Prevention ofHealthcare-associatedGastrointestinal Infections

Learning objectives

1 List the types of microorganisms that can cause gastrointestinal infections (GI) associated with health care facilities

2 Define diarrhoea3 Identify risk factors for GI infections4 Outline methods to prevent GI infections

Dec

emb

er 1

20

13

2

Time involved

bull 45 minutes

Dec

emb

er 1

20

13

3

Introductionbull Many microbes cause GI problems

bull Most outbreaks caused by viruses bull Norovirus

bull Bacterial gastroenteritis associated with food andor water bull Another cause - toxigenic strains of Clostridium difficile

bull Food-borne infections occurbull Especially in low resource countries during warmer months

Dec

emb

er 1

20

13

4

Key points bull Critical elements for prevention and control

bull Isolationbull Contact Precautionsbull Decontamination of spillages

bull Antibiotic stewardship essential to prevent Clostridium difficile infections

bull Hand hygiene with soap and water in outbreaksbull In food production - temperature controlbull Inspection and auditing often reveal deficiencies

in practices

Dec

emb

er 1

20

13

5

Definitions

bull Diarrhoeabull 2 or more episodes of watery stools (Bristol Stool

Type 7) orbull 3 or more episodes of loose stools (Bristol Stool

Type 6) bull Over a period of 24 hours

bull All cases of acute diarrhoea andor vomiting regarded as potentially infectious

Dec

emb

er 1

20

13

6

Non-infectious causes of diarrhoeabull Exclude when investigating infections

bull laxative usebull allergic reactionsbull chemical and physical agentsbull nasogastric feedingbull inflammatory bowel diseasebull surgery on the gastrointestinal tractbull constipation associated with faecal impaction

Dec

emb

er 1

20

13

7

Food-borne outbreakbull Considered when two or more

persons who have consumed the same food develop gastroenteritis within 24 hours

bull Cases occur in the same ward in short time

bull Causesbull Common vehicle bull Poor hygiene and non-compliance

of practices

Dec

emb

er 1

20

13

8

Viral gastroenteritis - 1

bull Norovirus Adenovirus Rotavirus bull Vomit major symptom

bull Sudden and projectile

bull Elderly most affected bull Often resolves spontaneouslybull Immunosuppressed shed viruses longer

Dec

emb

er 1

20

13

9

Viral gastroenteritis - 2

bull Noroviruses highly infectious

bull Transmissionbull Direct

bull Hand contact

bull Indirect bull Contamination of

environment and subsequent contamination of hands

Dec

emb

er 1

20

13

10

Viral gastroenteritis - 3

bull Characteristic of outbreaksbull Short incubation period

bull 15 to 48 hours

bull Limited duration of illness bull 12 to 60 hours

bull Vomiting the key symptombull Affect both patients and staff

Dec

emb

er 1

20

13

11

Prevention of outbreaks - 1bull Admissions with GI symptoms isolated or

cohorted immediatelybull Gloves and apron for all contacts

bull patients and environment

bull Hand washing with soap and water after every contact

bull Alcohol-based hand rub should not be usedbull No masksbull Bed linen and clothing changed daily

Dec

emb

er 1

20

13

12

Prevention of outbreaks - 2bull Environmental cleaning

bull Perform at least once a day bull Disinfect (eg 1000 ppm chlorine)

bull Special attention to toilets bathroom and bedpans bull Attention to horizontal and frequently touched

surfacesbull Decontamination of all spillages of vomit and faeces

bull Cohorting of staff and patients

Dec

emb

er 1

20

13

13

Decontamination of all spillages of vomit and faecesbull Wear personal protective equipment

bull Disposable gloves apron visor or mask discard

bull Absorb by paper towels discardbull Wash area

bull Hot water and detergent then disinfect with fresh chlorine solution at 10000 ppm

bull Hand washing

Dec

emb

er 1

20

13

14

Cohorting of staff and patients

bull Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case

bull Affected staff should be excluded until they have been symptom-free for 48 hours

Dec

emb

er 1

20

13

15

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Learning objectives

1 List the types of microorganisms that can cause gastrointestinal infections (GI) associated with health care facilities

2 Define diarrhoea3 Identify risk factors for GI infections4 Outline methods to prevent GI infections

Dec

emb

er 1

20

13

2

Time involved

bull 45 minutes

Dec

emb

er 1

20

13

3

Introductionbull Many microbes cause GI problems

bull Most outbreaks caused by viruses bull Norovirus

bull Bacterial gastroenteritis associated with food andor water bull Another cause - toxigenic strains of Clostridium difficile

bull Food-borne infections occurbull Especially in low resource countries during warmer months

Dec

emb

er 1

20

13

4

Key points bull Critical elements for prevention and control

bull Isolationbull Contact Precautionsbull Decontamination of spillages

bull Antibiotic stewardship essential to prevent Clostridium difficile infections

bull Hand hygiene with soap and water in outbreaksbull In food production - temperature controlbull Inspection and auditing often reveal deficiencies

in practices

Dec

emb

er 1

20

13

5

Definitions

bull Diarrhoeabull 2 or more episodes of watery stools (Bristol Stool

Type 7) orbull 3 or more episodes of loose stools (Bristol Stool

Type 6) bull Over a period of 24 hours

bull All cases of acute diarrhoea andor vomiting regarded as potentially infectious

