TRANSMISSION-BASED PRECAUTIONS FOR HOSPITALIZED PATIENTS

\\Spefp01\groups1\hr dept\SRN Staff\COMPETENCIES\INITIALS\TRANSMISSION BASED PRECAUTIONS\Transmission Based Precautions-MRSA-SLM.ppt 4-08TRANSMISSION-BASED PRECAUTIONS FOR HOSPITALIZED PATIENTS Based On CDC Guidelines 20071ISOLATION PRECAUTIONS - 2000Infection Control12003 Guidelines2007 GuidelinesThe term NosocomialHealthcare Associated (HA)Cough etiquette during flu season Respiratory Hygiene/Cough Etiquette now a part of Standard Precautions- year roundNegative Pressure (TB) RoomsAirborne Infection Isolation Room (AIIR)Categories: Airborne, Droplet, Contact and RO (Resistant organism) IsolationAirborne, Droplet and ContactPrecaution signs- Airborne, Droplet, Contact, RO, Stop Childhood IllnessRO sign deleted Contact sign now greenYellow hand wash soap and water only addedAll signs stay posted until terminal cleaning completedFamily and visitors not encouraged to wear N95 respirator when visiting a patient in Airborne Infection IsolationFamilies and visitors will be offered the N95 respirator mask-nursing will offer education on the proper use as indicatedFamily and visitors do not wear gowns and gloves while visiting in a contact isolation roomFamily and visitors are encouraged to wear the appropriate PPE when assisting with direct patient careCDC Guidelines 20072ISOLATION PRECAUTIONS - 2000Infection Control2New NameTransmission Based Precautions for Hospitalized Patients

To emphasize the reason for precautionsMethod of transmission

Was titled Isolation Precautions for Hospitalized PatientsReasons Behind the Changeshealthcare delivery has moved from primarily acute care hospitals to other healthcare settings (e.g., home care, ambulatory care, free-standing specialty care sites, long-term care)

the emergence of new pathogens (e.g., SARS and Avian influenza in humans)

renewed concern for evolving known pathogens (e.g., C. difficile, Noroviruses, community associated MRSA) CDC Guidelines 2007

4ISOLATION PRECAUTIONS - 2000Infection Control4Visitor RequirementsAirborne

Droplet

Contact

An N95 mask will be offered

Standard mask will be offered

Gown and gloves are encouraged if visitors are assisting with direct patient care Updated P&P #05300 Transmission Based PrecautionsHand Hygiene Upon Entering and Leaving the Room.5ISOLATION PRECAUTIONS - 2000Infection Control5Standard PrecautionsPrevents contact with blood or other potentially infectious materials.Involves Hand Hygiene and glove use as the most important procedure for prevention of infection.Wear gloves when:Handling blood, body fluids, excretions & secretionsSurfaces, materials & objects are visibly soiled with themContact with non-intact skin (includes rashes) and mucous membranes is expected.Wear facial protection when face likely to be splashed with blood or body fluids.Wear gowns when clothing may become soiled with body fluids, blood, secretions or excretions.6ISOLATION PRECAUTIONS - 2000Infection Control6Hand HygieneAlcohol based hand gel is more effective than soap and water on most organismsUse before and after each patientApply product to palm of one had and rub hands togetherCover all surfaces of hands and fingers until hands are dryFast acting and cause less skin irritation than soap and waterHands visibly soiled must be washed with soap and waterPrecautions for Clostridium difficile include:Performing handwashing with only soap and waterC. Diff is a spore that is NOT killed by alcohol based hand gelTeach visitors about importance of proper hand hygiene7ISOLATION PRECAUTIONS - 2000Infection Control7Hand Hygiene: Gloves and FingernailsThe use of gloves does not eliminate the need for hand hygieneLikewise, the use of hand hygiene does not eliminate the need for glovesGlovesReduce hand contamination by 70-80%Prevents cross-contaminationProtects patients and health care personnel from infectionArtificial fingernails or extenders are not permitted for staff having direct contact with patientsArtificial fingernails are defined as the application of a product to the nail to include but not limited to acrylic, overlay, tips, extensions, gels or silk wraps.Keep all natural nail tips less than inch long.See P&P 05704.99 for further information.8ISOLATION PRECAUTIONS - 2000Infection Control8Initiation of Transmission-Based PrecautionsPhysicians responsibility: indicate infectious disease that is known or suspected

Nurse responsibility:initiates appropriate precautions as indicated by laboratory or clinical results or physician diagnosis notifies admitting physician if not already informed.

