1. Best Practices for Environmental Cleaning
Welcome to Module 5 – Additional Precautions.  This is the 5th module in the training program developed in support of the Best Practices document for Environmental Cleaning for Prevention and Control of Infections in all health care settings, developed by the Provincial Infectious Diseases Advisory Committee.  Health care settings are encouraged to work towards best practices in an effort to improve quality of care.  My name is insert name and title and I will be your presenter for this module.
MODULE 5 – Additional Precautions

2. Learning Objectives
Describe and demonstrate appropriate procedures for cleaning rooms of clients/patients/residents on additional precautions.
Describe and demonstrate appropriate procedures for specialized cleaning.
The learning objectives for this modules are:
To describe and demonstrate appropriate procedures for cleaning rooms of clients/patients/residents on additional precautions.
And
2. To describe and demonstrate appropriate procedures for specialized cleaning.

3. What are Additional Precautions?
Additional Precautions are necessary in addition to Routine Practices for certain pathogens or clinical presentations. These precautions are based on the method of transmission (e.g. contact, droplet, airborne). (PIDAC 2009)
So, what are additional precautions?
There are certain germs or ways that our clients/patients/residents present with symptoms that require us to use more than Routine Practices. These are ‘Additional Precautions’ or what some people call isolation. Additional Precautions are used based on how the particular germ or symptoms might be spread. Examples of germs/symptoms that would require Additional Precautions are:
- someone develops a fever and symptoms of a cold (for example coughing or sneezing) – that person should be placed on droplet precautions since they may have a respiratory illness that could be spread to others
- a client/patient/resident develops sudden diarrhea – that individual should be placed on contact precautions

4. Principles of Additional Precautions
Additional Precautions are used in addition to Routine Practices for clients/patients/residents known or suspected to be infected or colonized with certain microorganisms to interrupt transmission.
Additional Precautions include the use of barriers, such as PPE, and additional environmental controls that are put in place for encounters with the client/patient/resident or their immediate environment. In some instances, specialized engineering controls or enhanced cleaning protocols may be required.
Additional precautions are always used ‘in addition to’ Routine Practices. You still need to assess your risk of exposure to blood, body fluids, secretions and excretions.
Additional precautions use added barriers, such as personal protective equipment, and environmental controls to reduce the risk of other staff/clients/patients/residents becoming infected. In some instances, specialized engineering controls (for example negative pressure rooms for individuals with tuberculosis) or enhanced cleaning protocols, for individuals with C. difficile, may be required.

5. Additional Precautions
Additional Precautions are based on the mode of transmission
There are three categories of Additional Precautions:
Contact Precautions
Droplet Precautions
Airborne Precautions
The practices used in Additional Precautions may vary with the type of health-care setting
As we said earlier, additional precautions are based on how germs may be spread.
There are three categories of Additional Precautions:
- Contact Precautions – for germs that may be spread by direct or indirect contact with the client/patient/resident and/or their environment
- Droplet Precautions – for germs that may be spread through droplets, such as when a person sneezes
- Airborne Precautions – for germs that are spread by remaining in the air for prolonged periods and that can then be inhaled by other people
Within health-care settings, the practices used for Additional Precautions may vary. This will be based on the risk to health-care staff and other clients/patients/residents.

6. Elements of Additional Precautions
Communications
Limited Transport
Dedicate Equipment and Additional Cleaning Measures
Barrier Equipment
Specialized Accommodation and Signage
Routine Practices
There are several elements that make up additional precautions.
It starts with Routine Practices. Then specialized accommodation may be needed. Signage should always be posted either on entry to the room or where it can be seen before staff enter the client/patient/resident bedspace. Next, barrier equipment, or PPE, is necessary. This will vary depending on the type of Additional precautions. Clients/patients/residents on additional precautions should have equipment dedicated for their use and additional cleaning measures may be needed. Your supervisor will let you know if this is required.
Transporting of the client/patient/resident outside of their room should be limited to only that which is necessary for their treatment. This will reduce the risk of spread to others in the setting.
Most importantly, good communication is required to ensure that the client/patient/resident understands why they are on additional precautions and that staff and visitors understand what precautions need to be taken.

7. Learning Checkpoint
Here is a learning checkpoint. Ask the group the question on the next slide. 7 7 7

8. Learning Checkpoint Which of the following is a true statement about
Additional Precautions?
Additional precautions should be used only when your supervisor informs you of these.
Additional precautions are used in addition to Routine Practices to care for some clients/patients/residents.
Additional precautions are used only by nursing staff.
Additional precautions are the same in all health- care settings.
Read question

9. Learning Checkpoint Answer
The correct answer is: b – Additional precautions are always used with routine practices when you are working with some clients/patients/residents who have specific germs or symptoms that may be transmitted to other clients/patients/residents/staff and/or visitors in the health-care setting.
The correct answer is b.
The need for Additional precautions should be indicated by a sign near the entrance to the patient’s/resident’s room or bedspace. All health-care staff, including environmental staff, should follow the precautions indicated on this sign. Just as hospitals are different from long-term care, the way additional precautions are implemented will vary depending on what setting you work in.

10. Contact Precautions Routine Practices plus:
PPE as indicated on signage
VRE and C. difficile require special cleaning
All high touch surfaces must be cleaned at least daily
Remove and launder all curtains when visibly soiled and on discharge/vacancy cleaning
Contact Precautions are used for germs or symptoms that may be spread through direct or indirect contact with the client/patient/resident and/or their environment. Examples of clinical symtoms/presentations that may require contact precautions are; antibiotic resistant organisms such as MRSA or VRE, clients/patients/residents with diarrhea and/or vomiting, scabies, C. difficile
Contact precautions includes PPE which should be indicated on a sign that is posted on the door to the room or immediately outside the bedspace. Most often the PPE used is gown and gloves. In acute care this will be put on to enter the room however in long-term care these will be used only to provide direct or ‘hands-on’ care. Rooms of clients/patients/residents with VRE or C. difficile require special cleaning that we will cover next. Because these germs are spread by direct or indirect touching all surfaces that are ‘high-touch’ should be cleaned thoroughly at least once a day. When the client/patient/resident is discharged, transferred or precautions are discontinued a discharge/vacancy clean should be done and all curtains should be removed and laundered.
Sample sign only

11. Contact Precautions – C. difficile environmental cleaning
Daily cleaning – clean room twice per day
In addition to routine cleaning:
Use a fresh bucket and mop head for each room
After cleaning, apply a sporicidal disinfectant to all surfaces and ensure sufficient contact time (if product used for cleaning is sporicidal this step is not necessary)
For C. difficile, in addition to your usual thorough daily cleaning for contact precautions there are some added details that are used to reduce the risk of spread.
Rooms of clients/patients/residents with C. difficile should be cleaned twice a day. The agent that is used should be sporicidal (able to kill spores) and the product used will determine the process you use. If you are using bleach as the sporicidal agent then you will need to clean the room with the regular disinfectant and then repeat the process using the sporicide. This will be done twice each day. Remember that a fresh bucket and mop head need to be used for each room.

12. Contact Precautions – C. difficile environmental cleaning
Discharge cleaning – double cleaning
Use when precautions are discontinued or resident/patient discharged or transferred
Remove all dirty/used items
Remove curtains
Discard all disposable supplies
Use fresh cloths, mop, supplies and solutions to clean the room for each cleaning
Ensure appropriate contact time for disinfectant
Discharge cleaning also has special procedures.
Discharge cleaning should be done when a client/patient/resident is discharged, transferred, or the precautions are discontinued. The cleaning procedure is done twice in a row to ensure that all the C. diff spores have been removed.
Start by removing all dirty or used items from the room and then remove all curtains. Next, all disposable supplies should be discarded. Now the regular contact cleaning process can be done.
Remember to use fresh equipment and supplies for each cleaning of the room and ensure that the product is left on the surfaces for the correct contact time.

13. Contact Precautions – VRE environmental cleaning
Daily cleaning
In addition to routine cleaning:
Use a fresh bucket and mop head for each VRE room
If a low-level disinfectant is not used for cleaning; then apply a low-level disinfectant after cleaning to all surfaces and ensure sufficient contact time
Rooms of clients/patients/residents with VRE also require enhanced cleaning measures. Daily cleaning of these rooms is required with careful attention to all high-touch surfaces. The use of friction, or elbow-grease, is important in removing VRE from surfaces in the environment. Simply wiping the surface is not enough to get rid of the germ. Be sure to rub the surface and get into all nooks and crannies when you are cleaning. A fresh bucket of solution and mop head are needed for each room. In addition, your supervisor will let you know if the product used to clean is different from your usual product.

14. Contact Precautions – VRE environmental cleaning
Discharge cleaning:
Use when precautions are discontinued or resident/patient discharged
Remove all used/dirty items
Remove curtains
Discard all disposable supplies
Use fresh cloths, mop, supplies and solutions to clean room
Ensure appropriate contact time for the disinfectant
Similarly to C. difficile , discharge cleaning for VRE is done whenever the client/patient/resident is discharged or transferred or precautions are discontinued.
In addition to your normal discharge cleaning protocols discharge cleaning for clients/patients/residents on Contact Precautions due to VRE includes;
- removing all dirty or used items from the room
- removing all curtains and sending these for laundering
- discarding all disposable supplies that have been left in the room
Make sure to use fresh cloths, mop, and solutions for each room. Never place a used cloth back into a bucket of solution. This will contaminate the solution and may actually spread the germs throughout the room.
Use friction when applying the product to surfaces and make sure that there is appropriate contact time of the product so that it is able to do its job.

15. Droplet Precautions Routine Practices plus:
PPE as indicated on signage
Routine cleaning of patient/resident room
All high touch surfaces in the room must be cleaned at least daily
Droplet precautions are used along with Routine Practices for clients/patients/residents who have illnesses that may be spread by droplets. Droplets occur when the client/patient/resident coughs or sneezes and expels small particles into the air around them. These small particles, droplets, may travel about 2 metres from the client/patient/resident but do not remain floating in the air. They quickly land on surfaces. Examples of conditions that would require the use of Droplet Precautions are; influenza, whooping cough, meningitis, and strep throat.
The need for droplet precautions will be indicated by a sign posted on or near the door to the client/patient/resident’s door or bedspace. Most often facial protection (mask, eye protection) is required when you are within 2 metres of the client/patient/resident.
Since surfaces immediately around the client/patient/resident may become contaminated with these droplets it is essential that all high-touch surfaces are cleaned daily. Routine room cleaning is sufficient and there is no need to use special products in cleaning these rooms.
Sample sign only

16. Routine Practices plus:
Airborne Precautions
Routine Practices plus:
Fit-tested N95 respirator on entry to room
Routine cleaning of patient/resident room
All high touch surfaces in the room must be cleaned at least daily
Room to be at negative pressure to other adjacent areas
Airborne precautions are used, in addition to Routine Practices, for clients/patients/residents who have illnesses that may be spread through the airborne route. This occurs when the client/patient/resident expels small particles through coughing, sneezing, laughing that are so tiny they remain floating on the air currents in the room for long periods of time. An important aspect of Airborne Precautions is the need to maintain the patient/resident environment at a negative pressure to the areas around it. This requires special engineering controls that may not be available in long-term care homes. If these are not available, arrangements will be made as soon as possible to transfer the resident to a facility where negative pressure is available. Examples of illnesses that are spread through Airborne are some forms of tuberculosis, measles, chickenpox, and new viruses that have not been seen before.
Clients/patients/residents on Airborne precautions must be in a room with negative pressure to ensure that the germs do not leave the room and possibly infect others. The door to the room must remain closed and all staff entering the room must wear a fit-tested N95 respirator. You should know what respirator is appropriate for you to wear and should only wear this particular one. Remember to do a seal check when you put your respirator on.
As with all rooms that have additional precautions, high touch surfaces should be cleaned daily. However, the environment is not a mechanism for transmission of illnesses spread by the airborne route so your routine cleaning is sufficient for these rooms. On discharge, if possible, you should wait for a period of time to allow all the air in the room to be changed over before you do your discharge/vacancy cleaning. Your supervisor will let you know when this can be done.
Sample sign only

17. Combinations of Additional Precautions
Some microorganisms may have more than one way of being transmitted. In these instances a combination of Additional Precautions may be used.
E.g. Respiratory viruses may be spread through droplets and indirect contact with objects in the immediate environment, therefore both Droplet and Contact Precautions are used.
There are a number of germs that can be spread by more than one way. In these instances, a combination of additional precautions may be used.
An example would be Respiratory Syncytial virus, a virus that is common in young children and has been seen more often in long-term care. While droplet transmission is the primary route of transmission it may also contaminate the environment and be spread through indirect contact. In this case, Droplet and Contact Precautions would be used.

18. Learning Checkpoint
Here is a learning checkpoint. Ask the group the question on the next slide. 18 18

19. Match the correct statement to the type of Additional Precaution
Fit-tested N95 respirator required
Room to be cleaned using a sporicidal agent
Disposable supplies to be discarded during discharge clean
PPE includes mask and eye protection
Contact Precautions
Airborne Precautions
Droplet Precautions
Contact Precautions – VRE
Contact Precautions – C. difficile
Droplet and Contact Precautions
To test your knowledge of the information we have just covered, match the statements on the left hand side of this slide to the type of precautions listed on the right hand side of the slide. Check your answers on the next slide.

20. Learning Checkpoint Answer
Fit-tested N95 respirator required – Airborne Precautions
Room to be cleaned using a sporicidal agent – Contact Precautions C. difficile
Disposable supplies to be discarded during discharge clean – 2 correct answers – Contact Precautions – VRE and Contact Precautions – C. difficile
PPE includes mask and eye protection – Droplet Precautions
A fit-tested N95 respirator must be worn whenever you enter the room of a client/patient/resident on Airborne precautions.
A sporicidal agent should be used when cleaning the room of a client/patient/resident with C. difficile. The regular disinfectants will not eliminate the spores from the environment.
Disposable supplies to be discarded during discharge clean is correct for both “Contact Precautions – VRE” & “Contact Precautions – C. difficile.” If you gave either answer you were correct. If you correctly identified both, you’ve really been paying attention. Congratulations!
PPE includes mask and eye protection – the correct answer is Droplet Precautions. The droplets may enter through mucous membranes of eyes, nose or mouth so it is important to keep these covered when you are within 2 metres of a client/patient/resident on Droplet Precautions.

21. When you return to your job, what will you do differently as a result of this session?
When you return to your job, what will you do differently as a result of this session? Make a list of three things you will do differently as a result of this session.
Ask question. Offer suggestions. May also be used as small group activity with larger groups.
Another option would be ask participants to write their ideas on paper – collect and read back.
Note: This is an important application activity. Be sure to allow time for it. 21 21

22. Thank You!
This concludes module 5 on Additional Precautions. Thank you! 22 22

23. Image Sources – Module 5
Microsoft Office Clipart used in slides 7 & 18
Images in slides 10, 15 & 16 are © PHO 2013