NSW Health (1) - Infection Control Policy

Policy Directive
Department of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) 9391 9000 Fax (02) 9391 9101 http://www.health.nsw.gov.au/policies/
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Infection Control Policy

space Document Number PD2005_247 Publication date 27-Jan-2005 Functional Sub group Population Health - Infection Control Clinical/ Patient Services - Infectious diseases Summary Outlines the broad principles of infection control for public and private health care settings. Author Branch Aids and Infectious Diseases Branch contact 9391 9248 Applies to Area Health Services/Chief Executive Governed Statutory Health Corporation, Board Governed Statutory Health Corporations, Affiliated Health Organisations, Community Health Centres, Dental Schools and Clinics, Divisions of General Practice, Environmental Health Officers of Local Councils, Government Medical Officers, NSW Ambulance Service, NSW Dept of Health, Private Hospitals and Day Procedure Centres, Private Nursing Homes, Public Health Units, Public Hospitals Distributed to Public Health System, Community Health Centres, Dental Schools and Clinics, Divisions of General Practice, Environmental Health Officers of Local Councils, Government Medical Officers, Health Associations Unions, Health Professional Associations and Related Organisations, NSW Ambulance Service, NSW Department of Health, Public Health Units, Public Hospitals, Private Hospitals and Day Procedure Centres, Private Nursing Homes, Tertiary Education Institutes Review date 27-Jan-2010 File No. 01/336 Previous reference 2002/45 Issue date 11-Feb-2002 Status Active
Director-General space Compliance with this policy directive is mandatory.
CIRCULAR
File No Circular No Issued Contact 01/336 2002/45 11 April 2002 Ms J Hunt (02) 9391 9869 AIDS/Infectious Diseases Unit
Infection Control Policy This Policy sets out the broad principles of infection control for public health are settings; and state government residential aged care, licensed private hospitals, licensed nursing homes, licensed day procedure centres and multi purpose Services. This Policy should be read in conjunction with the following NSW Health Department documents: Circular 96/55 Circular 97/58 Circular 97/61 Colour Coding of Cleaning Equipment Incidents Reportable to the Department Policy and Guidelines for the Safe Use of Glutaraldehyde in NSW Public Health Care Facilities Circular 98/11 Management of Health Care Workers Potentially Exposed to HIV, Hepatitis B or Hepatitis C Circular 98/89 Waste Management Guidelines for Health Care Facilities Circular 99/57 Coroners cases and amendments to Coroners Act 1980 (1) Jurisdiction of Coroner; (2) Anaesthetic Deaths; (3) Obligation to Report Death; (4) Guidelines for Nursing Staff and Medical Officers on Coroners Cases Dying in Hospital; (5) Transfer of Medical Records for Post Mortems; (6) Discharge Type Summaries for Coronial Cases in Hospitals; and (7) Objections to a Post Mortem Examination Circular 99/88 Health Care Workers Infected with HIV, Hepatitis B or Hepatitis C Circular 99/95 Control of Foodborne Listeriosis in Health Care Institutions Circular 2000/99 Policy Framework and Guidelines for the Prevention and Management of Latex Allergy Circular 2001/55 Management of Reportable Infection Control Incidents Circular 2001/71 Health Care Worker Tuberculosis Screening & Protection Policy
Distributed in accordance with circular list(s): A F K 44 5 4 B 4 C H 35 26 D I N 4 2 19 E J P 7 18 7 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) 9391 9000 Facsimile (02) 9391 9101
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In accordance with the provisions incorporated in the Accounts and Audit Determination, the Board of Directors, Chief Executive Officers and their equivalents, within a public health organisation, shall be held responsible for ensuring the observance of Departmental policy (including circulars and procedure manuals) as issued by the Minister and the Director-General of the Department of Health.
Circular 2001/91 Occupational Screening and Vaccination of Health Care Workers Against Infectious Diseases Circular 2002/19 Effective Incident Response: A Framework For Prevention And Management In The Health Workplace NSW Health Cleaning Service Standards, Guidelines and Policy for NSW Health Facilities, 1996 The policy supersedes the following NSW Health Department documents: Circular 86/7 Circular 97/95 Circular 99/87 IB2000/13 AIDS and the Use of Human Blood Products in Laboratories Disinfection of Transvaginal Ultrasound Transducers Infection Control Policy Creutzfeldt-Jakob Disease (CJD) and other Transmissible Spongiform Encephalopathies
The NSW Infection Control Resource Centre has developed a series of resources to assist with local implementation of this policy. The Centre can be contacted on (02) 9332 9712 or by emailing albicr@sesahs.nsw.gov.au.
Robert McGregor Acting Director-General
Table of Contents 1. 2. 3. 4. 5. 6. 7. 8. 9. Introduction ...................................................................................................................... 1 Infection Control Systems ................................................................................................ 3 Hand Washing, Hand Cleaning and Hand Care .............................................................. 9 Protective Gowns ........................................................................................................... 10 Gloves ............................................................................................................................ 11 Masks, Face Shields and Protective Eyewear ............................................................... 13 Safe Handling, Use and Disposal Of Sharps ................................................................. 14 Management of Clinical Waste ...................................................................................... 16 Processing of Instruments and Equipment .................................................................... 17
10. Environmental Cleaning ................................................................................................. 26 11. Blood and Body Substance Spills .................................................................................. 27 12. Food Services ................................................................................................................ 28 13. Laundry and Linen Services........................................................................................... 29 14. Procedures for Specific Clinical Practices...................................................................... 30 15. Procedures for Specific Clinical Settings ....................................................................... 33 16. Prevention of Antimicrobial Resistance in Hospitals ...................................................... 35 17. Creutzfeldt-Jakob Disease and Other Forms of Transmissible Spongiform Encephalopathies........................................................................................................... 38 18. Outbreak Management, ................................................................................................. 44 Glossary................................................................................................................................. 46 References............................................................................................................................. 48
3 NSW Health Infection Control Policy
INTRODUCTION Background NSW Health is committed to ensuring the health and safety of all patients in health care settings and providing a safe and healthy working environment for all employees. This commitment includes adopting an infection control policy position that minimises the risk of health care consumers and providers acquiring a healthcare associated or occupational infection. This goal is best achieved by having an evidence based infection control program within each health care facility.
1.1.
1.2. Purpose This document outlines the broad principles of infection control for public health care settings; and licensed private hospitals, nursing homes, extended care facilities and day procedures centres. It is intended as a framework within which Area Health Services and health care facilities can develop detailed operational guidelines appropriate to their own setting. Variation in the type of public and licensed private health care facilities in NSW, and the range of clinical services provided in each facility, dictate that locally applicable infection control programs and policies be developed and implemented.
In this document the term: must indicates a mandatory practice required by law or by Departmental directive. A Departmental directive is only issued where it is considered necessary in the interests of patient and health care worker safety; should indicates a strongly recommended practice; patient includes all consumers of health care in NSW including residents in nursing homes and long term care facilities; and health care facility includes all types of health facilities and services, the NSW Ambulance Service, Corrections Health Services and residential facilities.
It is recommended that when referencing any Australian and New Zealand Standards or other guidelines or legislation relevant to this document the current edition of the referenced document is reviewed.
1.3. Development and review This policy has been developed in accordance with available evidence; and in consultation with key infection control stakeholders and experts including the NSW Health Department Infection Control Advisory Group and the NSW Health Department Infection Control Practice Group. This policy is subject to regular review. 1.4. Key elements Key elements of the infection control policy continue to be incorporated in regulations that define the registration requirements for medical practitioners, nurses, physiotherapists, dentists, dental technicians and podiatrists in NSW. Under the relevant Act, a practitioner must not, without reasonable excuse, fail to comply with the infection control regulations. The key elements constitute the minimum standard for infection control in all NSW public and licensed private health care settings. All health care facilities and health care workers have a common law duty of care to take all reasonable steps to safeguard patients, staff and the general public from infection. The Occupational Health and Safety (OH&S) Act 2000 prescribes the employers duty of care to provide a safe and healthy working environment for all employees and other persons on their premises. The OH&S Act also prescribes responsibilities for managers (who manage OH&S within the areas that they control and influence) and employees (who must cooperate with
NSW Health Infection Control Policy
the employer and not put anyone at risk by their acts or omissions). There is also a requirement for employers to provide the information, instruction, training and supervision necessary to ensure the health and safety of employees at work.
1.5. Local infection control program To facilitate implementation of this policy and a coordinated approach to infection control,1 public health care facilities and licensed private health care facilities must have an infection control program in place that includes the following:
coordination by a suitably experienced and qualified health care worker. In smaller facilities this function may be combined with other tasks; development of an annual strategic plan for infection control that includes surveillance, education and staff health strategies; strategies to modify procedures and equipment associated with increased risk of occupational exposure to blood and/or body substances and ensure management of such in accordance with Circular 98/11: Management of Health Care Workers Potentially Exposed to HIV, Hepatitis B and Hepatitis C. strategies to monitor the effectiveness of the infection control program and ongoing compliance with regulatory and licensing requirements; and contingency plans to manage outbreaks of healthcare associated infections and infection control critical incidents.
A variety of infection control measures are used for reducing the risk of transmission of micro-organisms in health care settings. These measures make up the fundamentals of Standard Precautions and include: hand washing and gloving; masks, respiratory protection, eye protection, face shields; gowns and protective apparel; patient placement; and routine cleaning and cleaning on separation.
Each of these fundamentals is addressed in this document.
2.
INFECTION CONTROL SYSTEMS
Introduction The two-tiered approach to infection control NSW Health has endorsed includes, firstly and most importantly, those precautions designed for the care of all patients, regardless of their diagnosis or presumed infection status. These precautions are known as Standard Precautions and constitute the minimum acceptable level of practice in infection control. The second tier includes precautions that are applicable only for the care of specified patients. These additional Transmission Based Precautions are for patients known or suspected to be infected by pathogens spread by airborne or droplet transmission or by contact with dry skin or contaminated surfaces or by any combination of these routes. Standard Precautions Standard Precautions apply to all patients receiving care in health care facilities, regardless of their diagnosis or presumed infection status. Standard Precautions apply to: blood; all body substances, secretions and excretions except sweat, regardless of whether or not they contain visible blood; non-intact skin; and mucous membranes.
2.1
2.2
Standard Precautions are designed to reduce the risk of transmission of micro-organisms from both recognised and unrecognised sources of infection in health care facilities. Standard Precautions involve the use of safe work practices and protective barriers including: 2.2.1 Hand washing Wash hands after touching blood, body substances, and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of micro-organisms to other patients or environments. It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. 2.2.2 Gloving Wear gloves (clean non-sterile gloves are adequate) when touching blood, body substances, and contaminated items; put on clean gloves just before touching mucous membranes and non-intact skin. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of micro-organisms to other patients or environments. 2.2.3 Masking Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. 2.2.4 Gowning Wear a fluid-resistant gown or apron made of impervious material to protect skin and prevent soiling of clothes during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions or cause soiling of
clothing. 2.2.5 Appropriate device handling Handle used patient care equipment soiled with blood and body substances in a manner that prevents skin and mucous membrane exposures, contamination of clothing and transfer of micro-organisms to other patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed; and that single use items are properly discarded after use. 2.2.6 Appropriate handling of laundry Handle, transport and process linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures; contamination of clothing; and transfer of micro-organisms to other patients and environments.
2.3 Transmission Based Precautions Transmission Based Precautions are designed for patients known or suspected to be infected with pathogens for which additional precautions beyond Standard Precautions are needed to interrupt transmission in health care facilities.
2.3.1 Types of Transmission Based Precautions There are three types of Transmission Based Precautions: Airborne Precautions; Droplet Precautions; and Contact Precautions.