Dec

emb

er 1

20

13

6

Non-infectious causes of diarrhoeabull Exclude when investigating infections

bull laxative usebull allergic reactionsbull chemical and physical agentsbull nasogastric feedingbull inflammatory bowel diseasebull surgery on the gastrointestinal tractbull constipation associated with faecal impaction

Dec

emb

er 1

20

13

7

Food-borne outbreakbull Considered when two or more

persons who have consumed the same food develop gastroenteritis within 24 hours

bull Cases occur in the same ward in short time

bull Causesbull Common vehicle bull Poor hygiene and non-compliance

of practices

Dec

emb

er 1

20

13

8

Viral gastroenteritis - 1

bull Norovirus Adenovirus Rotavirus bull Vomit major symptom

bull Sudden and projectile

bull Elderly most affected bull Often resolves spontaneouslybull Immunosuppressed shed viruses longer

Dec

emb

er 1

20

13

9

Viral gastroenteritis - 2

bull Noroviruses highly infectious

bull Transmissionbull Direct

bull Hand contact

bull Indirect bull Contamination of

environment and subsequent contamination of hands

Dec

emb

er 1

20

13

10

Viral gastroenteritis - 3

bull Characteristic of outbreaksbull Short incubation period

bull 15 to 48 hours

bull Limited duration of illness bull 12 to 60 hours

bull Vomiting the key symptombull Affect both patients and staff

Dec

emb

er 1

20

13

11

Prevention of outbreaks - 1bull Admissions with GI symptoms isolated or

cohorted immediatelybull Gloves and apron for all contacts

bull patients and environment

bull Hand washing with soap and water after every contact

bull Alcohol-based hand rub should not be usedbull No masksbull Bed linen and clothing changed daily

Dec

emb

er 1

20

13

12

Prevention of outbreaks - 2bull Environmental cleaning

bull Perform at least once a day bull Disinfect (eg 1000 ppm chlorine)

bull Special attention to toilets bathroom and bedpans bull Attention to horizontal and frequently touched

surfacesbull Decontamination of all spillages of vomit and faeces

bull Cohorting of staff and patients

Dec

emb

er 1

20

13

13

Decontamination of all spillages of vomit and faecesbull Wear personal protective equipment

bull Disposable gloves apron visor or mask discard

bull Absorb by paper towels discardbull Wash area

bull Hot water and detergent then disinfect with fresh chlorine solution at 10000 ppm

bull Hand washing

Dec

emb

er 1

20

13

14

Cohorting of staff and patients

bull Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case

bull Affected staff should be excluded until they have been symptom-free for 48 hours

Dec

emb

er 1

20

13

15

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Time involved

bull 45 minutes

Dec

emb

er 1

20

13

3

Introductionbull Many microbes cause GI problems

bull Most outbreaks caused by viruses bull Norovirus

bull Bacterial gastroenteritis associated with food andor water bull Another cause - toxigenic strains of Clostridium difficile

bull Food-borne infections occurbull Especially in low resource countries during warmer months

Dec

emb

er 1

20

13

4

Key points bull Critical elements for prevention and control

bull Isolationbull Contact Precautionsbull Decontamination of spillages

bull Antibiotic stewardship essential to prevent Clostridium difficile infections

bull Hand hygiene with soap and water in outbreaksbull In food production - temperature controlbull Inspection and auditing often reveal deficiencies

in practices

Dec

emb

er 1

20

13

5

Definitions

bull Diarrhoeabull 2 or more episodes of watery stools (Bristol Stool

Type 7) orbull 3 or more episodes of loose stools (Bristol Stool

Type 6) bull Over a period of 24 hours

bull All cases of acute diarrhoea andor vomiting regarded as potentially infectious

Dec

emb

er 1

20

13

6

Non-infectious causes of diarrhoeabull Exclude when investigating infections

bull laxative usebull allergic reactionsbull chemical and physical agentsbull nasogastric feedingbull inflammatory bowel diseasebull surgery on the gastrointestinal tractbull constipation associated with faecal impaction

Dec

emb

er 1

20

13

7

Food-borne outbreakbull Considered when two or more

persons who have consumed the same food develop gastroenteritis within 24 hours

bull Cases occur in the same ward in short time

bull Causesbull Common vehicle bull Poor hygiene and non-compliance

of practices

Dec

emb

er 1

20

13

8

Viral gastroenteritis - 1

bull Norovirus Adenovirus Rotavirus bull Vomit major symptom

bull Sudden and projectile

bull Elderly most affected bull Often resolves spontaneouslybull Immunosuppressed shed viruses longer

Dec

emb

er 1

20

13

9

Viral gastroenteritis - 2

bull Noroviruses highly infectious

bull Transmissionbull Direct

bull Hand contact

bull Indirect bull Contamination of

environment and subsequent contamination of hands

Dec

emb

er 1

20

13

10

Viral gastroenteritis - 3

bull Characteristic of outbreaksbull Short incubation period

bull 15 to 48 hours

bull Limited duration of illness bull 12 to 60 hours

bull Vomiting the key symptombull Affect both patients and staff

Dec

emb

er 1

20

13

11

Prevention of outbreaks - 1bull Admissions with GI symptoms isolated or

cohorted immediatelybull Gloves and apron for all contacts

bull patients and environment

bull Hand washing with soap and water after every contact

bull Alcohol-based hand rub should not be usedbull No masksbull Bed linen and clothing changed daily

