Presentation on theme: "Respiratory & Enteric Outbreak Preparedness in Long-Term Care Homes and Retirement Homes Hello and welcome to our webinar."— Presentation transcript:
1Respiratory & Enteric Outbreak Preparedness in Long-Term Care Homes and Retirement Homes Hello and welcome to our webinar
2Presenter Catherine Edl, RN, BScN Infection Prevention and Control TeamYork Region Community and Health Servicesext. 4555For those of you who don’t know me, my name is Catherine Edl and I am a Public Health Nurse with York Region Community and Health Services and I will be your presenter today.I’d like to extend a special thank-you to Mabel Lim, Infection Control Consultant of the CRICN and Kathy Torkos, Network Assistant also of the CRICN for hosting this webinar.These presentation slides and notes will be available on our website shortly after the webinar atAlso, so that we can keep improving, you will be sent an evaluation via following the webinar – please take the time to complete it so that we can make improvements for next year.
3Webinar Instructions Please mute your phone Questions: use *6 or mute buttonQuestions:If you have questions during the presentation, please use the chat box you see on your screenQuestions will also be taken the end of the presentationBest to ask IT related questions through the chat box during the presentation if needed.Otherwise, please save questions to the end and we will open the phone line up and answer questions verbally or through the chat box.
4Presentation Outline We will review: Organism transmission Common outbreak pathogensOutbreak identification, notification and first stepsOutbreak control measuresImportance of outbreak policies and proceduresWe are coming up to respiratory outbreak season so we figured this would be a good time of year to review control measures as well as outbreak identification and managing an outbreak.The principles and practices contained in this presentation can be applied in both LTCHs and Retirement Homes. Note that the principles and practices contained in this presentation remain consistent for both settings, however, they may be implemented differently due to the setting type.
5Organism Transmission Back to BasicsIt’s best to start with a brief review of the Basics – we’ll start with Organism Transmission
6How organisms travel to new host Infectious AgentSourcePortal ofExitMeans of TransmissionSusceptibleHostEntryChainofTransmissionOrganismsFactors that make a host more vulnerable to getting sickWhere organisms liveExposure to an infectious organism is not always followed by disease. The spread of infection requires all 6 elements of the Chain of Transmission to be satisfied.How organisms enter a new hostHow organisms leave the hostHow organisms travel to new host
7Breaking the Chain Identify/manage the agent Reduce the reservoir Identify mode of transmission and prevent spreadReduce host susceptibilitySuccessfully preventing infection is all about reducing the chance of infection. So how can we reduce the chance of infection?We can:Identify/manage the agent: through regular, active surveillance; early identification; timely reporting of suspected outbreak and any changes in resident status; ill staff policies; visitor restrictions; etc.Reduce the reservoir: early identification and management of ill residents; vaccination; food safety; cleaning and disinfection; etc.Identify mode of transmission and prevent spread: regular use of routine practices (hand hygiene, risk assessment, use of PPE); timely implementation of additional precautions and other outbreak control measures; etc.Reduce host susceptibility: resident, volunteer and staff immunization; promotion of a healthy lifestyle; etc.Let’s now review how organisms are transmitted…
8How Are Organisms Spread? contactdropletdroplet/contactairborneThere are 4 main ways an organism can be transmitted
9Contact TransmissionThe spread of an infectious agent through touchingThe most common routeDirect: hand to handIndirect: touching a contaminated object
10Droplet Transmissioncoughs or sneezes generate large respiratory dropletsInfected droplets enter the eyes, nose or mouth of another person and can cause infection in the receiving hostDroplets can land on surfaces contaminating themMost common type of diseases associated with droplet transmission are respiratory in nature. The only exception is norovirus which is also spread through droplets when vomiting occurs.Droplets can be propelled up to 2 metres!!Droplets can land on surfaces contaminating them, thus making them a potential source of contamination for anyone that comes into contact with it – this is a good example of droplet/contact transmission.
11Airborne Transmission Very tiny droplets exit the respiratory tract of an infected person when they cough or sneeze and remain suspended in the air and travel on air currentsThese tiny droplets need to be inhaled to cause infectionExamples of germs spread via this route:Tuberculosis, chickenpoxNot usually seen in LTCHs or Retirement Homes
12Outbreak Pathogens Respiratory & Enteric What pathogens are causing the outbreaks we experience here in York Region?