Infection Prevention personnel:may be consulted for clarification when appropriatehas authority to supersede the patient's physician decision regarding need for precautions when the safety of patients, personnel, or visitors is a concern.9ISOLATION PRECAUTIONS - 2000Infection Control9When possible, patients with highly transmissible or epidemiologically important microorganisms are placed in a private room with hand washing and toilet facilities. If private room not available and the patient does not use a bedpan:patient not to use a community bathroomplace dedicated commode at bedsideif commode must be used for another patient, clean it thoroughly with approved hospital disinfectant (arms, seat, bucket, legs) and allow to dry A private room for source patient: has poor hygienic habitscannot assist in maintaining infection control precautionsWhen a private room is not available:may be placed with appropriate roommates: i.e. patients infected or colonized with the same microorganism can share a roomstaff use appropriate barriers between patient contacts.postoperative patient should not share a room with a patient who has a draining woundPatient PlacementAirborne Precautions

Airborne precautions signChildhood diseases stop signPlace on door if patient has a childhood illness, e.g. measles, mumps or chicken pox11ISOLATION PRECAUTIONS - 2000Infection Control11Airborne Precautions DiseasesTuberculosis, confirmed infectious case - diagnosed with pulmonary or laryngeal TB by positive culture. Tuberculosis, suspected infectious case - a respiratory specimen is positive for AFB, or the physician indicates TB is highly possible. Large draining tuberculosis wounds with culture swabs that are positive for AFB, or the physician indicates TB is highly possible.Rubeola virus (Measles), confirmed or suspected.Chickenpox, confirmed or suspected.Disseminated Varicella zoster, confirmed or suspected. (Disseminated zoster is diagnosed when the patient has 30 or more lesions out side of the affected dermatome.)12ISOLATION PRECAUTIONS - 2000Infection Control12Airborne Precautions DiseasesLocalized Varicella zoster in immunocompromised patient. SARS (Severe Acute Respiratory Syndrome) confirmed or suspected infectious case. (See Attachment A)Viral Hemorrhagic FeversOther unusual viruses or bacteria suspected of being transmitted via airborne route.13ISOLATION PRECAUTIONS - 2000Infection Control13Specifications of Airborne PrecautionsSpecifications - ROOMRoom will have negative air pressure in relation to corridor. Keep door closed. (See Attachment D for specific rooms).Nursing unit personnel should notify Engineering department that the negative air pressure room needs to be monitored daily, unless the nursing unit already monitors routinely.In the event negative air pressure is lost, contact Engineering to initiate back-up support to sustain negative air pressure in Airborne Infection Isolation Room.When no Airborne Infection Isolation Room is available, contact Infection Prevention for further assistance and place a standard mask on the patient.14ISOLATION PRECAUTIONS - 2000Infection Control14Specifications of Airborne PrecautionsSpecifications - SIGNPost Airborne Precautions sign outside of the room. When Airborne Infection Isolation precautions are discontinued, the room should remain closed with the sign posted until the air inside is totally exchanged.Specifications - MASK/HoodMasks for Airborne precautions (N95 Particulate Filter Respirator) are specially designed to filter particles the size of the TB organism. This mask is to be worn by all health care workers.The N95 mask must be fit tested annually to ensure mask fits properly. Those who fail the fit testing will wear a hood/PAPR (personal powered air-purifying respirator with a HEPA filter).The N95 mask may be worn more than once as long as the mask is clean, dry and intact. The mask must be worn each time the room is entered and removed after leaving the room.Place a regular mask on patient during transport (N95 mask is not necessary)15ISOLATION PRECAUTIONS - 2000Infection Control15Duration of Airborne PrecautionsSuspected TB patient may be removed from precautions if the respiratory specimen fails to show AFB and the physician rules out active TB.For confirmed cases of TB, precautions are maintained until three (3) sputum AFB smears, taken at least 8 hours apart, with at least one being an early a.m. specimen, are negative. For confirmed cases of Chickenpox, precautions are maintained until lesions are crusted over.

16ISOLATION PRECAUTIONS - 2000Infection Control16Droplet Precautions Diseases

17ISOLATION PRECAUTIONS - 2000Infection Control17Droplet Precautions DiseasesMumpsRubella*ParvovirusMeningococcal disease (meningitis)PertussisMycoplasma pneumoniaePneumonic plagueDiphtheria, pharyngeal Respiratory Syncytial Virus (RSV)RhinovirusSARS-associated coronavirusStreptococcusInfluenza, confirmed or strongly suspicious* = childhood illness.