A combination may be required for diseases that have multiple routes of transmission. The use of Transmission Based Precautions should always be in addition to Standard Precautions. Health care facilities should provide suitable accommodation with appropriate equipment and trained staff for the treatment of patients requiring Transmission Based Precautions. 2.3.2 Airborne Precautions Airborne Precautions apply to patients known or suspected to be infected with pathogens that can be transmitted by the airborne route. Airborne Precautions are designed to reduce the risk of airborne transmission of infectious agents. Airborne transmission occurs by dissemination of either airborne droplet nuclei (small-particle residue [5 m or smaller in size] of evaporated droplets that may remain suspended in the air for long periods of time) or dust particles containing the infectious agent. Patient placement and special air handling and ventilation requirements must be considered. Controlling Tuberculosis in New South Wales2 contains guidelines for the application of Transmission Based Precautions for the management of patients with active tuberculosis. 2.3.3 Droplet Precautions Droplet Precautions apply to any patient known to be or suspected of being infected with pathogens that can be transmitted by droplet. Droplet Precautions are designed to reduce the risk of droplet transmission of infectious agents. Droplet transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large particle droplets (larger than 5 m in size) containing micro-organisms generated from a person who has a clinical disease or who
is a carrier of the micro-organism. Because droplets do not remain suspended in the air, special air handling and ventilation are not required to prevent droplet transmission. 2.3.4 Contact Precautions Contact Precautions are designed to reduce the risk of transmission of micro-organisms by direct or indirect contact. Direct contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonised person, such as when health care workers reposition patients, bathe patients, or perform other patient care activities that require physical contact. Direct contact transmission can also occur between two patients (eg. by hand contact), with one serving as the source of infectious micro-organisms and the other as a susceptible host. Indirect contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the patients environment. Contact Precautions consist of: appropriate patient placement in a single room. When a single room is not available, the infected patient should be placed with a patient(s) infected with the same microorganism; wearing of gloves (clean non-sterile gloves are adequate) when entering the room for cleaning or general patient care other than aseptic procedures where sterile items are used. During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of micro-organisms (eg. faecal material and wound drainage). Remove gloves before leaving the patients room and wash hands immediately with an antiseptic agent. After glove removal and hand washing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patients room to avoid transfer of micro-organisms to other patients and environments; wearing a gown when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patients room, or if the patient is incontinent, or has diarrhoea, an ileostomy, a colostomy, or wound drainage not contained by a dressing. Remove and dispose of the gown before leaving the patients room. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of micro-organisms to other patients and environments; limiting the movement and transport of the patient from the room for essential purposes only. Transfer to other wards should also be limited. If the patient is transported out of the room, ensure that precautions are maintained to minimise the risk of transmission of micro-organisms to other patients and contamination of environmental surfaces or equipment; ensuring that patient care items, bedside equipment, and frequently touched surfaces receive daily cleaning; and when possible, dedicating the use of non-critical patient care equipment and items such as stethoscope, sphygmomanometer, bedside commode, or electronic rectal thermometer to a single patient to avoid sharing between patients. If use of common equipment or items is unavoidable, then clean before use on another patient.
Table 1 provides a guide for recommended infection control precautions for a variety of
infected patients. It purposely does not include all infectious diseases or conditions. Routine use of Airborne, Droplet, or Contact Precautions In many instances, the risk of healthcare associated transmission of infection may be highest before a definitive diagnosis can be made and before precautions based on that diagnosis can be implemented. The routine use of Standard Precautions for all patients should greatly reduce this risk for conditions other than those requiring Airborne, Droplet, or Contact Precautions. While it is not possible to identify prospectively all patients needing Airborne, Droplet, or Contact Precautions, certain clinical syndromes and conditions carry a sufficiently high risk to warrant the addition of enhanced precautions while a definitive diagnosis is pursued.
2.4
Table 1: Summary of recommended infection control precautions (this list does not include all infectious diseases or conditions) Airborne Precautions Tuberculosis (TB) suspect/confirmed Contact Precautions also required: Varicella (chickenpox)b Zoster (shingles), disseminatedb Zoster (shingles), immunocompromised patientsb Viral haemorrhagic fever, eg. Ebolab, c Neisseria meningitidis septicaemia/meningitisf Whooping cough (caused by Bordetella pertussis) Influenzae Measlesb Parvovirus B19 infection Respiratory syncytial virus infection Rubella Group A streptococcal infections in infants and young children Group A Streptococcal pneumonia or scarlet fever in all age groupsf Droplet Precautions Contact Precautions
Isolation Type
Standard Precautions All patients All blood, body fluids, secretions (except sweat), excretions, and contaminated items
Single Room No
Noa Yes - Door closed Yes
Negative Pressure
No
Resistant bacteria (MRSA, VRE and others named by infection control committee)e Herpes simplex ( neonatal or mucocutaneous) Highly contagious skin infections/infestations (ie. scabies, pediculosis [lice], impetigo)e Zoster (shingles), localised and disseminated Infants/young children (<6 years), or any patient incontinent with: - enteroviral infection - hepatitis A - rotaviral enteritis, shigellosis, giardiasis or other forms of gastroenteritis If possible, or cohort with patient with like condition No
Yes See Standard Precautions
Yes, if available otherwise single room accommodate the number of air changes depending on environmental conditions and disease Yes Yes
Yes See Standard Precautions Yes
Hand Washing Gloves
Yes, when there is a potential exposure to blood and/or body substances and handling contaminated items
Gown
If soiling likely
See Standard Precautions
See Standard Precautions
Mask See Standard Precautions See Standard Precautions
Yes, including particulate mask for TB See Standard Precautions See Standard Precautions
Yes
If the HCWs clothing will have substantial contact with the patient, environmental surfaces or items in the patients room See Standard Precautions See Standard Precautions Single use or disinfect before next patient Notify area receiving patient
Protect face if splash likely Protect face if splash likely Yes d
Protective Eyewear Special Handling of Equipment Transport of Patients Regular mask for patient Notify area receiving patient
Cover all patients open wounds
Miscellaneou s
Avoid contaminating environmental surfaces with gloves
Particulate mask for the patient with activeTB All others, regular mask for patient Notify area receiving patient Teach patient to cover nose and mouth when coughing or sneezing Cohort requires one metre of patient separation
Remove gloves and gown, wash hands before leaving patient room
a Except certain circumstances determined by Infection Control, eg. neutropenic/ transplant patients. b Contact Precautions also apply for these diseases. c All waste should be treated as Clinical Waste. d Handle needles, syringes and sharps with care. Use rigid containers for disposal. DO NOT recap, break or bend needles. Exposures to blood/body substance immediately wash site, notify supervisor and seek management of exposure. e Refer to specific local policy. f Droplet precautions for meningococcal infections only need to be continued until the patient has had 24 hours of effective antibiotic treatment. The same applies for Group A Streptococcal infections, as far as pharyngeal carriage is concerned. However, Group A Streptococcal infections may need to be isolated in special circumstances, such as burns units, until there is evidence of clearance of the organism from the burn.
3.
HAND WASHING, HAND CLEANING AND HAND CARE
3.1
Introduction Hand washing is the single most important procedure for preventing healthcare associated infections.3 The frequency and duration of hand washing is dependent upon the nature, intensity, duration and sequence of the work activity. It is prudent to encourage hand washing when health care workers are in doubt about the need to do so.4, 5
Health care workers should be able to easily access hand washing facilities. When clean, running water is inaccessible non-water cleansers or antiseptics, such as alcohol-based hand rub or foam provide an appropriate alternative. However, hands should be washed with soap and water if visibly soiled.
3.2
Situations requiring hand washing Hands must be cleaned immediately before and after any direct patient care. This requirement does not apply in circumstances where treatment is required to be performed urgently and cleaning facilities are not readily available. Methods of hand washing Hands may be cleaned by: using washing facilities involving water and a soap or antiseptic; or if any of the above items are unavailable, using non-water cleansers or antiseptics.
3.3
3.4
Contaminated hands or skin surfaces Hands or other skin surfaces that are contaminated with a patients blood or body substances must be cleaned immediately or as soon as it is practical to clean them. Drying hands Paper towels or single use cloth towel should be used to dry hands in patient care areas.3 Glove usage and hand washing The requirement to clean hands applies regardless of whether gloves are also required to be worn. Hand care Skin that is intact, that is without cuts, abrasions or lesions, is a natural defence against infection. Health care workers should cover cuts and abrasions on exposed skin with a water-resistant occlusive dressing which should be changed as necessary or when the dressing becomes soiled. Other lesions that cannot be covered should have the condition assessed by a medical practitioner. Temporary redeployment of staff may be necessary based on the advice of the employees medical practitioner or staff health service. Hands can be protected from chafing by the regular use of non-oil based moisturising creams or lotions. Compatibility between lotion and antiseptic products and the integrity of gloves should be considered. Lotions or creams should be dispensed by using collapsible squeeze tubes/bottles or pump packs. If lotions or creams cannot be decanted, then single use applicators or spatulas should be used.
3.5 3.6
3.7
4.
Protective gowns
4.1
Introduction Gowns and protective apparel provide a barrier and reduce opportunities for transmission of pathogens in health care settings. Gowns can protect the health care workers skin and clothing from exposure to blood and body substances. Requirement to wear a protective gown or apron A fluid-resistant gown or apron made of impervious material must be worn during any procedure where there is a likelihood of splashes or contamination with blood or other body substances. Clothing contaminated with blood or body substances should be removed as soon as possible and before health care workers attend other patients. If skin is contaminated with blood or body substances, health care workers should wash their hands and all affected areas after the removal of clothing and/or personal protective equipment.
4.2
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5.
Gloves
This section should be read in conjunction with Circular 2000/99: Policy Framework and Guidelines for the Prevention and Management of Latex Allergy. Gloves are worn as a barrier to protect the wearers hands from contamination or to prevent the transfer of organisms already on the hands.
5.1
Gloves use in particular settings Gloves must be used in situations where the health care worker is potentially exposed to blood and/or body substances, in particular: during any procedure where direct contact is anticipated with a patients blood or body substances, mucous membranes or non-intact skin; while suctioning a patient; while handling items or surfaces that have come into contact with blood or body substances; and while performing an invasive procedure, venepuncture or a finger or heel stick.
5.2
Glove selection and types The type of glove selected should be appropriate to the type and risk of the procedure and a suitable size for the user. 5.3.1 Sterile gloves Sterile gloves must be worn if the procedure involves contact with tissue that would be sterile under normal circumstances. 5.3.2 Medical examination gloves Medical examination gloves that meet the Australian/New Zealand Standard AS/NZS 4011: Single-Use Examination Gloves Specifications should be used for all procedures that may involve direct skin or mucous membrane contact with blood or fluid capable of transmitting blood borne pathogens. Use of medical examination gloves for reasons other than preventing the transmission of blood borne pathogens may be indicated (eg. procedures involving other infectious agents or contaminated equipment). 5.3.3 General purpose gloves For housekeeping activities, instrument cleaning and decontamination procedures, generalpurpose household gloves (eg. neoprene, rubber, butyl) are appropriate. These can be washed and reused but should be discarded when they become peeled, cracked, discoloured, torn or punctured. 5.3.4 Seamed gloves Seamed plastic or vinyl gloves should be worn during food preparation. 5.3.5 Subcutaneous, intramuscular or intradermal injection and glove use Gloves need not be worn for subcutaneous, intramuscular or intradermal injection unless exposure to blood is anticipated. 5.3.6 Changing and discarding gloves Gloves must be changed and discarded: as soon as they are torn or punctured; after contact with an individual is complete and before care is provided to another; and when performing separate procedures on the same patient and there is a risk of
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transmitting infection from one part of the body to another. Use of gloves does not eliminate the need for hand washing or cleaning. Hands should be washed or cleaned after removal and disposal of gloves.
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6.
masks, face shields and protective eyewear
6.1
Introduction A fluid-repellent mask or face shield must be worn while performing any procedure where there is a likelihood of splashing or splattering of blood or other body substances. The type of masks selected should be appropriate to the type and risk of the procedure. In cases where a mask or face shield is required to be worn, it must be worn and fitted in accordance with the manufacturers instructions. A mask must be discarded once it has been worn and it must not be used again. Nondisposable face shields should be cleaned according to manufacturers instructions prior to reuse.
6.2