13Summary of Reported Respiratory Outbreaks in York Region (2012-2013) # of OutbreaksCausative AgentSetting TypeRespiratory48Undetermined (38%)Influenza (25%)Rhinovirus (13%)Coronavirus (8%)Parainfluenza (6%)RSV (6%)Entero/Rhinovirus (2%)Metapneumovirus (2%)Long term care home (98%)Retirement home (2%)This is data from Sept – Aug. 2013- Causative agent: Of the 48 respiratory outbreaks in York Region, there were various causative agentsSetting type: Of the 48 respiratory outbreaks, 98% of the outbreaks had occurred in LTCHs and 2% in Retirement HomesVery rarely are respiratory outbreaks declared in day nursery settings or other community settings
14Respiratory Outbreak Causative Agents 2012-2013 Graphic representation of causative agent dataData from Sept 2012 – August 2013Reasons for such a large percentage of “undetermined” causative agents include: an organism that isn’t tested for, bad sample was taken, sample taken from wrong resident (one who is not ill), no samples were taken as OB was reported too late (call Public Health within 48 hrs of onset)
15Respiratory Outbreak Setting Types 2012-2013 This bar graph represents outbreak data in terms of setting type. Of the 48 respiratory outbreaks, 41 were in LTCH and 7 were in Retirement Homes.Of the 41 outbreaks in LTCHs, 9 were confirmed influenza.Of the 7 outbreaks in Retirement Homes, 3 were confirmed influenza.Most of the influenza outbreaks occurred in December 2012 and January 2013.
16Influenza – A Common Causative Agent in Respiratory Outbreaks Incubation period – 1-3 daysPeriod of communicability – 24 hrs prior to symptom onset to 7 daysCommon symptoms – runny nose, fever (3-4 days), sore throat, coughing, extreme fatigueTreatment- antivirals should be started within 48 hrs of symptom onsetAnnual flu vaccinePeriod of Communicability -24 hrs prior to onset to 7 days but may be longer in immuno-compromised individualsTransmission through:indirect contact –touching surfaces that have been infected and then putting their hands near their mouth ,nose and eyesdirect contact- person to person through coughing and sneezingMost common symptoms – runny nose, fever that usually lasts 3-4 days (although fever may be absent in the elderly), sore throat, coughing, extreme fatigueTreatment- antivirals should be given within 48 hrs after onset. Prophylaxis should be given to those who are not ill and should be started immediatelyAnnual Flu vaccine should be encouraged for all staff and residents - to protect themselves and others, it reduces severe complications and time off workVaccines allocated to York Region for the Season are:Agriflu (pre-filled syringe of 0.5mL)Vaxigrip (5mL multi-dose vial)Fluviral (multi-dose vial)Fluad (pre-filled syringe of 0.5mL, contains adjuvant)Used primarily for residents of LTCHs aged 65yrs or olderCommunication from our vaccine team to LTCHs/Retirement homes will likely be in early October
17Rates of Influenza Immunization Coverage for 2012-13 among Staff in York Region LTCHs YR Average64%Each bar represents the Staff immunization rate in a LTCH in York Region.27 LTCHs are represented here; only 1 LTCH did not report their rate.The York Region average of 64% is not bad, however, there is always room for improvement especially when we see that most influenza outbreaks are in December and January and the vaccine is typically available in October for staff and residents. Influenza immunization is highly encouraged for you, as role models, and your staff.Data Source: The Seasonal Influenza Immunization rates at LTCHs reporting forms from 2009/10 to 2012/13.
18How are Respiratory viruses spread? Droplet and ContactDropletthrough the air by droplets excreted when infected individuals cough or sneeze2 metre ruleContact (direct and indirect)touching people/objectsViruses can survive onsurfaces for long periods of time2 metresIf these droplets enter the mucous membranes (eyes, nose, mouth) of another person…The virus could incubate and cause symptoms in the new host…And so on, and so on…Viruses typically live on surfaces for hours (2-48 non-porous items, less for porous items).If you touch a contaminated object, then rub your eyes, transmission is possible.
19Summary of Reported Enteric Outbreaks in York Region (2012-2013) # of OutbreaksCausative AgentSetting TypeEnteric59Undetermined (78%)Norovirus (13%)Rotavirus (3%)C.diff (2%)Girardia (2%)Campylobacter (2%)Child care (44%)Long term care home (27%)Other (17%)Retirement home (12%)This is data from Sept – Aug. 2013- Causative agent: Of the 59 enteric outbreaks in York Region, 13% of the outbreaks were associated with Norovirus while 78% were unknown.Setting type: Of the 59 enteric outbreaks, 44% of the outbreaks occurred in child care settings followed by LTCHs, “Other” and Retirement Homes.“Other” setting type includes: school, food premise/restaurant, hospitalIt is very difficult to get stool samples from children in day nursery settings which leads to the high number of unknown causes for enteric outbreaks
20Enteric Outbreak Setting Type 2012-2013 This is a graphic representation of what setting type had enteric outbreaks. We see most are in the Child Care setting at 44%, followed by LTCHs at 27% and Retirement homes at 12%. The ‘Other’ category at 17% includes settings such as schools, food premise/restaurants and hospitals.
