

fluids, low risk protection is needed.

• See OSHA’s Ebola PPE Selection Matrix:

– https://www.osha.gov/Publications/OSHA3761.pdf

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PPE Options for Healthcare Workers

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Designated areas for putting on (donning) and taking off (doffing) PPE

• Ensure that space and layout allows for clear separation between clean and potentially contaminated areas.

Photo: U Nebraska Medical Center

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Donning & Doffing ProceduresMust be in Writing

• A checklist must be used to ensure all

procedures are followed.

• The Nebraska Biocontainment Unit’s

procedures include 26 steps!

• PPE must be put on and taken off in

proper order to avoid contamination.

• Need a trained observer to assist and

document.

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DECONTAMINATION & WASTE MANAGEMENT

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In this section, we will …

• Describe proper disposal of different types of potentially infectious waste

• Describe the need to use proper decontamination and cleaning solutions in handling and disposing of infectious waste

• Describe proper waste management and decontamination for materials generated during care of persons with Ebola virus disease

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Cleaning vs. Decontamination

• Cleaning is the removal of visible soil (e.g., organic and inorganic material) from objects and surfaces.

• Decontamination removes pathogenic microorganisms from objects so they are safe to handle, use, or discard.

• Disinfection describes a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects.

• Sterilization describes a process that destroys or eliminates all forms of microbial life.

(CDC, 2008)

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Waste Management• Major categories of medical waste that require

special handling and disposal precautions: – 1) microbiology laboratory wastes; – 2) bulk blood, blood products, blood, and bloody body

fluid specimens; – 3) pathology and anatomy waste; and – 4) sharps [e.g., needles and scalpels].

• Inform personnel involved in handling and disposal of potentially infective waste of possible health and safety hazards.

• Ensure that they are trained in appropriate handling and disposal methods.

(CDC, 2003)

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Proper Sharps Disposal

• Place sharps into puncture-resistant containers

located as close as practical to the point of use.

• Do not bend, recap, or break used syringe

needles before discarding them into a container.

(CDC, 2003)

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• PPE– Use single use equipment/supplies whenever possible.

• Surfaces– Use non-porous surfaces whenever possible

• Approved Decontamination solutions– Chlorine Bleach

• 0.5%-equipment, surfaces, and waste decon• 0.05%-skin, reusable medical equipment, laundry, eating utensils

• EPA approved solutions– Read label or insert to determine if it is approved.– Label should identify for use against a non-enveloped

virus.

Decontamination

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Decontamination (cont.)

• Clean up of spills, vomit, and excrement.

– Remove bulk spill matter.

– Clean remaining area with EPA-registered hospital disinfectant.

– Need to allow sufficient contact time to disinfectant to neutralize.

• Avoid activities that might aerosolize the material, such as vigorous spraying.

Remember - particulate respirator filters will not protect against chemical exposures; additional protection may be needed.

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Management of Medical Waste

• Handling of waste– Medical waste

• Leak proof medical waste bag in a rigid walled receptacle.

– Human waste• Each patient can generate gallons of waste each day.

– Safe for EVD patient to use the bathroom.

• Inactivation of virus– Incineration

– Sterilization/Autoclaving

– Chemical decontamination has not been standardized and guidance has not been issued. Cannot recommend this as of now.

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US Department of TransportationRegulations on transport of Ebola Contaminated Waste

• The treatment of Ebola patients creates a large quantity of contaminated medical waste.

– A single EVD patient can generate 1000 pounds of waste.

– 3 to 4 bags per day (mainly PPE) and 10 quarts of liquid waste per day.

• Materials contaminated with Ebola are Category A infectious substances(Hazardous Materials Regulations§173.196)