Protective eyewear Protective eyewear must be worn while performing any procedure where there is a likelihood of splashing or splattering of blood or other body substances. In cases where protective eyewear is required, it must be worn and fitted in accordance with the manufacturers instructions. Single use protective eyewear must be discarded once it has been worn and not used again. Protective eyewear that is reusable must be cleaned in accordance with the manufacturers instructions after use.
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7.
safe handling, use and diSposal of sharps
7.1
Introduction The potential for transmission of blood borne diseases is greatest when needles, scalpels and other sharp instruments or devices are used. Wherever possible, the use of sharps should be minimised. Special care should be taken to prevent injuries during procedures, when cleaning reusable sharp instruments and during disposal of used sharps. Disposable sharps should be disposed of as soon as practical following use.
7.2
Responsibility for sharps Health care facilities have a responsibility to ensure adequate and accessible resources for the disposal of sharps. Each health care worker is responsible for the management and disposal of the sharps they use. Passing sharps Sharps must not be passed by hand between a health care worker and any other person. A puncture resistant tray must be used to transfer sharps. However, this requirement does not apply if, in any case involving an invasive procedure, the proper conduct of the procedure would be adversely affected. Transportation of reusable sharps Reusable sharps must be placed immediately after use in a puncture-resistant sharps container specially kept for that purpose. When more than one reusable sharp is carried in a container special care should be taken to prevent injury during placement of sharps into the container and during removal. Special units must ensure that safe handling procedures are in place for the transportation of reusable sharps.
7.3
7.4
7.5
Removing scalpel blades from scalpel handles The procedures and devices specified in the Australian/New Zealand Standard AS/NZS 3825: Procedures and Devices for the Removal and Disposal of Scalpel Blades from Scalpel Handles, should be followed for the removal and disposal of scalpel blades and other similar instruments eg. stitch cutters,6 from scalpel handles. Removing and bending needles A needle must not be removed from a disposable syringe for disposal, or be purposely broken or otherwise manipulated by hand, unless: it is necessary to remove the needle for technical reasons; or the practitioner is performing a procedure in which the needle is required to be bent. A needle must not be bent after it is contaminated with blood or other body substances. In the event, the practitioner is performing a procedure in which the needle is required to be bent, a suitable pair of forceps should be used to manipulate the needle.
7.6
7.7
Re-sheathing needles Needles should not be re-sheathed except in special circumstances such as dental practice. Where re-sheathing is required: the needle must be properly recapped;
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the sheath must not be held in the fingers; and either a single-handed technique or forceps, or a suitable protective guard designed for the purpose must be used.
7.8
Sharps containers Sharps containers should: comply with Australian/New Zealand Standard AS/NZS 4261: Reusable Containers for the Collection of Sharp Items Used in Human and Animal Medical Applications, if they are reusable and Australian Standard AS 4031: Non-Reusable Containers for the Collection of Sharp Medical Items Used in Health Care Areas, if they are non-reusable; be puncture-resistant, waterproof and leak-proof; have an opening that is wide enough to allow sharps to be dropped into the container by a single hand operation; be clearly labelled with black lettering on yellow background with the biohazard symbol printed on the container; never be overfilled; and be securely sealed with a lid before disposal.
Sharps containers should be placed as close as practical to the point of use to limit the distance between use and disposal. Sharps containers should be placed so visitors, particularly children, can not easily access them. Sharps should never be forced into sharps container. Reusable sharps containers should: be cleaned and disinfected before reuse; be inspected before reuse to ascertain that they are clean, intact and without leaks; if found to be defective, be repaired before use or taken out of service; and be resistant to leakage, impact rupture and corrosion.
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8.
management of Clinical Waste
Clinical waste must be managed in accordance with the:
New South Wales Environment Protection Authority (EPA) Guidelines;7 New South Wales EPA. Waste Avoidance and Resource Recovery Act, 2001;8 and NSW Health. Waste Management Guidelines for Health Care Facilities.9
Clinical waste is waste that has the potential to cause sharps injury, infection or offence. Clinical waste includes the following types of waste: sharps; human tissue (excluding hair, teeth and nails); bulk body fluids and blood; visibly blood stained body fluids and visibly blood stained disposal material and equipment; and laboratory specimens and cultures, animal tissues, carcasses or other waste arising from laboratory investigation or for medical or veterinary research unless treated to standards approved by the Director-General of NSW Health.
Clinical waste should be segregated (ie. placed in appropriate leak-proof bags or containers) and contained at the source of generation. Clinical waste bags must have sufficient strength to contain the waste safely. Disposable sharps must be disposed of in a puncture resistant container immediately after use. Clinical waste bags and containers should not be overfilled. Overfilling will prevent closure and increase the risk of rupture in transit. Clinical waste bags should be tied or sealed, then stored in a secure place for collection. Clinical waste bags and containers should not be transported in chutes. Clinical waste bags and containers should be coloured yellow with the biohazard symbol printed on the bag or container. Mobile garbage bins, trolleys, storage areas and protective personal apparel used for the transportation and storage of clinical waste should conform to the requirements of the NSW Health, Waste Management Guidelines for Health Care Facilities. Workers involved in disposal of blood or body substances (including emptying of urine and other fluid collection bags) must: wear appropriate personal protective equipment; slowly pour liquid waste down a drain connected to a sanitary sewer system and flush immediately after disposal; minimise splashing or contamination to mucosa or skin; and ensure that disposable products containing liquids (such as disposable suction liners) are sealed, not emptied, before disposal into clinical waste bags and containers.
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9.
processing of instruments and equipment
This section should be read in conjunction with the following documents: Australian Standard AS 4187: Cleaning, Disinfecting and Sterilizing Reusable Medical and Surgical Instruments and Equipment, and Maintenance of Associated Environments in Health Care Facilities;10 National Health and Medical Research Council. Report of the National Health and Medical Research Councils (NH&MRC) Expert Panel on the Re-use of Medical Devices Labelled as Single Use, 1997;11 NSW Health Peak Purchasing Council. Guidelines for Storage and Handling of PreSterilized Consumables;12 NSW Health. Circular 97/61: Policy and Guidelines for the Safe Use of Glutaraldehyde in NSW Public Health Care Facilities;13 NSW Health. Circular 97/97: Critical Incident Manual: Policy and Guidelines Minimising and Managing Critical Incidents in NSW Public Health Care Facilities;14 and NSW Health. Circular 2001/55: Management of Reportable Infection Control Incidents.15
9.1 Introduction On 1 September 1996 the NSW Poisons Amendment (Therapeutic Goods) Act 1996,16 transferred NSW therapeutic goods powers to the Commonwealth. The intent of this legislation was to recognise the role of the Therapeutic Goods Administration (TGA) of the Commonwealth Government in the assessment and validation of various therapeutic goods and devices. These goods and devices include sterilants, disinfectants and benchtop/portable sterilizers. 9.2 The Australian Register of Therapeutic Goods Only those disinfectants and sterilants specified in the Australian Register of Therapeutic Goods (ARTG) are to be used by health care workers for disinfection and sterilization. The disinfectant or sterilant should only be used for the approved purpose. Sponsors of disinfectants or sterilants are not required to document the products listing on the ARTG on the product label. However, TGA will issue a listing certificate or registration certificate to sponsors with disinfectants or sterilants listed on the ARTG. These certificates are valid unless they are: cancelled by the sponsor advising TGA that they are no longer able to supply the listed disinfectants or sterilants; or cancelled by the Secretary of the Australian Department of Health and Ageing.
Health care workers involved in the purchase or use of disinfectants or sterilants, should, prior to purchase, seek a copy of the TGA listing certificate or registration certificate from the sponsor (supplier). 9.3 Type of processing The process indicated for an item depends on its intended use. Any micro-organisms, including bacterial spores that come in contact with normally sterile tissue can potentially cause infection. These must be eliminated from items intended for use in sterile sites by cleaning and sterilization. In general, intact skin acts as an effective barrier to most microorganisms, thus, items that touch intact skin need only be cleaned unless contaminated by blood and other body fluids or knowingly used on a patient with a multi-resistant organism eg. methicillin resistant Staphylococcus aureus (MRSA) or vancomycin resistant Enterococci
17
(VRE). Personal protective apparel is required when cleaning and processing equipment and instruments to protect against splashing, spraying or aerosol. Consideration of the reprocessing requirements, ie. cleaning, and disinfection or sterilization should be given when purchasing equipment. 9.4 Cleaning of instruments and equipment Any instrument or equipment that comes into contact with intact skin must be cleaned before it is used. Any instrument or equipment that is required under this section to be disinfected or sterilized must be cleaned before it is disinfected or sterilized. The process of cleaning must involve water and physical or mechanical action (such as washing machines) and a cleaning agent such as detergent or proteolytic enzyme. All cleaning agents must be removed from instruments and equipment by rinsing prior to further processing. 9.5 Disinfection of instruments and equipment Any instrument or equipment that comes into contact with non-sterile tissue (other than intact skin), must be disinfected before it is used. Disinfection is not a sterilizing process. All instruments and equipment must be cleaned prior to disinfection. Disinfection must be achieved by either thermal or chemical methods. Thermal disinfection (hot water/pasteurisers) must be used in preference to chemical disinfection. Chemical disinfection may only be used for items for which thermal methods are unsuitable. The manufacturers instructions must be checked for compatibility of the instrument or equipment with the method of disinfection to be used. Where thermal disinfection is used, all parts of the item must be subjected to moist heat at or above the recommended temperature for the recommended duration.
The minimum surface temperature/time relationship for thermal disinfection is as follows:17 Surface temperature C 90 80 75 70 Minimum disinfection time (minutes) 1 10 30 100
The combinations have been calculated and predicted from known thermal inactivation kinetics of vegetative micro-organisms subjected to thermal disinfection.18
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Where chemical disinfectants are used, only those specified for use in the ARTG may be used, and the relevant manufacturers instructions must be followed. Items are at risk of being contaminated if not used immediately following disinfection. Items should not be stored in disinfectants before or after any form of disinfection. Procedures should be in place to ensure that handling, packaging and storing techniques prevent contamination of the item. 9.6 Sterilization of instruments and equipment Any instrument or equipment used to enter, or that is capable of entering tissue that would be sterile under normal circumstances, or the vascular system of a patient, must be sterilized before it is used. The method of sterilization must be compatible with the particular type of instrument or equipment. If a sterilizer is used (whether it is a benchtop/portable sterilizer or a permanently plumbed or wired sterilizer), the following criteria must be met:
the relevant manufacturers instructions must be followed; and an ongoing monitoring program which reflects the requirements of Table 7.1 Sterilizer Tests and Test Frequencies of Australian Standard AS 4187 must be followed.
All instruments and equipment must be cleaned prior to sterilization. The manufacturers instructions should be checked for compatibility of the instrument or equipment with the method of sterilization. Unless an instrument or equipment has been sterilized by the wrapped method and stored in a manner, which maintains sterility, it cannot be considered sterile unless it is used immediately. Sterilization must be consistent with Australian Standard AS 4187: Cleaning, Disinfecting and Sterilizing Reusable Medical and Surgical Instruments and Equipment, and Maintenance of Associated Environments in Health Care Facilities. Microwave ovens, pressure cookers, dishwashers, ultraviolet cabinets, ultrasonic cleaners and similar devices do not sterilize and therefore must not be used for the purpose of sterilization.18 Sterilization must be achieved by using one of the following methods. 9.6.1 Steam under pressure (moist heat) sterilization Ensure that the recommended temperature/pressure/holding time is reached when processing items. Penetration time must be established and added to the times listed below. C 121 126 132 Kpa 103 138 186 Psi 15 20 27 Holding time plus safety factor (minutes) 15 10 4
19
134
206
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Manufacturers instructions for effective and safe use of the sterilizer must be followed. All packaged and wrapped sterile instruments and equipment must be stored in a manner that ensures sterility is maintained. 9.6.2 Dry heat sterilization Manufacturers instructions for effective and safe use of the sterilizer must be followed. Maintain instruments and equipment in a dry air oven (dry heat sterilizer hot air type) at 160C for a minimum one-hour holding time. All packaged and wrapped instruments and equipment must be stored in a manner, which ensures sterility is maintained. 9.6.3 Low temperature hydrogen peroxide plasma sterilization Manufacturers instructions for effective and safe use of the sterilizer must be followed. Low temperature hydrogen peroxide plasma is used to achieve low temperature/low moisture sterilization within a cycle specified by the relevant manufacturer. 9.6.4 Low temperature peracetic acid Manufacturers instructions for effective and safe use of the sterilizer must be followed. Moist low temperature peracetic acid is used to achieve low temperature sterilization in an environmentally sealed chamber within a cycle specified by the relevant manufacturer. Items that have been sterilized by low temperature peracetic acid are at risk of contamination if not used immediately after sterilization.10 9.6.5 Ethylene oxide Manufacturers instructions for effective and safe use of the sterilizer must be followed. Ethylene oxide is used to sterilize heat sensitive and moisture sensitive items, which cannot withstand temperatures greater than 60C. 9.7 Flash sterilization Emergency instrument (flash) sterilizers are designed for one-off sterilization of instruments (eg. an instrument which has been inadvertently left out of a set or dropped). Instruments that are flashed sterilized must be cleaned before sterilization.10 Due to the difficulty of air removal, the efficiency of processing large volumes of instruments at one time cannot be established, therefore flash sterilizers should not be used for such purpose. Flash sterilization should never be used for reasons of convenience such as either an alternative to purchasing additional instrument sets or as a general time-saver. The performance of specifically designed containers for use in flash sterilizers and transporting flash sterilized instruments should be validated for the sterilizer in which they are to be used. The emergency instrument (flash) sterilizer should be performance tested daily to ensure