21Enteric Outbreak Causative Agents 2012-2013 Here is a graphic representation of the enteric outbreak causative agents.Norovirus is the second largest causative agent for enteric outbreaks at 13%.
22Norovirus – A Common Causative Organism in Enteric Outbreaks Spread through stool and vomitDroplet/contact precautions neededNoroviruses can survive on practically any surface including door handles, sinks, railings and carpet for long periods of timeHighly infective virus!only 10 virus particles are needed to cause illnessDroplets may be generated with vomiting or aerosolized when cleaning up vomit.Immunity is not necessarily obtained with infection, one may be re-infected with same or different strain in the same season.
23How are Enteric viruses spread? Contact (direct and indirect)touching people/objectsviruses can survive onsurfaces for long periods of timeDroplet (if vomiting)through the air by droplets excreted when infected individuals vomit2 metre ruleIf these droplets enter the mucous membranes (eyes, nose, mouth) of another person…The virus could incubate and cause symptoms in the new host…And so on, and so on…Viruses typically live on surfaces for hours (2-48 non-porous items, less for porous items).If you touch a contaminated object, then rub your eyes, transmission is possible.
24What ‘season’ are we in? Virus Type Spring Summer Fall Winter Influenza√RSVPara-influenzaRhinovirusEnterovirusNorovirusThese viruses all have typical times of the year when they are most active.
25Pocket Guide Book Mabel.Lim@oahpp.ca This resource is available from the Central Region Infection Control Network. You can contact Mabel Lim for copies.
26Outbreak Identification, Notification & First Steps
27Outbreak Identification Early detection of an outbreak is keyNeed to recognize when illness rates exceed your facility’s baselineConsult with Public Health when your facility has minimum two cases presenting with similar symptoms in a similar location within a specified timeframeImplementing outbreak control measures early is vital in controlling an outbreakResults in a shorter number of days in outbreakRecognizing when illness rates exceed baseline can be a challenge in large, multi-floor facilities. It is important to consider how you collect surveillance data so you are aware when illness rates exceed baseline.The earlier you implement control measures, the better chance you have at minimizing the spread. Don’t wait to have an outbreak confirmed before implementing control measures!
28If you suspect that you may have an outbreak, Call Public Health, ext during business hoursafter business hoursIt is ultimately the responsibility of the facility to manage the outbreak, but public health is here to assist you.
29Public Health’s Role:Review line list and determine if in outbreak/surveillanceCreate case definitionProvide investigation/outbreak numberReview facility details:Determine which units are affectedNumber of residents on the unit and whole facilityNumber of staff on the unit and whole facilityFacility lay-outFacilitate and coordinate specimen collection and testing by PHO labSend outbreak notification to external stakeholdersFor respiratory outbreaks review rates of flu vaccination for staff and residentsLine list is to be faxed to the health unit as soon as possible and then daily by noon.Line lists look at the following:What are the symptoms? (determine definition) Unit or facility? We ask whether they are able to completely isolate the unit from the rest of the facility (residents not going to other parts of facility, dedicated staff to the affected unit, residents from the affected unit stay within unit all the time, even for meals) What the facility looks like (how many floors, units eating/dining areas etc.) Additional information about flu vaccinations rates will be required for respiratory outbreaksPublic health will notify CCAC, EMS, fire, all LTCHs and hospitals in YR
30Facility’s First Steps Once Outbreak Confirmed Assemble the outbreak management team and set meetingNotify stakeholder groups of outbreakCollect clinical specimens (in consult with PH) and submit to Public Health LabExpect outbreak inspection from PHIFurther implementation of control measuresPublic health’s inspection will focus on control measures such as PPE carts, donning and doffing PPE, cleaning and disinfection practices, hand hygiene and signage. For an enteric outbreak, public health will also inspect the kitchen with possible food samples taken.