Dec

emb

er 1

20

13

12

Prevention of outbreaks - 2bull Environmental cleaning

bull Perform at least once a day bull Disinfect (eg 1000 ppm chlorine)

bull Special attention to toilets bathroom and bedpans bull Attention to horizontal and frequently touched

surfacesbull Decontamination of all spillages of vomit and faeces

bull Cohorting of staff and patients

Dec

emb

er 1

20

13

13

Decontamination of all spillages of vomit and faecesbull Wear personal protective equipment

bull Disposable gloves apron visor or mask discard

bull Absorb by paper towels discardbull Wash area

bull Hot water and detergent then disinfect with fresh chlorine solution at 10000 ppm

bull Hand washing

Dec

emb

er 1

20

13

14

Cohorting of staff and patients

bull Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case

bull Affected staff should be excluded until they have been symptom-free for 48 hours

Dec

emb

er 1

20

13

15

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Introductionbull Many microbes cause GI problems

bull Most outbreaks caused by viruses bull Norovirus

bull Bacterial gastroenteritis associated with food andor water bull Another cause - toxigenic strains of Clostridium difficile

bull Food-borne infections occurbull Especially in low resource countries during warmer months

Dec

emb

er 1

20

13

4

Key points bull Critical elements for prevention and control

bull Isolationbull Contact Precautionsbull Decontamination of spillages

bull Antibiotic stewardship essential to prevent Clostridium difficile infections

bull Hand hygiene with soap and water in outbreaksbull In food production - temperature controlbull Inspection and auditing often reveal deficiencies

in practices

Dec

emb

er 1

20

13

5

Definitions

bull Diarrhoeabull 2 or more episodes of watery stools (Bristol Stool

Type 7) orbull 3 or more episodes of loose stools (Bristol Stool

Type 6) bull Over a period of 24 hours

bull All cases of acute diarrhoea andor vomiting regarded as potentially infectious

Dec

emb

er 1

20

13

6

Non-infectious causes of diarrhoeabull Exclude when investigating infections

bull laxative usebull allergic reactionsbull chemical and physical agentsbull nasogastric feedingbull inflammatory bowel diseasebull surgery on the gastrointestinal tractbull constipation associated with faecal impaction

Dec

emb

er 1

20

13

7

Food-borne outbreakbull Considered when two or more

persons who have consumed the same food develop gastroenteritis within 24 hours

bull Cases occur in the same ward in short time

bull Causesbull Common vehicle bull Poor hygiene and non-compliance

of practices

Dec

emb

er 1

20

13

8

Viral gastroenteritis - 1

bull Norovirus Adenovirus Rotavirus bull Vomit major symptom

bull Sudden and projectile

bull Elderly most affected bull Often resolves spontaneouslybull Immunosuppressed shed viruses longer

Dec

emb

er 1

20

13

9

Viral gastroenteritis - 2

bull Noroviruses highly infectious

bull Transmissionbull Direct

bull Hand contact

bull Indirect bull Contamination of

environment and subsequent contamination of hands

Dec

emb

er 1

20

13

10

Viral gastroenteritis - 3

bull Characteristic of outbreaksbull Short incubation period

bull 15 to 48 hours

bull Limited duration of illness bull 12 to 60 hours

bull Vomiting the key symptombull Affect both patients and staff

Dec

emb

er 1

20

13

11

Prevention of outbreaks - 1bull Admissions with GI symptoms isolated or

cohorted immediatelybull Gloves and apron for all contacts

bull patients and environment

bull Hand washing with soap and water after every contact

bull Alcohol-based hand rub should not be usedbull No masksbull Bed linen and clothing changed daily

Dec

emb

er 1

20

13

12

Prevention of outbreaks - 2bull Environmental cleaning

bull Perform at least once a day bull Disinfect (eg 1000 ppm chlorine)

bull Special attention to toilets bathroom and bedpans bull Attention to horizontal and frequently touched

surfacesbull Decontamination of all spillages of vomit and faeces

bull Cohorting of staff and patients

Dec

emb

er 1

20

13

13

Decontamination of all spillages of vomit and faecesbull Wear personal protective equipment

bull Disposable gloves apron visor or mask discard

bull Absorb by paper towels discardbull Wash area

bull Hot water and detergent then disinfect with fresh chlorine solution at 10000 ppm

bull Hand washing

Dec

emb

er 1

20

13

14

Cohorting of staff and patients

bull Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case

bull Affected staff should be excluded until they have been symptom-free for 48 hours

Dec

emb

er 1

20

13

15

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Key points bull Critical elements for prevention and control

bull Isolationbull Contact Precautionsbull Decontamination of spillages

bull Antibiotic stewardship essential to prevent Clostridium difficile infections

bull Hand hygiene with soap and water in outbreaksbull In food production - temperature controlbull Inspection and auditing often reveal deficiencies

in practices

Dec

emb

er 1

20

13

5

Definitions

bull Diarrhoeabull 2 or more episodes of watery stools (Bristol Stool

Type 7) orbull 3 or more episodes of loose stools (Bristol Stool

Type 6) bull Over a period of 24 hours

bull All cases of acute diarrhoea andor vomiting regarded as potentially infectious

Dec

emb

er 1

20

13

6

Non-infectious causes of diarrhoeabull Exclude when investigating infections

bull laxative usebull allergic reactionsbull chemical and physical agentsbull nasogastric feedingbull inflammatory bowel diseasebull surgery on the gastrointestinal tractbull constipation associated with faecal impaction