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that the parameters of the sterilizer performance comply with Table 7.1 of the Australian Standard AS 4187. Items that have been flash sterilized are at risk of contamination if not used immediately after sterilization.10 9.8 Categorisation of instruments and equipment Instruments and equipment are divided into three categories, based on the degree of risk of infection associated with their use. Examples are listed in Table 2.
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Table 2:
Level of process required for specific items and procedures (this list is not exhaustive) Application Instruments and equipment which enter, or are capable of entering, tissue that would be sterile under normal circumstances or the vascular system. Process Sterilization Example Instruments and equipment covered by this category include surgical instruments, diagnostic and interventional radiology catheters, cystoscopes, arthroscopes, biopsy forceps, cannula, cardiac catheters, implants, laryngoscope blades, dental hand pieces, ultrasonic scalers and injection needles. Instruments and equipment covered by this category include one-way breathing valves, pneumotachograph screens, mouth shutters, respiratory therapy equipment, prosthetic dental appliances and impressions, vaginal ultrasound transducers, colonoscopes, gastroscopes and specula. Instruments and equipment covered by this category include for example, bedpans, linen, beds and stethoscopes.
Category Critical
Semi-critical
Instruments and equipment which come into contact with non-sterile tissue (other than intact skin).
Disinfection
Non-critical
Instruments and equipment which come into contact with intact skin.
Cleaning
9.9 Storage of sterilized instruments and equipment Sterilized items must be stored and handled in a manner that maintains the integrity of the packaging material, and prevents contamination of the contents.10 Sterilized items should be stored so that packaging is not crushed or bent or compressed or punctured19 or held together with elastic bands or paper clips. The contents of any sterilized package should be considered contaminated if the packaging is either damaged or becomes wet. 9.9.1 Shelf life and rotation of stock10 Factors, which influence shelf life, are event-related and include: package design; packaging material; and storage and handling conditions.
A stock rotation policy and procedure should be developed for all areas of the facility in which sterile supplies are stored. The system of stock rotation should be based on the date of sterilization. 9.10 Documentation Documentation should be maintained in relation to equipment validation, which incorporates the commissioning procedure, ongoing maintenance and performance testing using physical, chemical and biological means.
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9.11 Instruments and equipment that require special processing 9.11.1 Endoscopy Endoscopes and accessory equipment should be handled, reprocessed, and stored in accordance with Australian Standard AS 4187: Cleaning, Disinfecting and Sterilizing Reusable Medical and Surgical Instruments and Equipment, and Maintenance of Associated Environments in Health Care Facilities. Endoscopes and accessory equipment must be manually cleaned after use and before processing by automated endoscope washer disinfector. Accessory equipment such as biopsy forceps, which enter, or are capable of entering tissue that would be sterile under normal circumstances, must be sterilized before use. Health care workers involved in the reprocessing by automated endoscope washer disinfector should understand and be trained in the principles of machine operation and the limitations of each machine. Specific technical instructions must be in place and available for staff on the use of automated endoscope washer disinfector for each model of endoscope. The manufacturers instructions must be checked for compatibility of the endoscope with the automated endoscope washer disinfector. Documentation should be maintained in relation to bacteriological screening of standard flexible endoscopes including colonoscopes and duodenoscopes. Testing should be undertaken by NATA Accredited laboratories in accordance with the recommendations and testing protocols stipulated by the Gastroenterological Society of Australia and the Gastroenterological Nurses Society of Australia.20, 21 9.11.2 Baby bottles/teats and breast feeding equipment All babies bottles and teats should be cleaned then disinfected according to the manufacturers instructions after each use. Breast feeding equipment such as breast pump components must be cleaned between use and sterilized between patient use. 9.11.3 Thermometers If used for an individual patient glass thermometers should be wiped with an alcohol preparation (80% ethyl alcohol or 60-70% isopropyl alcohol) after each use, and stored dry. Between patients, glass thermometers and their containers must be washed in water and detergent and dried prior to cleaning with alcohol as above and stored dry. 9.11.4 Tonometer There have been reported adenovirus outbreaks in eye clinics from contaminated instruments such as tonometers and from inadequate disinfection procedures.22 Tonometers must be cleaned after each use prior to disinfection. Users must establish the compatibility of the instrument with the method of reprocessing.
9.12 Loaned instruments and equipment Any instrument or equipment on loan should be reprocessed according to the manufacturers instructions, prior to use.
On receipt into the health care facility, the loaned item must undergo a complete routine cleaning and processing prior to disinfection or sterilization. Lack of time must not permit the
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cleaning process to be bypassed. Following use, and before being returned to their source, all loan items should be cleaned and disinfected or sterilized. Health care workers personal instruments or equipment come within the category of loaned items.
9.13 Use of covers or sheaths on instruments and equipment The use of a cover or sheath must not be used as a substitute for cleaning and disinfection or sterilization.
Instrument or equipment for which a cover or sheath is used during procedures must be cleaned and disinfected or sterilized as appropriate after each use. The cover or sheath must be discarded after each procedure.
9.14 Single use items Re-use of medical devices labelled as single-use which enter or may entire sterile sites must not occur.23
There are some medical devices listed on the ARTG as single use, which are intended for use in critical and semi critical sites, for which health care facilities may wish to consider reprocessing. However, a single use device which enters or may enter sterile sites, which is to be reused, must be remanufactured (reprocessed) to the original manufacturers specifications and labelled accordingly in a Good Manufacturing Practices (GMP) approved facility that includes a monitoring system to ensure microbiological safety and product integrity.24 At present there are no GMP guidelines for reprocessing and no authorised reprocessing facilities. GMP guidelines on the reprocessing of single use medical devices are currently being developed by the TGA. This circular will be revised to include changes relevant to re-use of single use medical devices when the TGA has finalised its guidelines and is in a position to authorise reprocessing facilities. Parametric release of sterilized items and contingency plan for retrieval of suspected unsterile or inadequately disinfected goods An instrument or piece of equipment should be determined to be sterile based on either the sterilizers physical or chemical process data. In some instances, both physical and chemical process data are required. This declaration is known as parametric release and is the accepted method of determination in all types of health care facilities. Parametric release requires: pre-use validation of sterilization processes; routine monitoring and recording of the sterilization process; and maintenance of the sterilizer as referred to in Australian Standard AS 4187.
9.15
In the event of a sterilizer failure the machine must not be used again until satisfactory results are obtained from physical, chemical and biological monitoring. If a usually sterile item(s) is suspected of being unsterile, or its sterility is unable to be guaranteed, the item(s) should not be used. Health care facilities should have a contingency plan in place in the event of sterilization or disinfection failure. The plan should include guidelines for informing appropriate personnel
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including the: Sterilizing Services Manager; Maintenance Department; appropriate medical and nursing personnel; Area Chief Executive Officer (CEO) or CEO of private health care facility; Infection Control; and patients scheduled for procedures, which will be delayed or cancelled.
If any item(s) has been used prior to discovering it is unsterile or inadequately disinfected, the health care facility should determine the extent of the problem in accordance with Circular 2001/55: Management of Reportable Infection Control Incidents. The incident must be fully documented and the health care facilitys CEO or equivalent advised. The incident may need to be treated as a Reportable Incident and reported to the NSW Health Department. If the incident occurs in a private health care facility it should be reported to the NSW Health Departments Private Health Care Branch.
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10.
environmental cleaning
This section should be read in conjunction with: NSW Health. Circular 96/55: Colour Coding of Cleaning Equipment; and NSW Health. Cleaning Service Standards, Guidelines and Policy for NSW Health Facilities.25
Deposits of dust, soil and microbes on surfaces are a potential source of healthcare associated infection.26 Cleaning items, including solutions, water, buckets, cleaning cloths and mop heads should be changed routinely and immediately following the cleaning of blood or body substances spills or contaminated areas such as operating rooms or isolation rooms. These items should be stored dry between use. A neutral detergent should be used for general cleaning. Disinfectants should not be used for general cleaning. Work surfaces should be cleaned regularly. Surfaces should be cleaned immediately following spills or when visibly soiled. Walls, blinds and curtains should be cleaned regularly and when they are visibly soiled. Curtains should be changed regularly and as necessary. Disinfectant fogging must not be used. Carpets should be vacuumed daily. General purpose gloves should be worn when cleaning. If there is a likelihood of splashing during environmental cleaning, then a fluid-resistant gown, protective eyewear and mask should be worn.
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11.
blood and body substance spills
In the event of spills of blood or body substances staff involved in the management of spills should immediately: don protective apparel including gloves; confine and contain the spill; cover the spill with paper towels to absorb the bulk of the blood or body substances; treat debris as clinical waste; and clean the spill site with a neutral detergent and water.
It is likely that products that can clean spills of blood or other potentially infectious materials on carpets will cause damage to the carpet. Spills on carpet should be managed as follows: mop up as much of the spill as possible using disposable towels; and clean with a neutral detergent and arrange for the carpet to be shampooed with an industrial carpet cleaner as soon as possible.
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12.
food services
This section should be read in conjunction with: NSW Health. Circular 99/95: Control of Foodborne Listeriosis in Health Care Institutions;27 NSW Food Act, 1989;28 and NSW Food Regulation, 2001.29
In general no special precautions are necessary for the delivery or collection of meals, eating utensils and trays. Regardless of diagnosis patients can use reusable eating utensils, crockery, cutlery and food trays. Hot water and detergent used in hospital dishwashers will effectively decontaminate cutlery, crockery and glass.30 Food preparation staff must: wash hands before handling food or utensils; wash hands and clean nails after: using the toilet; having contact with unclean equipment and work surfaces, soiled clothing and dishcloths; removing gloves; and arriving for work. wear a hair covering that completely covers hair; avoid direct touching of ready to eat food by following proper food handling technique and using clean implements or gloves; advise their supervisor of any gastrointestinal illness; and not prepare food whilst suffering from any gastrointestinal illness until at least one full day after recovery, or from any hand infection.
Staff involved in either delivery or collection of food trays are not required to wear gloves.
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13.
laundry and linen services
This section should be read in conjunction with Australian Standard AS4146: Laundry Practice.31 The risk of disease transmission from soiled linen is negligible.32 However, employees involved in the handling, transport and processing of used linen soiled with blood, body fluids, secretions and excretions should carry out these tasks in a manner that prevents skin and mucous membrane exposure, contamination of clothing and transfer of micro-organisms to other patients and environments. Laundry staff should wear appropriate protective apparel including general-purpose gloves when handling and sorting soiled linen. Clean and used linen should be transported and stored separately. Soiled linen should be handled as little as possible and with minimal agitation to prevent gross contamination of the air and linen handlers. Used linen should be put in bags at the point of generation. Linen bags should not be overfilled. Overfilling will prevent closure and increase the risk of rupture in transit. Used linen should not be rinsed or sorted in patient care areas. Staff should ensure sharps and other objects are not discarded into linen bags. Linen soiled with blood or body substances should be bagged, transported and stored in leak proof bags. Double bagging of linen is not necessary. The laundering of linen must be consistent with Australian Standard AS 4146: Laundry Practice.
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14.
Procedures for specific clinical practices