31Outbreak Management Team (OMT) Meeting The OMT directs and oversees all aspects of an outbreakPlan your meeting as soon as possible - meet on day 1 or 2 of the outbreakInclude representatives who have the authority to make decisions within your facility:Infection Control DesignateDOC, Administrator, Medical AdvisorNursing Representative from each floor/unit where outbreak is occurringPharmacistPublic Health Nurse/Inspector (2)Environmental & Dietary ServicesActivity CoordinatorsMaintenance RepresentativesOther external service providersOMT will meet at the beginning of the outbreak and may schedule additional meetings if necessaryThe OMT should include these members but is not limited to them – it is essential that everyone is on the same page when trying to manage an outbreak31
32Public Health Representation at the OMT Two members of the health unit will attend the OMT:Infectious Diseases Control Division (IDCD) representativePublic Health LeadOutbreak Investigator (PHI or PHN)Case managementHealth Protection (HP) Division representativePublic Health Inspector (PHI)Infection Prevention and Control MeasuresFor questions pertaining to the outbreak, call the IDCD investigator32
33OMT Meeting Discussion Review line list(s) and confirm case definitionConfirm collection and submission of lab specimensReview the control measures necessary to prevent an OB from spreading furtherIdentify additional people who need to be notified of the OBPrepare a communication plan, only if necessaryPrepare internal communication for residents, staff and family
34Essential Communication for the Facility During an Outbreak Notify courier services for swab/stool pick-upsNotify residents and family membersNotify staff and volunteersManage any media concernsPost signage:Outbreak signage needs to be posted at entrances to the facility and the affected unit(s)Contact/Droplet/Airborne signage should be posted outside the ill residents room as appropriate
35This sign is available from your PHI or on our website
36Essential Communication with PH Throughout the Outbreak Daily line list faxed to public health atLine list is a system to track residents/staff symptoms that meet case definitionImmediate notification to public health if there are hospitalizations or deaths within the institutionLine lists look at: demographics, symptoms, specimen collection, hospitalizations, deaths, resolved, relapseLine lists need to be faxed on a daily basis by noonCommunication with the staff (DOC/ADOC/nursing staff ) by phone or if issues arise that cannot be captured on the line list or there is a significant change in illnessThe weekday investigator should be notified of any hospitalizations/deaths within the institution asap and if on weekends the on-call staff should be notified.
37Enteric and Respiratory Outbreak Management Poster This resource is available on our website
38Specimen Collection Kits Obtained from Public Health EntericOutbreaksStool KitRespiratoryOutbreaksNP KitYou should have these on hand at all times in the event of an outbreak.Check expiry dates and consult with public health if new kits are needed. Return expired kits to public health for recycling.
39Specimen Collection for Respiratory Pathogens Nasopharyngeal (NP) swabsSwab should be inserted one-half it’s lengthThe laboratory needs high levels of organism for respiratory viruses such as RSV, influenza virus A & B or parainfluenza virus.All NP swabs should be kept in the fridge until it is picked up by the courier so that the organism is not compromised.Ensure that the swab is labelled well with two identifiers such as DOB and name - without two identifiers the lab will refuse to test.
40NP Swab Collection Technique Wear appropriate PPETilt the patient’s head backRemove any excess mucous using the larger cotton tipped swabGently bend the wire swab while in the sterile package, to give it a slight arcInsert the flexible NP swab into one nostrilRub the swab back and forth several times, and leave the swab in place a few seconds to absorb the materialWithdraw the swab and insert into transport mediumRefrigerate and transport to the lab as soon as possibleEnsure that the outbreak # and two identifiers are on the requisition and the NP swabAs per PHL instructions.Keep NP swab in the fridge until picked up
41Specimen Collection for Enteric Pathogens Stool KitsBacterial, parasitic, and viral agents may produce gastroenteritis therefore the ‘Stool Kit’ has 3 vials - each with a colour-coded cap:Green - Bacterial examinationYellow - Parasitology examinationWhite - Viral and toxin examinationEnsure that the outbreak # and two identifiers are on the requisition and the specimen bottlesEach kit includes complete instructions on specimen collection, storage, and transportation; if these instructions are not followed the sample may not be testedTests for viral/bacterial and parasitesNeeds to be kept in the fridge so the sample is not compromisedResults usually within 3-4 daysTwo resident identifiers needed on the container
42Sending Specimens to Public Health Ontario Laboratory Confirm with Public Health investigator the contact information for courier servicesWhen specimens are ready for pick-up, call the courier.Inform the courier that the specimens will be going to the Public Health Ontario Laboratory (PHO Lab)If asked please quote the account # provided by Public HealthAll samples sent to the PHO Lab must be properly labelled and accompanied with the ‘General Test Requisition’ form supplied with the kitsRefrigerate samples until picked up.
43Public Health Inspection Once an outbreak is declared, a PHI will visit your facilityConduct an outbreak inspectionRespiratory – inspect affected unit(s)Enteric – inspect affected unit(s) and kitchenOther areas will be inspected as neededCommon areasFacility entrancesCollect samples if neededSamples may be taken of food, water or environmental is suspected to be a potential cause of outbreak
44Food Safety for Enteric Outbreaks Policies should be available on general safe food handling practicesOutbreak SpecificsFood retention policy needs to be in placeOnce an outbreak is declared, food samples should not be discardedKeep food samples (200 grams) of ready-to-eat potential hazardous food items, frozen (at or below -18°C) for 10 daysEnsure symptomatic food handlers are identified, excluded and notify Public HealthDiscard all ready-to-eat foods prepared by staff that become ill with enteric symptoms while on shiftPolicies should be available on the following:Food-service-worker hygiene (hand washing, confine hair, clean clothes and illness reporting);Kitchen sanitation (cross-contamination prevention, cleaning and sanitizing, dishwashing and general maintenance of kitchen);Safe food preparation and temperature control practices, including food-safety education;Record keeping for: temperature logs for refrigeration units and mechanical dishwashers; final cooking temperatures of food; and menu choices; catered and external/supplier information that provide food for residents. Records should be kept for no less than three (3) months;Routine retention of food samples – 200 grams of ready-to-eat potentially hazardous food items, from each meal, for a minimum of 5 days. Samples should be frozen or stored below -18°C; andDiscard all ready-to-eat foods (i.e. food not to be cooked) prepared by dietary staff that become ill with enteric symptoms while on shift.