Dec

emb

er 1

20

13

7

Food-borne outbreakbull Considered when two or more

persons who have consumed the same food develop gastroenteritis within 24 hours

bull Cases occur in the same ward in short time

bull Causesbull Common vehicle bull Poor hygiene and non-compliance

of practices

Dec

emb

er 1

20

13

8

Viral gastroenteritis - 1

bull Norovirus Adenovirus Rotavirus bull Vomit major symptom

bull Sudden and projectile

bull Elderly most affected bull Often resolves spontaneouslybull Immunosuppressed shed viruses longer

Dec

emb

er 1

20

13

9

Viral gastroenteritis - 2

bull Noroviruses highly infectious

bull Transmissionbull Direct

bull Hand contact

bull Indirect bull Contamination of

environment and subsequent contamination of hands

Dec

emb

er 1

20

13

10

Viral gastroenteritis - 3

bull Characteristic of outbreaksbull Short incubation period

bull 15 to 48 hours

bull Limited duration of illness bull 12 to 60 hours

bull Vomiting the key symptombull Affect both patients and staff

Dec

emb

er 1

20

13

11

Prevention of outbreaks - 1bull Admissions with GI symptoms isolated or

cohorted immediatelybull Gloves and apron for all contacts

bull patients and environment

bull Hand washing with soap and water after every contact

bull Alcohol-based hand rub should not be usedbull No masksbull Bed linen and clothing changed daily

Dec

emb

er 1

20

13

12

Prevention of outbreaks - 2bull Environmental cleaning

bull Perform at least once a day bull Disinfect (eg 1000 ppm chlorine)

bull Special attention to toilets bathroom and bedpans bull Attention to horizontal and frequently touched

surfacesbull Decontamination of all spillages of vomit and faeces

bull Cohorting of staff and patients

Dec

emb

er 1

20

13

13

Decontamination of all spillages of vomit and faecesbull Wear personal protective equipment

bull Disposable gloves apron visor or mask discard

bull Absorb by paper towels discardbull Wash area

bull Hot water and detergent then disinfect with fresh chlorine solution at 10000 ppm

bull Hand washing

Dec

emb

er 1

20

13

14

Cohorting of staff and patients

bull Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case

bull Affected staff should be excluded until they have been symptom-free for 48 hours

Dec

emb

er 1

20

13

15

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Definitions

bull Diarrhoeabull 2 or more episodes of watery stools (Bristol Stool

Type 7) orbull 3 or more episodes of loose stools (Bristol Stool

Type 6) bull Over a period of 24 hours

bull All cases of acute diarrhoea andor vomiting regarded as potentially infectious

Dec

emb

er 1

20

13

6

Non-infectious causes of diarrhoeabull Exclude when investigating infections

bull laxative usebull allergic reactionsbull chemical and physical agentsbull nasogastric feedingbull inflammatory bowel diseasebull surgery on the gastrointestinal tractbull constipation associated with faecal impaction

Dec

emb

er 1

20

13

7

Food-borne outbreakbull Considered when two or more

persons who have consumed the same food develop gastroenteritis within 24 hours

bull Cases occur in the same ward in short time

bull Causesbull Common vehicle bull Poor hygiene and non-compliance

of practices

Dec

emb

er 1

20

13

8

Viral gastroenteritis - 1

bull Norovirus Adenovirus Rotavirus bull Vomit major symptom

bull Sudden and projectile

bull Elderly most affected bull Often resolves spontaneouslybull Immunosuppressed shed viruses longer

Dec

emb

er 1

20

13

9

Viral gastroenteritis - 2

bull Noroviruses highly infectious

bull Transmissionbull Direct

bull Hand contact

bull Indirect bull Contamination of

environment and subsequent contamination of hands

Dec

emb

er 1

20

13

10

Viral gastroenteritis - 3

bull Characteristic of outbreaksbull Short incubation period

bull 15 to 48 hours

bull Limited duration of illness bull 12 to 60 hours

bull Vomiting the key symptombull Affect both patients and staff

Dec

emb

er 1

20

13

11

Prevention of outbreaks - 1bull Admissions with GI symptoms isolated or

cohorted immediatelybull Gloves and apron for all contacts

bull patients and environment

bull Hand washing with soap and water after every contact

bull Alcohol-based hand rub should not be usedbull No masksbull Bed linen and clothing changed daily

Dec

emb

er 1

20

13

12

Prevention of outbreaks - 2bull Environmental cleaning

bull Perform at least once a day bull Disinfect (eg 1000 ppm chlorine)

bull Special attention to toilets bathroom and bedpans bull Attention to horizontal and frequently touched

surfacesbull Decontamination of all spillages of vomit and faeces

bull Cohorting of staff and patients

Dec

emb

er 1

20

13

13

Decontamination of all spillages of vomit and faecesbull Wear personal protective equipment

bull Disposable gloves apron visor or mask discard

bull Absorb by paper towels discardbull Wash area

bull Hot water and detergent then disinfect with fresh chlorine solution at 10000 ppm

bull Hand washing

Dec

emb

er 1

20

13

14

Cohorting of staff and patients

bull Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case

bull Affected staff should be excluded until they have been symptom-free for 48 hours

Dec

emb

er 1

20

13

15

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Non-infectious causes of diarrhoeabull Exclude when investigating infections

bull laxative usebull allergic reactionsbull chemical and physical agentsbull nasogastric feedingbull inflammatory bowel diseasebull surgery on the gastrointestinal tractbull constipation associated with faecal impaction

Dec

emb

er 1

20

13

7

Food-borne outbreakbull Considered when two or more

persons who have consumed the same food develop gastroenteritis within 24 hours

bull Cases occur in the same ward in short time

bull Causesbull Common vehicle bull Poor hygiene and non-compliance

of practices

Dec

emb

er 1

20

13

8

Viral gastroenteritis - 1

bull Norovirus Adenovirus Rotavirus bull Vomit major symptom

bull Sudden and projectile

bull Elderly most affected bull Often resolves spontaneouslybull Immunosuppressed shed viruses longer

Dec

emb

er 1

20

13

9

Viral gastroenteritis - 2

bull Noroviruses highly infectious

bull Transmissionbull Direct

bull Hand contact

bull Indirect bull Contamination of

environment and subsequent contamination of hands

Dec

emb

er 1

20

13

10

Viral gastroenteritis - 3

bull Characteristic of outbreaksbull Short incubation period

bull 15 to 48 hours

bull Limited duration of illness bull 12 to 60 hours

bull Vomiting the key symptombull Affect both patients and staff

Dec

emb

er 1

20

13

11

Prevention of outbreaks - 1bull Admissions with GI symptoms isolated or

cohorted immediatelybull Gloves and apron for all contacts

bull patients and environment

bull Hand washing with soap and water after every contact

bull Alcohol-based hand rub should not be usedbull No masksbull Bed linen and clothing changed daily

Dec

emb

er 1

20

13

12

Prevention of outbreaks - 2bull Environmental cleaning

bull Perform at least once a day bull Disinfect (eg 1000 ppm chlorine)

bull Special attention to toilets bathroom and bedpans bull Attention to horizontal and frequently touched

surfacesbull Decontamination of all spillages of vomit and faeces

bull Cohorting of staff and patients

Dec

emb

er 1

20

13

13

Decontamination of all spillages of vomit and faecesbull Wear personal protective equipment

bull Disposable gloves apron visor or mask discard

bull Absorb by paper towels discardbull Wash area

bull Hot water and detergent then disinfect with fresh chlorine solution at 10000 ppm

bull Hand washing

Dec

emb

er 1

20

13

14

Cohorting of staff and patients

bull Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case

bull Affected staff should be excluded until they have been symptom-free for 48 hours

Dec

emb

er 1

20

13

15

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Food-borne outbreakbull Considered when two or more

persons who have consumed the same food develop gastroenteritis within 24 hours

bull Cases occur in the same ward in short time

bull Causesbull Common vehicle bull Poor hygiene and non-compliance

of practices

Dec

emb

er 1

20

13

8

Viral gastroenteritis - 1

bull Norovirus Adenovirus Rotavirus bull Vomit major symptom

bull Sudden and projectile

bull Elderly most affected bull Often resolves spontaneouslybull Immunosuppressed shed viruses longer

Dec

emb

er 1

20

13

9

Viral gastroenteritis - 2

bull Noroviruses highly infectious

bull Transmissionbull Direct

bull Hand contact

bull Indirect bull Contamination of

environment and subsequent contamination of hands

Dec

emb

er 1

20

13

10

Viral gastroenteritis - 3

bull Characteristic of outbreaksbull Short incubation period

bull 15 to 48 hours

bull Limited duration of illness bull 12 to 60 hours

bull Vomiting the key symptombull Affect both patients and staff

Dec

emb

er 1

20

13

11

Prevention of outbreaks - 1bull Admissions with GI symptoms isolated or

cohorted immediatelybull Gloves and apron for all contacts

bull patients and environment

bull Hand washing with soap and water after every contact

bull Alcohol-based hand rub should not be usedbull No masksbull Bed linen and clothing changed daily

Dec

emb

er 1

20

13

12

Prevention of outbreaks - 2bull Environmental cleaning

bull Perform at least once a day bull Disinfect (eg 1000 ppm chlorine)

bull Special attention to toilets bathroom and bedpans bull Attention to horizontal and frequently touched

surfacesbull Decontamination of all spillages of vomit and faeces

bull Cohorting of staff and patients

Dec

emb

er 1

20

13

13

Decontamination of all spillages of vomit and faecesbull Wear personal protective equipment

bull Disposable gloves apron visor or mask discard

bull Absorb by paper towels discardbull Wash area

bull Hot water and detergent then disinfect with fresh chlorine solution at 10000 ppm

bull Hand washing

Dec

emb

er 1

20

13

14

Cohorting of staff and patients

bull Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case

bull Affected staff should be excluded until they have been symptom-free for 48 hours

Dec

emb

er 1

20

13

15

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Viral gastroenteritis - 1

bull Norovirus Adenovirus Rotavirus bull Vomit major symptom

bull Sudden and projectile

bull Elderly most affected bull Often resolves spontaneouslybull Immunosuppressed shed viruses longer

Dec

emb

er 1

20

13

9

Viral gastroenteritis - 2

bull Noroviruses highly infectious

bull Transmissionbull Direct

bull Hand contact

bull Indirect bull Contamination of

environment and subsequent contamination of hands

Dec

emb

er 1

20

13

10

Viral gastroenteritis - 3

bull Characteristic of outbreaksbull Short incubation period

bull 15 to 48 hours

bull Limited duration of illness bull 12 to 60 hours

bull Vomiting the key symptombull Affect both patients and staff

Dec

emb

er 1

20

13

11

Prevention of outbreaks - 1bull Admissions with GI symptoms isolated or

cohorted immediatelybull Gloves and apron for all contacts

bull patients and environment

bull Hand washing with soap and water after every contact

bull Alcohol-based hand rub should not be usedbull No masksbull Bed linen and clothing changed daily

Dec

emb

er 1

20

13

12

Prevention of outbreaks - 2bull Environmental cleaning

bull Perform at least once a day bull Disinfect (eg 1000 ppm chlorine)

bull Special attention to toilets bathroom and bedpans bull Attention to horizontal and frequently touched

surfacesbull Decontamination of all spillages of vomit and faeces

bull Cohorting of staff and patients

Dec

emb

er 1

20

13

13

Decontamination of all spillages of vomit and faecesbull Wear personal protective equipment

bull Disposable gloves apron visor or mask discard

bull Absorb by paper towels discardbull Wash area

bull Hot water and detergent then disinfect with fresh chlorine solution at 10000 ppm

bull Hand washing

Dec

emb

er 1

20

13

14

Cohorting of staff and patients

bull Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case

bull Affected staff should be excluded until they have been symptom-free for 48 hours

Dec

emb

er 1

20

13

15

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Viral gastroenteritis - 2

bull Noroviruses highly infectious

bull Transmissionbull Direct

bull Hand contact

bull Indirect bull Contamination of

environment and subsequent contamination of hands

Dec

emb

er 1

20

13

10

Viral gastroenteritis - 3

bull Characteristic of outbreaksbull Short incubation period

bull 15 to 48 hours

bull Limited duration of illness bull 12 to 60 hours

bull Vomiting the key symptombull Affect both patients and staff

Dec

emb

er 1

20

13

11

Prevention of outbreaks - 1bull Admissions with GI symptoms isolated or

cohorted immediatelybull Gloves and apron for all contacts

bull patients and environment

bull Hand washing with soap and water after every contact

bull Alcohol-based hand rub should not be usedbull No masksbull Bed linen and clothing changed daily

Dec

emb

er 1

20

13

12

Prevention of outbreaks - 2bull Environmental cleaning

bull Perform at least once a day bull Disinfect (eg 1000 ppm chlorine)

bull Special attention to toilets bathroom and bedpans bull Attention to horizontal and frequently touched

surfacesbull Decontamination of all spillages of vomit and faeces

bull Cohorting of staff and patients

Dec

emb

er 1

20

13

13

Decontamination of all spillages of vomit and faecesbull Wear personal protective equipment

bull Disposable gloves apron visor or mask discard

bull Absorb by paper towels discardbull Wash area

bull Hot water and detergent then disinfect with fresh chlorine solution at 10000 ppm

bull Hand washing

Dec

emb

er 1

20

13

14

Cohorting of staff and patients

bull Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case

bull Affected staff should be excluded until they have been symptom-free for 48 hours

Dec

emb

er 1

20

13

15

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Viral gastroenteritis - 3

bull Characteristic of outbreaksbull Short incubation period

bull 15 to 48 hours

bull Limited duration of illness bull 12 to 60 hours

bull Vomiting the key symptombull Affect both patients and staff

Dec

emb

er 1

20

13

11

Prevention of outbreaks - 1bull Admissions with GI symptoms isolated or

cohorted immediatelybull Gloves and apron for all contacts

bull patients and environment

bull Hand washing with soap and water after every contact

bull Alcohol-based hand rub should not be usedbull No masksbull Bed linen and clothing changed daily

Dec

emb

er 1

20

13

12

Prevention of outbreaks - 2bull Environmental cleaning

bull Perform at least once a day bull Disinfect (eg 1000 ppm chlorine)

bull Special attention to toilets bathroom and bedpans bull Attention to horizontal and frequently touched

surfacesbull Decontamination of all spillages of vomit and faeces

bull Cohorting of staff and patients

Dec

emb

er 1

20

13

13

Decontamination of all spillages of vomit and faecesbull Wear personal protective equipment

bull Disposable gloves apron visor or mask discard

bull Absorb by paper towels discardbull Wash area

bull Hot water and detergent then disinfect with fresh chlorine solution at 10000 ppm

bull Hand washing

Dec

emb

er 1

20

13

14

Cohorting of staff and patients

bull Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case

bull Affected staff should be excluded until they have been symptom-free for 48 hours

Dec

emb

er 1

20

13

15

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Prevention of outbreaks - 1bull Admissions with GI symptoms isolated or

cohorted immediatelybull Gloves and apron for all contacts

bull patients and environment

bull Hand washing with soap and water after every contact

bull Alcohol-based hand rub should not be usedbull No masksbull Bed linen and clothing changed daily

Dec

emb

er 1

20

13

12

Prevention of outbreaks - 2bull Environmental cleaning

bull Perform at least once a day bull Disinfect (eg 1000 ppm chlorine)

bull Special attention to toilets bathroom and bedpans bull Attention to horizontal and frequently touched

surfacesbull Decontamination of all spillages of vomit and faeces

bull Cohorting of staff and patients

Dec

emb

er 1

20

13

13

Decontamination of all spillages of vomit and faecesbull Wear personal protective equipment

bull Disposable gloves apron visor or mask discard

bull Absorb by paper towels discardbull Wash area

bull Hot water and detergent then disinfect with fresh chlorine solution at 10000 ppm

bull Hand washing

Dec

emb

er 1

20

13

14

Cohorting of staff and patients

bull Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case

bull Affected staff should be excluded until they have been symptom-free for 48 hours