The following precautions refer to specific clinical practices and must be adopted in addition to Standard Precautions. Aseptic techniques must be adopted for invasive procedures and for the administration of sterile medication and solutions. 14.1 Sterile medications and solutions A medication or solution must be taken from a vial or ampoule (or other similar container) using a sterile needle and syringe to withdraw the contents. The needle and syringe must be discarded once they have been used. Precautions must be taken to ensure that the injection of contaminated material or fluid into a multi-dose vial or ampoule (or other similar container) does not happen. 14.2 Equipment for individual patient use Equipment, which is labelled by the manufacturer for individual patient use, including insulin pens and asthma spacers, must not be used for more than one patient or resident. Reprocessing of such devices must be in accordance with the manufacturers instructions. 14.3 Respiratory and anaesthetic apparatus Respiratory, anaesthetic, resuscitation and similar apparatus and ventilators used in anaesthesia and in intensive care units are generally classified as semi-critical items and should be sterilized wherever possible. If items cannot withstand sterilization, they must at least be disinfected.23 14.3.1 Anaesthetic apparatus If the anaesthetic breathing circuit uses a filter, the filter must be discarded after each patient. The part of the breathing circuit between the patient and the filter must either be discarded or cleaned and disinfected after each patient. In any case where a carbon dioxide absorber is also used, the part of the breathing circuit between the carbon dioxide absorber and the filter must either be discarded or cleaned and disinfected at the end of each procedure or operation list. In those cases where a carbon dioxide absorber is not used, the breathing circuit tubing that conducts the gas to and from the filter must either be discarded or cleaned and disinfected at the end of each procedure or operation list. If the breathing circuit does not use a filter, the breathing circuit must either be discarded or cleaned and disinfected or sterilized after each patient use. All anaesthetic apparatus which comes into contact with a patient, or is contaminated with blood or body substances must be either discarded or cleaned and either disinfected or sterilized as appropriate after each patient. Those parts of the breathing circuit not in contact with a patient and not likely to be contaminated with blood or body substances with each patient use should be cleaned daily. A tray or trolley should be available for used anaesthetic equipment.
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14.3.2 Use of filters on respiratory devices Equipment, which is used only on one person, does not require a filter. Equipment, such as older types of spirometers, which has a positive pressure while in use requires a filter. Wherever a blow-and-inhale procedure is to be performed a filter is required. The use of filters does not interfere with the quality of the recordings. 14.4 Emergency resuscitation Resuscitation devices should be available and accessible in all patient care areas. Resuscitation devices should be used during cardiopulmonary resuscitation (CPR) to prevent direct contact between the mouth of the resuscitator and the patient. Any CPR training provided or approved by the health care facility should include instructions in the use of resuscitation devices to prevent direct contact between the mouth of the resuscitator and the patient. 14.5 Invasive procedures Clipping should be used as the standard process for hair removal. Pre-operative shaving should not occur unless clinically indicated. If indicated, shaving should be performed immediately before the operation. In cases where it is technically feasible, retractors must be used for exposure and access during an invasive procedure. During an invasive procedure fingers must not be used for the purposes of exposure or to increase access for the passage of a suture. Only one sharp at a time is to be placed in a puncture resistant tray that is being used in connection with an invasive procedure. When suturing, forceps or a needle holder should be used to pick up the needle and draw it through the tissue. A puncture resistant tray must be used to transfer sharps. All surgeons involved in operating theatre procedures should wear double gloves with a larger sized glove on the inside. In the event of any tear, puncture or needlestick injury the surgeons gloves should be removed and hands washed prior to donning a new pair of gloves. Gloves should be changed as soon as it is safe to do so. If a glove is torn or punctured the glove should be removed as soon as practicable and a new glove put on, and the sharp or instrument involved in the incident should be removed from the sterile field. A fluid-resistant gown made of impervious material should be worn when performing invasive procedures especially if it involves the likelihood of splashes or contamination with blood or other body substances. Closed wound drainage systems should be used. Skin should be closed with staples whenever possible or practicable.
31
As much blood as possible should be cleaned from the patients skin after the operation. Wound dressings should be selected according to the wound type and the amount of exudate and if appropriate a dressing with an impervious outer covering should be used. Technologies should be reviewed to eliminate or minimise the use of sharps or sharp surgical equipment. 14.6 Patients with communicable diseases Health care workers and health care facilities must be aware of their duty of care in the provision of treatment for patients with communicable diseases. Standard Precautions should be used irrespective of a patients infectious status to ensure protection of patients and staff. Where a patient has a communicable disease that is transmitted by contact, airborne or droplet routes, additional precautions must be implemented to complement the Standard Precautions approach. Treatment of patients with communicable diseases includes: performing surgery if clinically indicated; deferring surgery while further investigations are carried out or consultation takes place with other health care workers; declining surgery or anaesthesia if the treatments are not in the best interest of the patient; or transferring the patient to a more appropriate health care facility.
Disclosure of a patients infectious status should occur only where the information is necessary for a person involved in providing care, treatment, or counselling to a person who has been tested for or who is infected with an infectious disease or if the information is required in connection with providing such care, treatment or counselling. Health care facilities should provide suitable facilities with appropriate equipment and trained staff for the treatment of patients with communicable diseases. 14.7 Pre-operative microbiological testing An assessment of the need for pre-operative, microbiological testing should preferably be undertaken as part of the taking of clinical history by the medical practitioner of first contact. This may be a general practitioner, or a medical practitioner in accident and emergency, the outpatient department or private rooms. In the case of elective surgery, any testing considered relevant should be completed prior to admission. Pre-operative testing of a patient for infectious agents, including blood borne viruses, is a clinical decision and medical practitioners should exercise their judgement following assessment of the patient, to order any clinically relevant test with the patient's informed consent. In addition, the institution may in some circumstances have an established policy for testing.
32
15.
procedures for specific clinical settings
The following precautions refer to specific clinical settings and must be adopted in addition to Standard Precautions. 15.1 Dental setting33 Dental health care workers are routinely exposed to high concentrations of aerosols and splatter during dental procedures. The use of barrier techniques that reduce cross-contamination and cross infection between the dental health care worker and the patient should be used. The type of protection should be related to the dental procedure. These include the: use of a rubber dam, high-velocity air evacuation and patient positioning; and use of personal protective apparel including protective eyewear for the patient and the dental team.
Air and water lines should be flushed for a minimum of two minutes at the start of the day and for 20-30 seconds between patients. All dental equipment, which supplies water to the oral cavity, is to be fitted with anti-retraction valves. 15.2 Haemodialysis setting Haemodialysis increases the patients risk of blood borne virus infection because it involves access to the circulatory system. Infection may be due to contamination occurring at various steps in the haemodialysis procedure or intrinsic contamination of any of the components of the dialysis system.34 Infections may be the result of inadequate haemodialysis systems or procedures, breaks in established procedures, lack of monitoring for known contaminants, reprocessing failure, or inadequately trained/educated staff.35,36,37 Risk of blood borne infection in the haemodialysis setting may be reduced by:38 adherence to Standard Precautions; adherence to procedures for disinfection and maintenance of equipment; knowledgable, well-trained staff that understand the implications of deviating from established infection control procedures; careful monitoring of all procedures in which blood contamination can occur; an effective patient eduction program that includes teaching patients and their families their role in prevention of infections; routine monitoring and follow up of patients undergoing haemodialysis in relation to blood borne viruses status; hepatitis B vaccination for all susceptible haemodialysis patients and staff; and separation of patients who are positive for HBsAg by room or area and use of a dedicated machine. There is insufficient evidence to justify routine use of
33
dedicated machines for dialysis or isolation of patients who are positive for anti-HCV. Although outbreaks of hepatitis C (HCV) have been reported in haemodialysis patients, efficiency of transmission appears low. 15.3 Post-mortem This section is to be read in conjunction with the following documents: NSW Health. Circular 99/57: Coroners cases and amendments to Coroners Act 1980
(1) Jurisdiction of Coroner; (2) Anaesthetic Deaths; (3) Obligation to Report Death; (4) Guidelines for Nursing Staff and Medical Officers on Coroners Cases (5) (6) (7)
Dying in Hospital; Transfer of Medical Records for Post Mortems; Discharge Type Summaries for Coronial Cases in Hospitals; and Objections to a Post Mortem Examination.39
Commonwealth Government Guidelines on Patient Management and Infection Control for Creutzfeldt-Jakob Disease and the Human Transmissible Spongiform Encephalopathies;40 and NSW Public Health Act, 1991.41
The essential purpose of these guidelines for post-mortem is to minimise the risk of exposure of a health care worker to a communicable disease and to minimise the risk of infection being passed outside the autopsy room to others and the environment. 15.3.1 Post-mortem care Standard Precautions are required at all times when handling bodies of deceased persons. Transmission Based Precautions should be adopted when handling bodies that are known or suspected to have been infected with a pathogen for which additional precautions are recommended. Transmission Based Precautions should be maintained until the body is completely enclosed for transport. 15.3.2 Post-mortem examination Those undertaking post mortem examinations should adopt Standard Precautions, and, depending on the known or suspected infectious status of the body, Transmission Based Precautions. Precautions should include engineering controls, work practices and the use of personal protective apparel.42,43 For example: work surfaces contaminated during post mortem procedures should be cleaned with neutral detergent. instruments and equipment used in post mortem procedures should be cleaned after use. Refer to Section 17 for guidelines on reprocessing of instruments and equipment for cases of known or suspected CJD. engineering controls such as ventilation and safety devices on autopsy equipment should be in place. Sharps injuries may be minimised by using cut resistant gloves and blunt dissection techniques.44,45,46
Under special circumstances non-restoration of the body may be appropriate. If a body is not being restored than all attempts should be made to enable viewing prior to autopsy.
34
prevention of antimicrobial resistance in hospitals47 16.1 Introduction Antimicrobial resistance leads to additional costs in financial and human terms. Appropriate use and control of antimicrobials is critical and includes: developing a comprehensive, local antimicrobial utilisation plan; overseeing surgical prophylaxis; and developing practice guidelines for the use of antibiotics.
16.2 Prudent antimicrobial use Medical practitioners can support prudent use of antimicrobial agents by adopting the recommendations in the Therapeutic Guidelines: Antibiotic.48 16.3 Prevention and reduction of antimicrobial resistance in hospitals Strategies which should be implemented include: a system for monitoring antimicrobial resistance among inpatients and outpatients (by site and hospital location); a system for monitoring antimicrobial use by hospital location or prescribing service; monitoring of the relationship between antimicrobial use and resistance; and applying Contact Precautions to specified patients known or suspected to be colonised or infected with epidemiologically important micro-organisms that can be transmitted by direct or indirect contact.
16.4 Colonised patients Isolation or cohorting of patients colonised with organisms that the hospital has decided to control may not be practical for some hospitals. When possible, colonised patients should be managed in the same manner as patients clinically infected with those organisms. 16.5 Transfer of patients with multi-resistant organisms (MROs) to other health care facilities Long periods of colonisation are reported with methicillin resistant Staphylococcus aureus (MRSA), vancomycin resistant Enterococci (VRE) and other MROs and the optimal time for ceasing Transmission Based Precautions is not defined. The extent to which a patient contributes to environmental contamination through shedding of a MRO is dependent upon the site of their infection or colonisation, their personal hygiene and the ability to cover lesions with dressings that prevent strike-through of blood and/or exudate. A patients admission or transfer to a health care facility must not be precluded on the basis of their known or suspected colonisation or infection with a MRO. However, local policy may preclude placement of such patients in areas where other patients are at increased risk for example, either patients undergoing prosthetic surgery or having medical device implantation or who are immunosuppressed. 16.6 Methicillin resistant Staphylococcus aureus49 MRSA has become a prevalent healthcare associated pathogen in New South Wales. In hospitals the most important reservoirs of MRSA are infected or colonised patients. Hospital personnel can serve as reservoirs for MRSA and have been identified as a link for transmission between patients. The main mode of transmission of MRSA is via hands (especially health care workers' hands) which may become contaminated by contact with: colonised or infected patients;
35
colonised or infected body sites of the personnel themselves; or devices, items or environmental surfaces contaminated with body fluids or substances containing MRSA.