45Preventing Further Spread Most often at the beginning of an outbreak the organism will be unknown…
46Outbreak Control Measures Routine PracticesHand hygiene and PPECleaning and disinfectionAccommodationsVisitor RestrictionsWorkload managementAdmissions/transfer considerationsOutbreak policiesStaff/volunteer education & health considerationsEnvironmental ControlsAdministrative ControlsThese are what Public Health is assessing when we conduct the outbreak audit.Environmental Controls include: cleaning and disinfection and resident accommodationsAdministrative Controls include: visitor restrictions, workload management, admissions/transfer considerations, workplace policies, staff/volunteer education & health considerations (immunizations)It is really important that staff are educated on these control measures at the beginning of each outbreak and as needed.
47Routine Practices Risk Assessment Hand Hygiene PPE RP = Assumes blood and body fluid of ANY client could be infectiousRisk assessment is the most important step and is often not done correctly. Think before you act!
48Risk Assessment To be performed prior to each resident interaction Consider the following:Risk of exposure to blood or bodily fluidsThe procedure and the skill level of the HCW performing the procedureResident’s level of cooperation and cognitive awarenessUsing infection prevention strategies during every resident/HCW interactionRisk of exposure to body fluids or blood during the procedure - thorough hand hygiene is sufficient for minimal risk procedures, whereas higher risk procedures require both thorough hand hygiene and use of additional infection control practicesThe procedure and the skill level of the health-care worker performing the procedure need to be considered. Usually, the better trained a health-care worker is, the less likely they will be exposed to body fluids or bloodThe resident's level of cooperation and cognitive awareness need to be considered; for example, the more cooperative/cognitively aware, the lower the risk of transmissionUse infection prevention strategies during every resident and health-care-provider interaction
49Hand Hygiene Key Points Supplies should be easily accessible, stocked and not expiredShould be performed timely and properly by staff, visitors, volunteers, and residentsSignage posted at hand sanitizer stations and hand wash sinksHand sanitizer should be 70-90% alcohol basedUse liquid soapOne of the key elements of Routine Practices is hand hygieneHand hygiene facilities should be at facility and room entrances, washrooms, point of careAlcohol has broad spectrum efficacy and is recommended for health care useAuditing has been shown to improve compliance during an outbreak
50Hand Hygiene Resources Just Clean Your Hands ResourcesStaff and Resident Areas4 Moments for Hand HygieneHow to hand wash - 11 stepsHow to hand rub - 8 stepsYork Region ResourcesVisitor AreasCorrect hand washing procedures - 6 stepshand sanitizer poster - 3 stepsIf you observe that the wrong signs are posted, direct them to the JCYH website
51JCYH – 4 MomentsHomes are not required to post these signs, but they may be posted in common areas.
52JCYH – How to Hand Wash (11 steps) These should be posted in areas where HCW would perform hand washing
53JCYH – How to Hand Rub (8 steps) These should be posted in areas where HCW would perform hand sanitizer
54York Region – Hand Washing (6 steps) This can be posted in visitor areas
55York Region – Hand Sanitizer (3 steps) This can be posted in visitor areas
56PPE Key Points Risk Assessment prior to donning Proper use is key for protecting staff, visitors and residentsEnsure additional precaution signs are postedEnsure PPE supplies are availableEnsure appropriate use of PPE (type and sequence for removal)Ensure appropriate disposal of used PPEThe other key element of Routine Practices is PPEEnsure staff perform a risk assessment before interacting with a residentEnsure staff and visitors don and doff PPE properlyThe sequence for doffing (removal) is very importantEnsure PPE supplies are availablePPE carts should be set-up outside resident roomsStaff should know where PPE supplies are kept and have access to supply at all timesEnsure the appropriate PPE is being worn at the appropriate time and not in common areasEnsure appropriate disposal of usedPPE should be discarded immediately after use and inside the ill resident’s room if possible – this may be a challenge for Retirement Homes
57PPE for Routine Practices Gloves – Use when touching any bodily fluids, mucus membranes and when you have non-intact skinGowns – Use when contact of clothing/ exposed skin with bodily fluids is anticipatedMask and goggles – Use when anticipating splashes or sprays of bodily fluidsBased on the above, the HCW is expected to do a risk assessment to determine what they should don to protect themselves.