18ISOLATION PRECAUTIONS - 2000Infection Control18Specifications & Duration of Droplet PrecautionsSpecificationsPrivate room, door closed.Standard mask is worn when in the room.Post "Droplet Precautions" sign outside patient room.Post Childhood Illness ("Stop") sign when a patient has any disease in the list that is preceded by an *.Personnel who are immune to the * diseases do not need to wear a mask.

Duration of PrecautionsRefer to table in Attachment A in policy #05300.

19ISOLATION PRECAUTIONS - 2000Infection Control19CONTACTPRECAUTIONS

GOWN GLOVES

REQUIRED UPON ENTRY BY ALL HEALTHCARE WORKERS

VISITORS SHOULD CHECK WITH THE NURSE BEFORE ENTERING___________________________________________________VISITANTES DEBEN DE REPORTARSE CON LA ENFERMERA ANTES DE ENTRAR

20ISOLATION PRECAUTIONS - 2000Infection Control20ContactDiseases or Colonization/Infection with Microorganisms Requiring Precautions

Diseases may be transmitted via direct and indirect contact

With direct contact microorganisms are transferred fromone infected person to another person (without acontaminated intermediate object or person)

Examples of Direct contact transmission between patientsand healthcare personnel include:blood or other blood-containing body fluids from a patientdirectly entering a caregivers body through contact with amucous membrane or breaks (i.e., cuts, abrasions) in the skin.21ISOLATION PRECAUTIONS - 2000Infection Control21Contact Precautions DiseasesScabiesPediculosisShingles, localizedCongenital RubellaDiphtheria, cutaneousFurunculosis, StaphylococcusRotavirusImpetigoRSVMajor draining wounds (Staph/Strep) not contained in dressingHemorrhagic fevers*Clostridium difficile*MRSA*VRE*ESBL* and organisms labeled MDRO* *lab will notify the nursing unit when these organisms are identified22ISOLATION PRECAUTIONS - 2000Infection Control22Contact PrecautionsPrivate room door may be open

Contact Sign will be posted

In addition Clean Hands with Soap and Water Only sign may be posted for patients with C difficile

Patients with the same resistant organism during current admission may be cohorted in the same room

Gown/gloves will be worn upon entering the roomPlease contact the AL for appropriate placement23ISOLATION PRECAUTIONS - 2000Infection Control23Contact PrecautionsThe patient may leave the room to ambulate, but must clean their hands using the waterless alcohol-based hand sanitizer or wash their hands with soap and water before ambulating.

Patients infected with Clostridium Difficile must wash their hands with soap and water.a) Patient should limit contact with the environment when outside the transmission-based precautions room. b) Patient must wear a clean hospital gown over the gown they are wearing.c) Failure to comply with policy will restrict patient to their room Patient Equipment & SuppliesUse disposable (single patient) BP cuff, stethoscope and thermometer. Keep the equipment in the patient room during use, and send home with patient when discharged.

Send single use items and any items that cannot be wiped with hospital approved disinfectant home with the patient or discard the items upon discharge (gauze dressings, etc.)

If patients are being cohorted one patient may use the bathroom toilet and the other will use a bedside commode dedicated to the patient25ISOLATION PRECAUTIONS - 2000Infection Control25 Isolation Supplies-PPE Supply Stations

Personal Protection Equipment (PPE) Supply Containers are placed outside rooms of patients requiring transmission based precautionsUnit will be stocked appropriately with hospital items (not magazines, books, etc.) and not overstockedFollowing patient discharge the supplies will be removed and the holder will be cleaned with hospital approved disinfectant and will be stored in the designated area (determined by each patient care unit)26ISOLATION PRECAUTIONS - 2000Infection Control26Clean Hands with Soap

and Water onlyPleaseFor rooms in which the patient requires Contact Precautions due to C diff this sign will be posted and left in place until terminal cleaning performed 27ISOLATION PRECAUTIONS - 2000Infection Control27Duration of Contact Precautions-MRSAMRSA Maintain precautions for positive culture or swab during current hospitalization. If an attempt has been made to eradicate colonization/ infection, the patient may be screened for continued colonization/infection at the physicians discretion. Culture/swab must be taken after patient has completed antibiotic therapy for MRSA and the first culture/swab must be obtained no sooner than 48 hours after completion of therapy. Infection Prevention will review these cases on an individual basis. 28ISOLATION PRECAUTIONS - 2000Infection Control28Duration of Contact Precautions-VREIsolation precautions should remain in use until there are VRE negative culture results on at least three consecutive occasions, at least a week apart.

Cultures are to be obtained from the original body site(s) if possible, and from stool or rectal swab.

29ISOLATION PRECAUTIONS - 2000Infection Control29Duration of Contact Precautions-Other OrganismsPrecaution for other resistant organisms may be discontinued on a case by case basis30ISOLATION PRECAUTIONS - 2000Infection Control30Readmission of a Patient With Resistant Organisms Check face sheet under IC section for

MRSAVREGram negative rods31ISOLATION PRECAUTIONS - 2000Infection Control31Readmission of the patient with a known history of resistant organism colonization/infection- MRSAMRSA known patients who are not on antibiotics specific for treatment of MRSA may be candidates for screening to see if colonization exists

Swab nares and perineum (Refer to the Decision Tree for patients Re-admitted with the IC: MRSA.)

Swabs will be submitted for rapid molecular diagnostic testing or traditional culture, depending upon specific entity procedures and the results will be reviewed by the lab

If results are negative the nurse can contact Infection Prevention who will remove the MRSA coding on the admit facesheet IC code field

Patients with wounds will be cleared on an individual basis by Infection Prevention.

Note: at this time (2008) PCR testing is only performed on MRSA readmissions. Other organisms are screened via cultures32ISOLATION PRECAUTIONS - 2000Infection Control32Readmission of the patient with a known history of VREPatients with a history of VRE place them in Contact Precautions and obtain orders for VRE screening cultures and off antibiotic

If VRE culture results on at least three consecutive occasions, at least a week apart are negative the nurse will notify Infection Prevention to remove the patient from precautions

Cultures are to be obtained from the original body site(s) if possible, and from stool or rectal swab.33ISOLATION PRECAUTIONS - 2000Infection Control33VisitorsVisitors in the Transmission-Based Precautions RoomsAll visitors should be instructed to perform hand hygiene before and after patient contact.Visitors in rooms of patients with Clostridium difficile should be instructed to wash theirhands with soap and water.

Airborne Precautions for the TB patient: For visitors, offer a TB mask and instruct on itsuse prior to the visitor entering the negative pressure room.The patient will need to wear a standard mask in the presence of children.The patient will wear a standard mask when outside the negative pressure room.

Droplet Precautions: Visitors should wear the standard mask.

Contact Precautions: Gowns and gloves are encouraged if participation in direct patient care is anticipated. If the patient has Lice or Scabies, the patients physician should be alerted to the need toassess the household members for the need for treatment of the same condition.

Animals are not permitted in transmission-based precautions rooms except as stipulated in The SHC policy #05625, Animals in the Workplace.34ISOLATION PRECAUTIONS - 2000Infection Control34Airborne Infection Isolation and Room ExchangesRegular Patient Room90 minutesRegular Patient Treatment room90 minutesAirborne Designated Patient Room (AIIR)30 minutesMedical Air Unit30 minutesOR Suite30 minutesFollowing Discharge of a Patient Requiring Airborne Precautions, the door must be left closed for the period of time indicated below35ISOLATION PRECAUTIONS - 2000Infection Control35MRSA Screening of the Previously Positive Patient January 2008

ObjectivesIdentify patients with a previous history of Methicillin-resistant Staphylococcus Aureus (MRSA) colonizationPerform the screening procedures for obtaining appropriate specimens prior to or upon admission to the hospital admission hospitalDemonstrate proper specimen collection techniqueBrief History of MRSAOver the last decade, MRSA has increased from 38% of Staph aureus infections to greater than 60% of infections

Penicillin became available in the 1940Penicillin 1940Within ten years, Staph aureus began to develop resistance90% of community acquired and hospital acquired Staph aureus infections are resistant to the penicillin infections class drugsMethicillin is the test for penicillin resistanceIsolation Utilization Appropriate use of isolation is an important tool to help decrease transmission of MRSA between patients and staff Isolation impacts patients and staff through:Increased financial costs (supplies, blocked beds)High emotional costs (to patient)Workflow disruption (donning isolation gear)MRSA Statistics Patients with MRSA infections have:Double the mortality rate of other blood stream infectionsLonger hospital length of stayAnnual cost of treatment of MRSA infections in US hospitals is $3.2 4.2 billion

Setting for Screening Screening occurs at initial point of entry to our system:Emergency DepartmentPre-anesthesia Admission Evaluation Service (PAES) for elective surgical patientsTriageAny other nursing unitScope of Supervision MRSA Screening is a Procedure that is implemented by a physician order.