16.6.1 Controlling the spread of MRSA Standard Precautions should control the spread of MRSA in most instances. If MRSA is judged by the hospitals infection control program to be of special clinical significance, then Contact Precautions should be considered. 16.6.2 Culturing of personnel and management of personnel carriers of MRSA Unless the objective of the hospital is to eradicate all MRSA carriage and treat all personnel who are MRSA carriers, whether or not they disseminate MRSA, it may be prudent to culture only personnel who are implicated in MRSA transmission based on epidemiological data. MRSA carrier personnel who are epidemiologically linked to transmission should be removed from direct patient care until treatment of the MRSA carrier status is successful. If the hospital elects to culture all personnel to identify MRSA carriers then surveillance cultures need to be done frequently; and it is likely that personnel colonised by MRSA who are not linked to transmission and/or who may not be MRSA disseminators will be identified, subjected to treatment, and/or removed from patient contact unnecessarily. Because of the high cost of repeated surveillance cultures, routine culturing of personnel is not recommended. 16.6.3 Control of MRSA outbreaks When an outbreak of MRSA infection occurs, an epidemiological investigation should be initiated to identify risk factors for MRSA acquisition in the institution. Clinical isolates of MRSA should be saved and submitted for strain typing. Colonised or infected patients should be identified as quickly as possible, appropriate precautions should be instituted, and health care workers should be reminded of the need to adhere to standard precautions with particular emphasis on hand washing before and after each patient contact. If additional help is needed by the hospital, a consultation with the local public health unit or the NSW Infection Control Resource Centre may be of assistance. 16.7 Vancomycin resistant Enterococci (VRE)50 These recommendations apply only to acute-care hospitals, (ie. not to nursing homes, extended care or outpatient facilities). To minimise acquisition and transmission of VRE acute care hospitals should: ensure prudent vancomycin use; have in place an education program for hospital personnel on VRE; perform routine testing of all enterococci isolated from blood and sterile body sites (except urine) for vancomycin resistance; perform screening of all enterococcal isolates for vancomycin resistance if VRE are detected in the institution; and implement Transmission Based Precautions for all VRE infected or colonised patients.
Each hospital should develop a plan regarding the discharge of VRE infected or colonised patients to nursing homes and other facilities. The optimal time to discontinue Transmission Based Precautions for patients with VRE is
36
unknown. However, as VRE colonisation may persist for long periods stringent criteria are recommended. It is important to ensure that routine procedures for cleaning and disinfection of medical devices and environmental surfaces are followed carefully.
37
Creutzfeldt-Jakob disease Encephalopathies
and
other
forms
of
Transmissible
Spongiform
These infection control precautions are to be used for all patients with known or suspected to have prion disease including Creutzfeldt-Jakob disease (CJD), Gerstmann-StrausslerScheinker syndrome (GSS), fatal familial insomnia (FFI), or variant Creutzfeldt-Jakob disease (vCJD). 17.1 Introduction CJD is a rare, transmissible spongiform encephalopathy (TSE) that is characterised by progressive dementia accompanied by a variety of neurological signs, with an invariably fatal termination after a clinical course that may last from a few weeks to several years.51 The infectious agents are thought to be prions. Prions are made of an abnormal form of internal cell membrane protein (PrP), which are theorised to be involved in the transmission of disease. Prions are relatively hardy.40 17.2 Iatrogenic transmission Iatrogenic transmission (ie. infections that occur as a result of health care interventions) of the CJD has been reported in over 250 patients worldwide. Iatrogenic transmission of CJD agent from person to person has resulted from the direct inoculation, implantation, or transplantation of infectious materials either intracerebrally or peripherally.52 These cases have been linked to the use of contaminated human growth hormone, dura mater and corneal grafts. Six reported cases were linked to the use of contaminated equipment. Of the six reported cases only two have been confirmed. These two cases were both associated with sterotactic EEG depth electrodes. The remaining four cases are unconfirmed, but appear to be associated with the use of neurosurgical instruments.53 All of the equipment related cases occurred before the routine implementation of sterilization procedures such as currently used in health care facilities. No cases have been reported since 1976, and no iatrogenic CJD cases associated with exposure to the CJD agent from surfaces such as floors, walls, or countertops have been identified.53 17.3 Variant CJD New variant CJD (vCJD) was first reported in the United Kingdom in 1995. It is believed that vCJD was acquired through the consumption of beef infected with bovine spongiform encephalopathy (BSE). BSE appeared to have resulted from the exposure of cattle to meat and bone meal that was produced by a new rendering process in which the temperature was reduced and the hydrocarbon solvent extraction step was omitted.54 Patients with vCJD are typically aged about 30 years.55 Their epidemiological, clinical and pathological profiles differ from those of persons with sporadic CJD. Patients with vCJD frequently present with sensory and psychiatric symptoms that are uncommon in cases of sporadic CJD.
There have been no reported or confirmed cases of iatrogenic transmission of vCJD. Therefore, infection control guidelines for vCJD are still evolving. These guidelines will be reviewed, as further evidence becomes available. 17.4 Evaluating risk in healthcare environments When considering measures to prevent the transmission of CJD from patients to other individuals, it is important to understand the basis for different categories of risk. Risk is dependent upon three considerations:
38
the probability that an individual has or will develop TSE; the level of infectivity in tissues or fluids of these individuals; and the nature or route of the exposure to these tissues.55
17.4.1 Tissue infectivity 54,55 The table below is a guide to the predicted infectivity of body tissues and fluids of symptomatic and asymptomatic patients with classical CJD (cCJD). This information is based on studies of experimentally transmitted cCJD in non-human primates and from other animal models. Infection Risk High (demonstrated to be consistently infectious) Low (demonstrated to be infectious, but not consistently) None (have not been demonstrated to be infectious) Tissue Brain, dura mater, cerebrospinal fluid, spinal cord, eye (anterior, cornea). Appendix, dorsal root ganglia, kidney, liver, lymph nodes, lung, spleen, maxillofacial neurovascular tissue, placenta, tonsils, uterus. Adipose tissue, adrenal gland, blood, bone marrow, urine, faeces, heart muscle, skeletal muscle, intestine and stomach, prostate, thyroid gland, testes, nasal mucus, peripheral nerve, saliva, gingiva, sputum, tears, skin, trachea, bronchi, oesophagus.
17.4.2 Patient risk groups 55 For risk management it is necessary to define two risk categories that reflect the theoretical and demonstrable risks of transmitting CJD: higher risk people who represent a clear, definite risk of CJD transmission; and lower risk people who represent a remote, potential risk of CJD transmission.
39
The table below describes risk categories:54,55 High-Risk Groups Patients with confirmed clinical diagnosis and/or with a diagnosis of cCJD. Low-Risk Groups Any patient with undiagnosed progressive neurological illness of less than one years duration, with or without dementia. All members of a family in which there is a strong family history (two or more firstdegree relatives) of undiagnosed dementing or neurological illness. Recipients of dura mater homografts or transdural neurosurgery between 19721989, or for whom the use of dura mater homografts cannot be excluded by reference to patient records. Recipients of cadaver derived human pituitary hormones (growth hormone and gonadotrophons). Those persons with positive assays of proteins indicative of possible CJD.
Patients with high probability or suspected cCJD.
Carriers of disease linked mutations of the PrP gene.
Persons in whom the PrP gene has not been sequenced but who have two or more first-degree relatives with cCJD including GSS/FFI.
17.5 General infection control precautions Normal social and clinical contact and non-invasive clinical investigations with CJD patients do not present a risk to health care workers, relatives, or the community. 17.5.1 Standard Precautions Standard Precautions should be used for all patients with known or suspected CJD. Gloves should be worn for the handling of blood or other body substances. Masks, protective gowns and protective eyewear should be worn if there is a likelihood of splashing or splattering of blood or other body substances. Based on current knowledge, Transmission Based Precautions of patients are not necessary, the patient can be nursed in general ward areas using Standard Precautions. Management of clinical waste should be in accordance with Section 8. Handling of soiled linen should be in accordance with Section 13. The laundering of linen must be consistent with Australian Standard AS 4146: Laundry Practice. No special precautions are required for the handling of food utensils. 17.6 Decontamination of contaminated medical devices according to risk of specific tissue Prion diseases are rare and thus do not constitute a major infection control risk. Nevertheless, prions such as those possibly present in high risk tissue from persons in either the high or low risk group represent an exception to conventional disinfection and sterilization practices. Infection control professionals and other departments involved with infection control including surgical services, central sterilizing services and pathology should be notified when a patient
40
in the high or low risk group is scheduled to undergo any invasive procedure in which there may be exposure of personnel or instruments or equipment to high risk tissue. Every effort should be made to plan the procedure and for the handling, storage, cleaning and decontamination or disposal of equipment, instruments and tissue. Written protocols are essential. All staff directly involved in these procedures or in the subsequent reprocessing or disposal of potentially contaminated items, should be aware of the recommended precautions, and provided with appropriate training. Equipment that requires special prion reprocessing should be tagged after use and staff should be aware of any procedures or special prion reprocessing protocols in sufficient time to allow them to plan and to obtain suitable instruments and protective clothing and equipment. 17.6.1 Cleaning Wherever possible, instruments and other materials subject to re-use should be kept moist between the time of exposure to infectious materials and subsequent decontamination and cleaning. 17.6.2 Environmental surfaces and heat sensitive instruments To minimise environmental contamination, disposable cover sheets should be used on work surfaces. Surfaces contaminated with high risk tissue from a patient in the high or low risk group should be disinfected with 1M sodium hydroxide (NaOH) or undiluted sodium hypochlorite. All contaminated surfaces must be exposed to the disinfectant for at least 1 hour. The surface should then be mopped and rinsed with water. Endoscopes and other heat sensitive instruments that do not contact high risk tissue from a patient in the high or low risk group can be re-used after routine reprocessing. 17.6.3 Level of reprocessing of reusable items The level of reprocessing of reusable items is dependent on the level of risk of transmission of CJD. Emergency instrument (flash) sterilisation and low temperature sterilization must not be used for reprocessing.52 The methods of reprocessing in Table 3 are listed in decreasing order of effectiveness and are based on the best currently available evidence and will be reviewed as new evidence or directives are released.
41
Table 3:
Recommended reprocessing of instruments using appropriate additional levels of heat or chemical sterilization54,55 Recommended methods of reprocessing Scenario Use single use items. Incinerate. Reprocess and quarantine instruments pending determination of risk. If it is determined that there is a risk, then items should be destroyed or used exclusively for an individual patient for the course of therapy then destroyed. If it is determined there is no risk, then items should be put back into circulation. During invasive procedures adequate space should be made available to segregate contaminated items from uncontaminated items. 1. Immerse in 1M sodium hydroxidea (NaOH) and heat to 121OC for 30 minutes in a downward displacementc steam sterilizer. Clean, rinse in water and subject to routine steam sterilization. 2. Immerse in 1M NaOH a or 2% sodium hypochlorite solutionb (20,000 ppm available chlorine) for 1 hour. Transfer instruments to water. Heat to 121oC for 1 hour in a downward displacementc steam sterilizer. Clean and subject to routine sterilization. 3. Immerse in 1M NaOH a or 2% sodium hypochlorite solutionb (20,000 ppm available chlorine) for 1 hour. Remove and rinse in water. Heat for 1 hour in a gravity displacement sterilizer at 121oC or a prevacuum steam sterilizer at 134oC. Clean and subject to routine sterilization. 4. Immerse in 1M NaOH a and boil for ten minutes at atmospheric pressure. Clean, rinse in water and subject to routine sterilization. 5. Immerse in 2% sodium hypochlorite solutionb (20,000 ppm available chlorine) or 1M NaOHa at ambient temperature for 1 hour. Clean, rinse in water and subject to routine sterilization. 6. Autoclavee at 134oC for 18 minutes. During invasive procedures adequate space should be made available to segregate contaminated items from uncontaminated items.
Items that have been exposed to high risk tissue from a high or low risk group patient.
Items that have been exposed to low risk tissue from a high risk group patient.
Items that have been exposed to: Routine reprocessing. low risk tissue from a low risk group patient; or not at risk tissue from a low risk group patient; or high and low risk tissue from a not at risk group patient. a 1M NaOH readily reacts to CO2 in air to form carbonates that neutralize NaHO and diminish its disinfection properties. Therefore, 1M NaOH working solutions should be prepared fresh for each use from
42
dry NaOH or by dilution of a stock solution of 10M NaOH. NaOH is not suitable for instruments containing metals that are corroded by this compound eg. aluminium alloys. NaOH is very caustic, ensure adequate ventilation, avoid contact with eyes and mucous members and adhere to other OH&S guidelines. b Sodium hypochlorite efficacy depends on the concentration of available chlorine and should be 20 000 ppm available chlorine. Chlorine is evolved continuously by hypochlorite solutions that affect both the concentration in solution and the concentration in the environment. Working solutions should be prepared fresh for each use. OH&S guidelines should be adhered to when working with sodium hypochlorite. b Downward (gravity) displacement steam sterilizers are designed for general decontamination and sterilization of solutions and instruments. c Prevacuum (porous) steam sterilizers are not suited for liquid sterilization. d In worse case scenarios (brain tissue bake-dried on to surfaces) infectivity will be largely but not completely removed.
43
18.
outbreak management56, 57
This section should be read in conjunction with the following documents: NSW Health. Circular 97/97: Critical Incident Manual: Policy and Guidelines Minimising, and Managing Critical Incidents in NSW Health Care Facilities;14 NSW Health. Notifiable Diseases Manual;15 and NSW Health. Circular 2001/55: Management of Reportable Infection Control Incidents.58
An outbreak may be described as an epidemic, or an increase above the normal or expected level of healthcare associated infection within a clinical setting. The main goal of managing an outbreak is to prevent a further increase in incidence of healthcare associated infection, and identify factors, which may have contributed to the outbreak. This allows for the development and implementation of measures to prevent future outbreaks. The facilitys infection control committee should initially provide advice for the management and investigation of suspected outbreaks. In the event of a large outbreak of a notifiable condition the local public health unit must be contacted to provide assistance to the facilitys infection control committee. 18.1 Management steps 18.1.1 Case definition Define what is classified as a case in terms of diagnosis. There may need to be several categories in the initial stages of investigation: clinical diagnosis; probable diagnosis; possible diagnosis; and/or laboratory confirmation of diagnosis.
18.1.2 Case confirmation Review each case and ensure there are no discrepancies between clinical diagnosis and laboratory diagnosis. Confirm cases and identify infectious agent. 18.1.3 Establish background rate of healthcare associated infection Determine the normal rate of healthcare associated infection within this population (hospital or community). 18.1.4 Decide if there is an outbreak Once the background rate of healthcare associated infection has been determined, comparison can be made with the current situation to decide if an outbreak is occurring or has occurred. 18.1.5 Descriptive epidemiology Arrange collected information regarding cases in terms of person, place and time. Plot the information so as to recognise any trends in data. 18.1.6 Formulating hypotheses Formulate a tentative hypothesis, making the best assumptions regarding the source and route of exposure. 18.1.7 Testing hypotheses Determine if the hypothesis explains the situation for the majority of cases. It may be decided
44
at this stage that further investigation is needed. 18.1.8 Environmental investigation Where appropriate, environmental specimens may need to be collected to confirm the source of an outbreak. For example; food/drink, suspected as the source of gastroenteritis. 18.1.9 Infection control measures As soon as possible, implement appropriate infection control measures. 18.1.10 Communicate findings Document information.
45
glossary Ambient temperature: Ambient temperature is the temperature of the surroundings or the environment such as a room. Body substance: Body substance is used rather than body fluid to emphasise the need for precautions to prevent contact with solid tissue and faeces as well as body fluids. Decontamination: The processes of cleaning and disinfection that are required, separately or in combination, to make used equipment safe to handle. Disinfection: A process that eliminates many or all micro-organisms except bacterial spores. Healthcare associated infections (nosocomial): A localised or systemic infection acquired in health care facilities, which was not present or incubating at the time of admission. Iatrogenic infections: Infections that occur as a result of health care interventions which may manifest after leaving the health care facility. Methicillin resistant Staphylococcus aureus (MRSA): Also often referred to as Multi-Resistant Staphylococcus aureus and Golden Staph, the term methicillin resistance encompasses the organism Staphylococcus aureus that has now acquired resistance to many classes of antibiotics or antimicrobial agents. Monitoring: A programmed series of challenges and checks, repeated periodically, and carried out according to a documented protocol which demonstrates that the process being studied is both reliable and repeatable. Multi-resistant organism (MRO): An organism that has acquired resistance to virtually all systemic antibiotics or antimicrobial agents. Sharp: Any object capable of inflicting a penetrating injury, which may or may not be contaminated with blood and/or body substances. This includes needles and any other sharp objects or instruments designed to perform penetrating procedures. Sharps container: A receptacle designed to the relevant Australian Standard, for the disposal of sharps. Standard Precautions: Precautions designed to reduce the risk of transmission of micro-organisms from both recognised and unrecognised sources of infection in health care settings. Sterilization:
46
The destruction of all living organisms, including spores. Sterilization time: The total time of the sterilization stage after the sterilizing chamber and load has reached the required sterilizing temperature (penetration time plus holding time plus safety factor). Validation: Documented procedure for obtaining, recording and interpreting the results required to establish that a process will consistently yield a product complying with predetermined specifications. Vancomycin resistant Enterococci (VRE): Enterococcal organisms that have developed resistance to the antibiotic vancomycin.
47
REFERENCES
Scheckler, W.E., et al. (1998). Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: A consensus panel report. Infection Control and Hospital Epidemiology, 19: 114-124. NSW Health Department (1994). Controlling tuberculosis in New South Wales. Public Health Division, Sydney. Larson, E.L., 1992, 1993, 1994 (1995). APIC Guidelines Committee. APIC guideline for hand washing and hand antisepsis in health care settings. American Journal of Infection Control, 23: 251-269. Garner, J.S., & Favero, M.S. (1995). Guideline for hand washing and hospital environment control, 1985, Centers for Disease Control and Prevention. MMWR, 37 (24). Graham, M. (1990). Frequency and duration of hand washing in an intensive care unit. American Journal of Infection Control, 18: 77-80. Standards Australia and Standards New Zealand (1998). Australian/New Zealand Standard AS/NZS 3825: Procedures and devices for the removal and disposal of scalpel blades from scalpel handles. Standards Australia, Sydney. New South Wales Environmental Protection Authority (1997). Environmental guidelines for the assessment, clarification and management of non-liquid waste. Sydney. Available online at: http://www.epa.nsw.gov.au/waste/guidelines.htm. New South Wales Environmental Protection Authority (2001). Waste avoidance and resource recovery Act 2001. Available online at: http://www.epa.nsw.gov.au/waste/warra.htm. NSW Health Department (1998). Waste management guidelines for health care facilities. Environmental Health Branch, Sydney. Standards Australia (1998). Australian Standard AS 4187, Cleaning, disinfecting and sterilizing reusable medical and surgical instruments and equipment and maintenance of associated environments in health care facilities. Standards Australia, Sydney. Commonwealth Department of Health and Family Services, National Health and Medical Research Council (NHMRC) (1997). Report of the NHMRC expert panel on the re-use of medical devices labelled as single use. Canberra. NSW Health Department (2000). Guidelines for the storage and handling of presterilized consumables, working party for the implementation of Australian Standards AS 4187-9. Peak Purchasing Council, Sydney. NSW Health Department (1997). Circular 97/61: Policy and guidelines for the safe use of glutaraldehyde in NSW public health care facilities. Sydney
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NSW Health Department (1997). Circular 97/97: Critical incident manual: policy and guidelinesminimising and managing critical incidents in NSW public health care facilities. Sydney. NSW Health Department (2000). Notifiable diseases manual. Communicable Diseases Surveillance and Control Unit, Sydney. Commonwealth Department of Health and Family Services. (1996). Therapeutic Goods Order No. 54: Guidelines for the evaluation of sterilants and disinfectants. Canberra. International Organization for Standardization (ISO) Draft International Standard (DIS)/Preliminary Norme (prEN) 15883-1, Washer-disinfectors Part 1: General requirements, definitions and tests (1999), quoted in Standards Australia and Standards New Zealand, Australian/New Zealand AS/NZS 4187, Draft cleaning, disinfecting and sterilizing reusable medical and surgical instruments and equipment and maintenance of associated environments in health care facilities, May 2001, p83. Standards Australia, Sydney. Standards Australia and Standards New Zealand. Australian/New Zealand Standard AS/NZS 4187. Draft cleaning, disinfecting and sterilizing reusable medical and surgical instruments and equipment and maintenance of associated environments in health care facilities, May 2000. Standards Australia, Sydney. Mayhall, C.G. (Ed.) (1996). Hospital epidemiology and infection control. Williams & Wilkins, Baltimore. Deva, A.K., et al. (1998). Detection of persistent vegetative bacteria and amplified viral nucleic acid from in-use testing of gastrointestinal endoscopes. Journal of Hospital Infection, 39: 149-157. Gastroenterological Society of Australian and Gastroenterological Nurses Society of Australia (1999). Infection control in endoscopy: Guidelines. Gastroenterological Society of Australia, Sydney Manika, R.L. (2000). Epidemic Keratoconjunctivitis. In J.A. Pfeiffer (Ed.). APIC test of infection control and epidemiology, 1-86.4. Association for Professionals in Infection Control and Epidemiology Inc., Washington. Australian Department of Health and Ageing, Communicable Disease Network Australia and the National Centre for Disease Control. Draft Infection control in the health care setting: Guidelines for the prevention of transmission of infectious diseases, 2000. Canberra. Australian Department of Health and Ageing, Communicable Disease Network Australia and the National Centre for Disease Control. Draft Infection control in the health care setting: Guidelines for the prevention of transmission of infectious diseases, November 2001. Canberra. NSW Health Department (1996). Cleaning service standards: Guidelines and policy for NSW health facilities. Sydney.
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Chou, T. Environmental Services (1996). In R.N. Olmsted (Ed.). APIC infection control and applied epidemiology: Principles and practice, 107-111. Mosby, St Louis. NSW Health Department (1999). Circular 99/95: Control of foodborne listeriosis in health care institutions. Food Branch, Sydney. New South Wales (1989). Food Act 1989. Available online at: http://www.austlii.edu.au/au/legis/nsw/consol_act/fa198957/. New South Wales (2001). Food Regulation 2001. Available online at: http://www.austlii.edu.au/au/legis/nsw/consol_act/fa198957/. U.S. Department of Health and Human Services, Hospital Infection Control Practices Advisory Control Committee, Centers for Disease Control and Prevention (1996). Guideline for isolation precautions in hospitals: Part II. Recommendations for isolation precautions in hospitals. American Journal of Infection Control, 24: 32-52. Standards Australia (2000). Australian Standard AS 4146, Laundry practice. Standards Australia, Sydney. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (1997). Laundry: General information. http://www.cdc.gov.ncidod/diseases/hip/laundry.htm. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (1993). Recommended infection control practices for dentistry, MMWR, 42(RR-8). Garcia-Houchins, S. (2000). Dialysis. In J.A. Pfeiffer (Ed.). APIC text of infection control and epidemiology. Association of Professionals in Infection Control and Epidemiology Inc., Washington. Schneeberger, I.K., et al. (2000). The prevalence and incidence of hepatitis C virus infections among dialysis patients in the Netherlands: A nationwide prospective study. Journal of Infectious Diseases, 82: 1291-9. Aloys, C.M. et al. (1998). Hepatitis B and hemodialysis: The impact of universal precautions in preventing the transmission of bloodborne viruses. Infection Control and Hospital Epidemiology, 19: 508-510. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (1997). Control measures for hepatitis B in dialysis. http://www.cdc.gov.ncidod/hip/control.htm. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (2001). Recommendations for prevention transmission of infections among chronic hemodialysis patients. MMWR, 50 (RR05):1-43. NSW Health Department (1999). Circular 99/57: Coroners cases and amendments to coroners Act 1980. Public Health Division, Sydney.
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Australian Department of Health and Ageing, National Health & Medical Research Council (1996). Creutzfeldt-Jakob disease and other human transmissible spongiform encephalopathies: Guidelines on patient management and infection control. AGPS, Canberra. NSW Government Information Service (1992). Public health Act 1991, Sydney. Healing, T.D., Hoffman, P.N., & Young, S.E. (1995). The infection hazards of human cadavers. Communicable Disease Report, 5 (5): R61-R68. Young, S.E.J., & Healing, T.D. (1995). Infection in the deceased: A survey of management. Communicable Disease Report, 5 (5): R68-R73. Pugliese, G., & Favero, M.S. (1997). First reported case of occupationally acquired HIV from autopsy. Journal of Infection Control and Epidemiology, 18 (4): 243-244. McDonald, L.L. (1996). Post-mortem care. In R.N. Olmstead (Ed.). APIC infection control and applied epidemiology: Principles and practice. Mosby, St Louis. National Occupational Health and Safety Commission (1995). Infectious disease control: Post-mortem procedures. Worksafe Australia, Sydney. Shlaes, D.W., et al. (1997). Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the prevention of antimicrobial resistance: Guidelines for the prevention of antimicrobial resistance in hospitals. Infection Control Hospital Epidemiology, 18:275-291. Writing Group for Therapeutic Guidelines: Antibiotic (2000). Therapeutic guidelines: Antibiotic (11th ed). Therapeutic Guidelines Limited, Melbourne. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (1998). Methicillin-resistant Staphylococcus aureus. http://www.cdc.gov/ncidod/diseases/hip/mrsa.htm. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (1997). Vancomycin-resistant enterococci (VRE). http://www.cdc.gov/ncidod/diseases/hip/vancomyc.htm. MacMillan, C. (2000). Creutzfeldt-Jakob disease and other prions. In A.J. Pfeiffer, (Ed). APIC test of infection control and epidemiology. Association for Professionals in Infection Control and Epidemiology, Inc., Washington. Rutula, W.A. & Weber, D.J. (2001). Creutzfeldt-Jakob disease: Recommendations for disinfection and sterilization. Clinical Infectious Diseases, 32: 1348-1356. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (2001). Questions and answers regarding Creutzfeldt-Jakob disease infection control practices. http://www.cdc.gov/ncidod/diseases/cjd/cjd-inf-ctrl-qa.htm. Australian Department of Health and Ageing, Communicable Disease Network of Australia (2001). Draft Creutzfeldt-Jakob disease and related transmissible spongiform encephalopathies: Guidelines on patient management and infection control. Canberra.
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World Health Organization (WHO), Department of Communicable Disease Surveillance and Response (1999). WHO infection control guidelines for transmissible spongiform encephalopathies: Report of a WHO Consultation Geneva, Switzerland, 23-26 March 1999. Reingold, A.L. (1998). Outbreak investigations; A perspective. Emerging Infectious Diseases, 4 (1): 21-27. Checko, P.J. (1996). Outbreak investigation. In R.N. Olmsted (Ed.). APIC infection control and applied epidemiology: Principles and practice. Mosby, St Louis. NSW Health Department (2001). Circular 2001/55: Management of reportable infection control incidents. AIDS and Infectious Diseases Unit, Sydney.
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Policy Directive