58PPE & Additional Precautions PPE used in addition to Routine Practices:Contact PrecautionsDroplet PrecautionsAirborne PrecautionsAdditional Precautions need to be established and discontinued promptly!In some instances, healthcare personnel are required to wear PPE in addition to that recommended for Routine Practices. The three Additional Precaution categories where this applies are Contact and Droplet Precautions and Airborne Infection Isolation.Educate client and family visitors about diseases transmission, hand hygiene & PPE use.
59Additional Precautions - Contact Control Measures:PPEGown and gloves for contact with client (direct) or environment of care (indirect)Environmental ControlsDedicate or disinfect shared equipment after each useInfectious agent/symptoms that require contact precautions are:Diarrhea or C. difficileNorovirusInfluenzaContact Precautions requires gloves and gown for contact with the patient and/or the environment of care; in some instances, use of this PPE is recommended for even entering the patient’s environment.
60Additional Precautions - Droplet Control Measures:PPESurgical masks and eye protection within 2 metres of residentEnvironmental ControlsDedicate or disinfect shared equipment after each useInfectious agents/symptoms that require droplet precautions are:RSVNorovirus (if vomiting)Cough or shortness of breath and feverDroplet Precautions requires the use of a surgical mask and eye protection within 2 metres of the ill resident
61Additional Precautions – Droplet/Contact Control Measures:PPESurgical masks and eye protection within 2 metres of resident and gloves and gown if contact with resident or their environment anticipatedEnvironmental ControlsDedicate or disinfect shared equipment after each useInfectious agents/symptoms that require droplet/contact precautions are:InfluenzaNorovirus (if vomiting)Cough or shortness of breath and fever
62Additional Precautions - Airborne Control Measures:PPEParticulate respirator (N95 mask)Environmental ControlsSingle room, door closedNegative pressure roomInfectious agents that require airborne precautions are:TuberculosisMeaslesChickenpoxVery rare in LTCH and Retirement HomesStaff must be properly mask fit-tested for N95 mask use – see Ministry of Labour for guidelines
63Additional Precautions Signs These signs are available to you for print from our website and should be posted on the door of a symptomatic resident with an infectious disease or suspected infectious disease.
64Donning and Doffing PPE Remember the sequence and importance of hand hygieneWear the right PPE for the interaction anticipated so you reduce the risk of exposureCarefully remove PPE to reduce the risk of contaminating skin or clothingSequence of removal is very important – remove based on most contaminated items to least contaminated items. Treat all used PPE as contaminated.
65These posters have been provided to all LTCHs and are also available on our website should any Retirement Homes like a copy
66PPE Cart Principles Also called ‘Isolation Station’ When does this cart need to be set up?First symptom of residentWhere should it be located?Outside room, easily accessible, ‘clean area’Covered or uncovered?Covered is bestWhere to place in a dementia unit?Communicate location by posting signPlacement of garbage?Should be inside the room, PPE poster aboveOne of the top findings on the IC outbreak inspection conducted by our inspectors is the carts are not set up or they have inadequate supplies.Needs to be set up at the first symptom. Don’t wait for an outbreak to be declared.Should be located outside of the room of a symptomatic resident.Covered is best or kept in a clean area that is accessible to staff.For dementia units, placing a PPE cart outside the room may not be practical. Determine a location that is suitable (e.g., nursing station) and post a sign on the resident’s door communicating that PPE is to be worn and where it is located
67In ill resident’s room, away from clean supplies PPE Cart Set UpHand SanitizerGlovesGownsMasksGogglesWipesGarbageSignsIn ill resident’s room, away from clean suppliesEnsure staff are dedicated to re-stocking the PPE carts.