All patients with a history of MRSA are screened on entry to the hospitalPCR Technology vs. Cultures PCR (polymearase chain reaction) identifies DNA fragments of a specific bacteria; in this case, MRSA. The test results can be obtain very quickly i.e. within hours.Cultures are specimens placed in a media which feeds a specific bacteria allowing it to grow and usually takes up to 3 days to identify MRSA.Screening Procedure Step One: Determine history of MRSA by asking the patient if: They have ever had MRSAIf so, have they received treatment for MRSA within the past 48 hours

Step Two: Determine history of MRSA by: Review the Infection Control (IC) field on patients face sheet

Screening Procedure Step Three: Inquire whether the patient has received any of the following antibiotics within the past 48 hours Bactrim Vancomycin Doxycycline Linezolid Tetracycline Daptomycin Rifampin Clindamycin Mupirocin Tigarcycline

If the patient has received any of the above medications, NO further screening is required & place patient in Contact Precautions.MRSA Screening Exclusion Criteria MRSA Screening Not Indicated if the patient has a(n): Active infection with MRSA Previous MRSA infection (within the past 48 hours) treated with antibiotics NO FURTHER screening is necessary MRSA Specimen Collection Prior to obtaining, verify if specimens were collected pre--admission (ED,PAES, Physicians office)Collect specimens from nares and perineum if no open wounds are present.

Appearance of MRSA

MRSA Specimen Collection If the patient has an open wound, swab: Nares PerineumWoundLesionsAbscessesIf the patient has a tracheostomy or tubes/drains, swab:NaresPerineum Tube exit sitesNotify the Infection Control Practitioner by phone or mail that specimens have been collectedCollecting Nares Specimen Educate patientHave the patient sit facing youUse both swabettes providedOne per nostrilSwab UP TO the anterior fold onlyGently swab in a circular fashion FIVE times

Collecting Perineum Specimens Educate patient Have the patient lie comfortably in bed, with legs apartUse one swabette for swabbing the perineum and place in culture tube.Take swabette attached to the red handle and swab the skin in a zigzag fashion 5 times between the genitalia and anus.

Specimen Labeling and Disposition Replace the swabettes in the tube, sealing it with the red handle capLabel the specimen tube at the bedside with:Patient ID information (i.e. Name, MR, Billing#)Specimen site (nares & perineum, etc.)Collected by ________, RNDateTimePlace in biohazard plastic bag

Specimen Labeling and Disposition Label specimen bag with the patient identification stickerSend specimen to lab

How to Order in Carecast Go to Orders in Carecast & enter MRSA in the Non Med Orders field

Then Select MRSA mol

How to Order in CarecastSelect perineum under Source; nares also available for selection

How to Order in CernerAdd an order & search for MRSA.Select MRSA Molecular Amp.

Enter required fields as appropriate.

Prescheduled Surgery Screening Prior to prescheduled surgery, the PAES nurses screen patients who are able to come to the PAES clinic and collect specimens from the nares, and perineum when indicated.

If unable to collect all needed specimens, the PAES nurse places a Physician Order Sheet on the patients chart indicating which sites still need a specimen collected.Patient Education on Screening If the specimen is obtained prior to hospital admission, the PAES RN will notify the surgeon of all positive results if results are available prior to the day of surgery

If the final results are unavailable upon admission, the patient is placed in isolation, pending results of screening

Screening Results The Infection Control Practitioner reviews the results of all screens

If all PCR or culture results are negative, the MRSA designation is removed from the patient face sheet by the Infection Control Practitioner

The patient will no longer require isolation

Only 1 negative culture/PCR from each site is necessary

If the results return on the weekend, notify the Infection Control Practitioner so that the designation can be removed from the face sheet

Further Tests During Hospitalization If the results are positive, the patient remains in isolation

Infection Control Practitioner may order additional specimens to further assess colonization

Contact Precaution Guidelines Patients are to be placed in a private room

Patients can ambulate in the halls, however they must perform hand hygiene before and after leaving the room and not be allowed in other patient care areas.

For mother/baby isolation, the mother and infant will remain in isolation together.Benefits of Screening Current screening of patients with a history of MRSA results in 30 - 40% clearance rate meaning these patients are no longer infected or colonized and do not need isolation

Screening makes a difference for our patients and the care they receive

References/Credits Submitted:Gina Newman, RN, Infection Control Practitioner, SMHShannon Oriola, RN, CIC Infection Control Practitioner, SMMCJoan Ausloos, RN, PAES, SMHBobbie Bochichio, RN, PAES, SMHSusan Moore, RN, Senior Specialist, SMHMonee Gagliardo, RN, Infection Control Practitioner, SMBHW