Dec

emb

er 1

20

13

15

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Prevention of outbreaks - 2bull Environmental cleaning

bull Perform at least once a day bull Disinfect (eg 1000 ppm chlorine)

bull Special attention to toilets bathroom and bedpans bull Attention to horizontal and frequently touched

surfacesbull Decontamination of all spillages of vomit and faeces

bull Cohorting of staff and patients

Dec

emb

er 1

20

13

13

Decontamination of all spillages of vomit and faecesbull Wear personal protective equipment

bull Disposable gloves apron visor or mask discard

bull Absorb by paper towels discardbull Wash area

bull Hot water and detergent then disinfect with fresh chlorine solution at 10000 ppm

bull Hand washing

Dec

emb

er 1

20

13

14

Cohorting of staff and patients

bull Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case

bull Affected staff should be excluded until they have been symptom-free for 48 hours

Dec

emb

er 1

20

13

15

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Decontamination of all spillages of vomit and faecesbull Wear personal protective equipment

bull Disposable gloves apron visor or mask discard

bull Absorb by paper towels discardbull Wash area

bull Hot water and detergent then disinfect with fresh chlorine solution at 10000 ppm

bull Hand washing

Dec

emb

er 1

20

13

14

Cohorting of staff and patients

bull Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case

bull Affected staff should be excluded until they have been symptom-free for 48 hours

Dec

emb

er 1

20

13

15

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Cohorting of staff and patients

bull Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case

bull Affected staff should be excluded until they have been symptom-free for 48 hours

Dec

emb

er 1

20

13

15

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Prevention of outbreaks - 3

bull Monitor compliance with IPampC practices bull If cases continue despite intervention consider

closing ward and stopping new admissions bull Do not transfer patients to unaffected wards

unless urgent bull If so consult IPampC staff

bull Visitorsbull Restrict bull Gown or apron bull Hand hygiene while visiting and hand washing on

leaving

Dec

emb

er 1

20

13

16

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

End of outbreaks

bull IPampC team determines when overbull Expert opinion two complete incubation periods

without a new casebull Terminal disinfection and changing of bed

curtains bull Special attention to bathrooms and toilets

Dec

emb

er 1

20

13

17

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Antibiotic-associated Gastroenteritisbull Diarrhoea common complication in patients

bull Disruption of the flora in intestine

bull Can colonise with Clostridium difficile bull Can produce exotoxins resulting in mucosal

injury and inflammation

Dec

emb

er 1

20

13

18

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

C difficile infections bull Symptoms from mild diarrhoea to

pseudomembranous colitis and perforation bull Risk increases with health care staybull Antibiotic use major pre-disposing factor

bull All antibiotics especially wider spectrum can predispose

bull Antibiotic stewardship initiatives crucial for prevention

Dec

emb

er 1

20

13

19

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Prevention of Antibiotic-associated Gastroenteritis - 1bull IPampC measures promptly enforcedbull Hygienic interventions bull Hand hygiene with soap

bull Lack of activity of alcohol on spores

bull Gloves and disposable gowns or aprons

Dec

emb

er 1

20

13

20

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Prevention of Antibiotic-associated Gastroenteritis - 2bullProgramme of Cleaning

bull Critical to reduce environmental contamination with spores

bull Chlorine-based compounds main productbull Recently hydrogen peroxide mist has been used for

terminal decontamination

Dec

emb

er 1

20

13

21

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Prevention of Antibiotic-associated Gastroenteritis - 3bull Isolation of patients as soon as possible in a

single room with toiletbull If not achievable cohort

bull Screening or decolonisation not recommendedbull Single use items preferred or thorough

cleaningdisinfection between patients bull Disposable rectal thermometersbull Antibiotic Stewardship

Dec

emb

er 1

20

13

22

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Contact Precautions

Dec

emb

er 1

20

13

23

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Prevention of Food-borne Gastroenteritisbull Prevalence of healthcare-associated Salmonella

and Shigella infections 3 and 25 respectivelybull Hepatitis A Campylobacter Yersinia also cause

food-related illnessbull The role of IPampC Teams depends on facility

bull Simple supervision to a more significant contribution

bull IPampC personnel need to have a clear understanding of effective food hygiene

Dec

emb

er 1

20

13

24

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Food Hygienebull Food pathogens survive and multiply within the

temperature danger zone bull 6degC to 63degC

bull Cold food must be served as soon as possible after removal from refrigeration

bull Heating food to 75degC for 1-2 minutes guarantees destruction of any biological hazardbull Cooling of cooked food must be rapid

bull Maintain temperature control until food is servedbull Maintain hot holding temperatures above 63degC

Dec

emb

er 1

20

13

25

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Common causes of food-borne infections bull Preparing food more than a half day in advancebull Storage at room temperaturebull Inadequate coolingbull Inadequate reheatingbull Undercookingbull Cross contamination from raw to cooked foodbull Contamination from food handlers

Dec

emb

er 1

20

13

26

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Food Hygiene

bull Training should include bull Conditions for temperature and timebull Effective personal hygienebull Environmental hygiene bull Potential sources of contamination

Dec

emb

er 1

20

13

27

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Hazard Analysis Critical Control Points (HACCP) bull Pioneered in the 1960s by USArsquos National

Aeronautics and Space Administration program bull Incorporated into legislation of food safety both

in USA and the EU bull Evaluates food production to determine hazards

that may contaminate foodbull Identifies critical control points after which any

contamination cannot be reversedbull Preventive measures monitored and corrected

Dec

emb

er 1

20

13

28

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Elements of HACCP

bull Regular equipment cleaning and maintenance bull Provision of effective hygiene facilitiesbull Systems to control insects and other pests bull Temperature controlbull Regular training for staff on food hygiene

Dec

emb

er 1

20

13

29

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Adapting HACCP to health care food production

Dec

emb

er 1

20

13Process Concern Prevention Methods

Reception Growth of pathogens Toxin production Contamination

Temperature control

Storage Stored covered and dated Rotate stockEnsure a pest free environment

Preparation

Limit exposure to ambient temperatures Prepare with clean equipment Separate cooked and raw foods Wash hands before handling food

Cooking Cook food to 111308875degC in thickest part two minutes

Cooling Cool foods as quickly as possible Refrigerate within 90 minutes Do not leave at room temperature

Chilled storage

Temperature controlCheck expiration dates Consume within three days Store 6 inches above the floor and away from the wall Use in rotation

Hot holding Distribution

Keep food hot at gt63degC

Reheating Avoid if possible Reheat to gt75degC Serving Serve as soon as possible

Ensure hands and equipment clean

30

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Testing of food environment and individualsbull Not required to monitor food safety bull May be occasions when is useful

bull Confirmation of microbiological quality and safety bull Educational tool for behaviour changes among food

handlers

bull Semi-quantitative testing of production area simple and low cost

bull E coli a good indicator to identify poor hygienic food production practices

bull Routine testing of food handlers not indicated (eg faeces)

Dec

emb

er 1

20

13

31

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

emb

er 1

20

13

32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Whatrsquos on YOUR hands

Bobulsky G et al CID 2007 Farr et al LID 2001

Dec

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32

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Ward kitchens precautions

bull Kept clean bull Refrigerators away from direct heat or sunlight

bull Temperature monitoring

bull Items should be labelled dated and used within 72 hours

bull Separation between raw and cooked itemsbull Place cooked above if in the same refrigerator

Dec

emb

er 1

20

13

33

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Kitchen auditing

bull Checklists for every day documentation of critical points

bull Auditing of kitchen practices bull Including points related to causes of foodborne illness

bull Critical pointsbull Temperature control bull Compliance with hygiene practices

bull Itemised audit sheet

Dec

emb

er 1

20

13

34

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

Summary

bull There are many risks of GI infections in health care

bull Can be produced by bacteria and virusesbull Can be associated with incorrect IPampC practices

excessive antibiotic use and poor foodor water hygiene

bull Most outbreaks caused by viruses and spread by contact

Dec

emb

er 1

20

13

35

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

References

Dec

emb

er 1

20

13

1 Lewis SJ Heaton KW Stool form scale as a useful guide to intestinal transit time Scand J Gastroenterol 1997 32 (9) 920ndash4 httpinformahealthcarecomdoiabs10310900365529709011203 And Bristol Stool Scale httpenwikipediaorgwikiBristol_Stool_Scale

2 Koopmans M Noroviruses in healthcare settings a challenging problem J Hosp Infect 2009 73331-7

36

References

Dec

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1 Chadwick PR Beards G Brown D et al Management of hospital outbreaks of gastro-enteritis due to small round structured viruses J Hosp Infect 2000 451-10 httpwwwhpaorgukinfectionstopics_aznorovirushospital_noroviruspdf

2 World Health Organisation Five keys to Safer Food Manual [online] 2006 httpwwwwhointfoodsafetypublicationsconsumermanual_keyspdf

3 Food and Agriculture Organization of the United Nations Food Quality and Safety Systems - A Training Manual on Food Hygiene and the Hazard Analysis and Critical Control Point (HACCP) System 1998 httpwwwfaoorgdocrepW8088EW8088E00htm

37

Quiz1 Which of the following is effective to prevent food borne

infections a) Adopting a HACCP system in food productionb) Ensuring stringent temperature control when storing foodc) Avoiding preparing food too far in advanced) All of the above

2 Which of the following is NOT a strategy to prevent transmission of diarrhoea by Clostridium difficile

a) Antimicrobial prophylaxis for all surgical operationsb) Using narrow spectrum antibiotics where possiblec) Contact precautions for all cases of diarrhoead) Education of staff in infection prevention and antibiotic stewardship

3 Laboratory testing of food handlers is indicated whena) Neverb) To create awareness in workersc) To know epidemiology and causes of infectionsd) To identify potential risks

Dec

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er 1

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38

International Federation of Infection Controlbull IFICrsquos mission is to facilitate international networking in

order to improve the prevention and control of healthcare associated infections worldwide It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe

bull The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication consensus building education and sharing expertise

bull For more information go to httptheificorg

Dec

emb

er 1

20

13

39

International Federation of Infection Controlbull IFICrsquos mission is to facilitate international networking in

order to improve the prevention and control of healthcare associated infections worldwide It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe

bull The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication consensus building education and sharing expertise

bull For more information go to httptheificorg

Dec

emb

er 1

20

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39