69Key Points for Outbreak Cleaning and Disinfection (C&D) Follow the correct process: clean first, then disinfectUse a higher level of disinfectionIncrease the frequency of C&D in outbreak areasC&D of resident equipment is essentialEnsure proper handling of laundry and wasteAnother top finding on the IC outbreak inspection – cleaning and disinfection issues: not following the correct process, not using the right level of disinfection and not cleaning frequently enough (surfaces and medical equipment)
70Cleaning PrinciplesCleaning is the physical removal of dirt and debris using soap, water and mechanical action (friction)Must always be the first step in order to maximize effectiveness of the disinfectantClean spills/splashes/leaks promptlyClean from least contaminated to most contaminated (top to bottom)The cleaning process removes microorganisms primarily by mechanical action but does not destroy those remaining on the object. Removes 99 to 99.9% of micro-organisms and foreign particulates on a surface allowing for maximum efficacy of the disinfectant.70
71Disinfection Principles Disinfectants kill germsType of disinfectant used depends on the surface or item being disinfectedDifferent levels: Higher and LowerRegistered disinfectants have a drug identification number (DIN)Follow manufacturers’ instructions for dilution and contact timeDuring an outbreak higher level disinfection must be usedThe cleaning process removes microorganisms primarily by mechanical action but does not destroy those remaining on the object.Do not double dip and ensure saturation of cloth with disinfectant solution71
72Low Level or Hospital Grade Disinfectants Every Day Use Kill vegetative bacteria and enveloped viruses:Staphylococcus aureus (includes MRSA)SalmonellaHIV, Hepatitis B and CRSV and InfluenzaExamples:500ppm-1,000ppm sodium hypochlorite (bleach)3% hydrogen peroxideaccelerated hydrogen peroxide70-95% alcoholQUATs (Lysol, Everyday Disinfectant - ED)Low level will kill many common organisms, including influenza
73Higher Level Disinfectants Outbreak Situations Kill mycobacteria, non-enveloped viruses and fungi:Mycobacteria tuberculosisNorovirus and Hepatitis ACandidaExamples:5,000ppm sodium hypochlorite (bleach)6% hydrogen peroxideaccelerated hydrogen peroxideIn outbreak situations need to increase the disinfection level higher because you don’t know what you are dealing with initially. Again you do not need to wait until an outbreak is declared to increase the level of disinfectant used. When a resident is isolated in their room, a higher level disinfectant can be used and cleaning frequencies of that room should be increased.
74Bleach Solutions Low Level - every day (non-outbreak) High Level - outbreakThese are excerpts from our new Cleaning & Disinfection Chart that will be posted on our website very shortly. Please access it at
75Outbreak Cleaning and Disinfection – Frequently Touched Surfaces Assume all frequently touched surfaces are contaminatedIncrease cleaning and disinfection frequencies of:Common areas:Hallways, door knobs, light switches, dining areas, activity rooms, elevator buttonsIll Resident rooms (at least daily):Bed rails, overbed table, washroom areas (faucets, sinks, toilets, counter tops)
76Outbreak Cleaning and Disinfection - Resident Equipment Dedicate wherever possible or use disposable product if feasibleIf shared, clean and disinfect between residentsChoose a cleaning and disinfecting method that is compatible with the equipmentExamples of resident equipment:BP cuffStethoscopeThermometerWheelchairs/walkersLifts
77Disinfectant Wipes Follow manufacturer’s recommendations Wipes are not recommended as a routine cleaning/disinfectant toolThey should be used for items that cannot be soaked and for small items that must be disinfected between usesEnsure the surface or item remains wet for the required contact time (additional wipes may be needed)Wipes must be kept wet and discarded if they become dryWipes should not be used as a routine cleaning/disinfectant tool - it is difficult to attain adequate disinfection contact time using disinfectant wipes.Multiple wipes may be required to attain adequate contact time per manufacturer’s instructions - wipes are expensive!Wipes are good for small items that must be disinfected between residents at the point-of-care (e.g., stethoscope) or for items that cannot be soaked.Wipes must be kept wet and discarded if they become dry.
78Toileting Equipment in Enteric Outbreaks Toilets/commodes should be dedicated for illresidentsIf toileting facilities cannot be dedicated, they should be cleaned after each use by the symptomatic residentIf commodes/bedpans are used, same principles applyWhere are the contents being dumped?Visitor toilets should be separate from resident toiletsDo not use disinfectant wipes to clean toilets or commodesNeed to think about where the symptomatic residents are being toileted?If not using the toilet, where is the commode/bedpan being dumped?How is cleaning and disinfection being done/monitored?How are they being dumped? Use products to eliminate dumping (e.g, Hygie, Verna-care)Post signs if necessary to ensure dedicated washroom. Should not be used for HCW hand washing.
79Do your environmental cleaning staff use a cleaning checklist for ill resident’s rooms? If you are interested in copies of this checklist it is posted on our website at
80Environmental Cleaning Best Practices Educational Toolkit For more information:This toolkit has been designed to support Environmental Services Managers and Infection Control Professionals in providing training to staff regarding effective procedures for environmental cleaning. The program supports the Provincial Infectious Disease Advisory Committee’s (PIDAC) Best Practices document for Environmental Cleaning for Prevention and Control of Infections in all Health Care Settings. Each section of the toolkit is comprised of a narrated training presentation and additional support materials (there are 6 Modules). For more information or you can access it online at the Public Health Ontario (PHO) website.