Infection Control Policy

Director-General space Compliance with this policy directive is mandatory.

Robert McGregor Acting Director-General

3 NSW Health Infection Control Policy

NSW Health Infection Control Policy

Each of these fundamentals is addressed in this document.

NSW Health Infection Control Policy

INFECTION CONTROL SYSTEMS

NSW Health Infection Control Policy

NSW Health Infection Control Policy

NSW Health Infection Control Policy

NSW Health Infection Control Policy

Noa Yes - Door closed Yes

Yes See Standard Precautions

Yes See Standard Precautions Yes

Hand Washing Gloves

NSW Health Infection Control Policy

See Standard Precautions

See Standard Precautions

Mask See Standard Precautions See Standard Precautions

Protect face if splash likely Protect face if splash likely Yes d

Cover all patients open wounds

Avoid contaminating environmental surfaces with gloves

NSW Health Infection Control Policy

HAND WASHING, HAND CLEANING AND HAND CARE

NSW Health Infection Control Policy

NSW Health Infection Control Policy

NSW Health Infection Control Policy

NSW Health Infection Control Policy

masks, face shields and protective eyewear

NSW Health Infection Control Policy

safe handling, use and diSposal of sharps

NSW Health Infection Control Policy

NSW Health Infection Control Policy

management of Clinical Waste

Clinical waste must be managed in accordance with the:

NSW Health Infection Control Policy

processing of instruments and equipment

NSW Health Infection Control Policy

NSW Health Infection Control Policy

NSW Health Infection Control Policy

NSW Health Infection Control Policy

NSW Health Infection Control Policy

NSW Health Infection Control Policy

NSW Health Infection Control Policy

NSW Health Infection Control Policy

NSW Health Infection Control Policy

NSW Health Infection Control Policy

blood and body substance spills

NSW Health Infection Control Policy

NSW Health Infection Control Policy

laundry and linen services

NSW Health Infection Control Policy

Procedures for specific clinical practices

NSW Health Infection Control Policy

NSW Health Infection Control Policy

NSW Health Infection Control Policy

procedures for specific clinical settings

NSW Health Infection Control Policy

NSW Health Infection Control Policy

NSW Health Infection Control Policy

NSW Health Infection Control Policy