81Resident Accommodations Ill residents should remain in their room:Private room preferredIf in a multi-bed room, draw curtain around ill residentKeep 2 metres from other residentsMeals should be eaten in their roomIf a resident has to leave their room:For respiratory symptoms, resident should wear a maskFor enteric symptoms, the resident should be limited to using their own washroomSee page 32 of ‘Control of Gastroenteritis Outbreaks in LTCHs – Control Measures for Residents’, MOHLTC Sept 2011.
82Length of IsolationResidents with enteric symptoms should be isolated in their rooms until 48 hours after their symptoms have resolvedResidents with respiratory symptoms should be isolated in their rooms until 5 days after symptoms onset or until symptoms have completely resolved (minimum 48 hrs or whichever is shorter)Isolation should only be done as long as it does not cause the resident undue stress and can be done without using restraints
84Workload Management Institute staff cohorting Outbreak plans need to address varying levels of available staff to ensure continued provision of care and full implementation of infection control measures
85Admissions/Transfers New resident admissions should not occurRe-admission of cases from a hospital is permitted with appropriate accommodation and careRe-admission of non-cases from a hospital is generally not permittedResident appointments if non-urgent need to be rescheduledMeasures may be altered as the outbreak comes under control. Each re-admission has to be assessed in consultation with Public Health.The following should be considered:Outbreak under controlPhysician approvalAppropriate accommodationAdequate staff to care for residentInformed consent obtained
86Staff and Volunteer Health Ill staff and volunteers to be excluded until no longer infectiousFor enteric outbreaks, exclude staff until they are 48 hours symptom-freeFor respiratory outbreaks, exclude staff for 5 days after symptom onset or until symptoms have completely resolved (minimum 48 hours or whichever is shorter)Staff that become ill at work should report to IC/OH
87Visitor RestrictionsLarge group activities should be cancelled on the affected unit or facility depending on situationVisitors advised not to visit when illDiscourage children under the age of 12 from visitingGroup activities should be cancelled on the affected unit or facility depending on the situation – consult with Public Health if needed.
88Visitors to LTCH Pamphlet Contains the following information:Hand hygieneRespiratory etiquettePlanning a visit to a LTCHFood safetyOnline atThis resources is available on our website in the following languages: English, Chinese, Russian, Italian, Farsi, Tamil
89Education Resident and Visitor education to include: Proper hand hygiene methods and when to perform hand hygieneRoutine practices and, in specific instances, proper use of PPETransmission and prevention of disease including the requirement not to visit the LTCH when they are illOutbreak management –what to expect (such as visitor restrictions)Outbreak management – what to expect: staff changes (e.g., cohorting, use of antivirals, etc.), increased use of PPE, isolation carts, increased cleaning and disinfection, changes to routineThis education would also include roommates of those in a Retirement Home and any visitors
90Education Staff and Volunteer education to include: Transmission and prevention of infectionsRoutine Practices (including hand hygiene) and Additional PrecautionsCleaning and disinfecting of shared equipment and environmental surfacesFood safetyOccupational Health policiesRoutine daily surveillance for signs of infectionRoles and responsibilities of staff, administration, the ICP, and Public HealthSpecimen collection methodsOutbreak management and control
91Outbreak P&PsAll outbreak P&Ps should be updated annually or as needed in consultation with Public Health
92Outbreak P&Ps should cover these topics as discussed today: Outbreak management team compositionCommunication during an outbreakSpecimen collectionFood Safety for Enteric OutbreaksEducation of staff, volunteers and visitorsInfluenza outbreaksControl MeasuresControl measures include: PPE, cleaning and disinfection, accommodation, staff and volunteer health policy, visitor policy
93Influenza Outbreaks Policies should address the following: Annual influenza vaccination for residents and staffExclusion for non-immunized staff during an influenza outbreakAntiviral useCollection of nasopharyngeal swabsObtaining consent for prophylaxis with antiviralsObtaining pre-approved orders from physicians for antiviral prophylaxisInfluenza and pneumococcal (residents only) vaccination rates for staff and residents should be provided to the Public Health Coordinator - package will be sent out to every home in the fallCreatinine clearance should be taken at the beginning of every season for all residents
94QUESTIONS?Un-mute your phone (*6) and ask questions over the phone line or through the chat box.After today, if you have any IPAC related questions, please call your Public Health Liaison at or or visit our website atYou will be sent an evaluation via in the next few days and we would appreciate your feedback on the webinar.
95References PIDAC Best Practice Documents: Current PIDAC documents can be downloaded from the following website:Control of Gastroenteritis Outbreaks in Long-Term Care Homes, MOHLTC, 2011A Guide to the Control of Respiratory Infection Outbreaks in Long-term Care Homes, MOHLTC, 2004Laboratory Guide for Gastroenteritis Outbreaks available at: