1. Back to Basics ….& the Newest Version of the New Normal for Office Settings Suzanne Rhodenizer Rose RN BScN CIC Patsy Rawding RN BScN CIC Provincial Infection Control Consultants NS Department of Health

2. Objectives Review the Chain of Infection. Discuss Routine Practices & Additional Precautions. Explore prevention strategies in primary care settings. Review personal protective equipment (PPE).

3. Chain of Infection Causative Agent Reservoir Portal of Exit Mode of Transmission Portal of Entry Susceptible Host

4. Routine Practices The standard of care for ALL people during ALL care in ALL health care settings. Routine Practices are activities that you do to help reduce your risk of being exposed (or have potential to deal with): –Blood and body fluids –Secretions and excretions (except for sweat) –Non-intact skin –Mucous membranes

5. Routine Practices cont’d Various components to Routine Practices –Hand hygiene. –Cleaning & disinfection. Patient care equipment Environment –Safe sharps handling. –Use of PPE as indicated. Mask Gloves Gowns Eye protection

6. Routine Practices & Risk Assessment Based on the type of interaction you are going to have rather than the diagnosis or disease. Hand hygiene – need we say more?.......... we will If you are going to touch blood, body fluids, mucous membranes or non-intact skin…… If you are going to come in contact with potentially contaminated surfaces……

7. Routine Practices & Risk Assessment cont’d If you are going to be splashed or sprayed…. If your clothing is likely to become contaminated….. Perform a risk assessment before each patient interaction.

8. Hand Hygiene Traditional hand washing vs alcohol-based hand sanitizers. Proper technique essential! When, you ask? –Before and after patient care –After handling contaminated equipment –After the washroom – really!? –Before and after eating –After coughing and sneezing (respiratory hygiene works well too!) Jewelry can harbour germs and make hand hygiene difficult.

9. Cleaning & Disinfection Equipment and surfaces contaminated with secretions from patients should be cleaned before use with another patient: –Stethoscopes –Examining table –B/P cuffs

10. Cleaning & Disinfection Ensure multi-use equipment is not used in the care of another client until it has been properly cleaned and re-processed. Do not re-use single use items. Use clean hands to handle clean equipment. Any equipment or device that comes in contact with mucous membranes, open areas or beneath the skin in sterile sites must be re-processed correctly. Single use items, such as a tourniquet or needle, are one-client use only and are disposed of properly.

11. Disinfection of Patient Care Equipment Spaulding system: devices categorized based on contact with patient & risk of infection. Non-critical- touches only intact skin or does not directly contact the pt ie. Stethoscopes. Semi-critical- contact with non-intact skin and/or mucous membranes I.e. laryngoscope blades. Critical- enter sterile body cavities, including the vascular system i.e. surgical instruments.

12. Disinfection of Equipment Non-critical items low level i.e. stethoscopes, B/P cuffs, examining tables. Semi-critical items high level i.e. vag speculums, respiratory therapy equipment. Critical items sterilization i.e. surgical instruments, prostate biopsy guides. Chemical products or processors are classed as low level, high level, or chemosterilant /sterilizers.

13. Disinfection of Equipment All reusable equipment requires cleaning i.e. stethoscopes. Cleaning vs disinfection. Cleaning removes organic debris Disinfection has microbial kill Items requiring disinfection must be thoroughly cleaned prior to disinfection. Single Use Only items should be discarded. Monitor reusable equipment for integrity i.e pillows, mattresses. Use routine precautions.

14. Disinfection of Equipment Low Level 3% hydrogen peroxide Quaternary ammoniums (ultra- quat) Phenolics Disinfectant wipes High Level Pasteurization Glutaraldehydes & OPAs (Cidex) Peracetic acid 6% hydrogen peroxide

15. Disinfection of Equipment Sterilization Ethylene oxide Autoclaving Steam sterilizer 2% glutaraldehydes Peracetic acid Remember: All disinfectants are not created equal!!

16. Environmental Surfaces Be aware of how you inadvertently contaminate the environment. –exam tables –exam lamps –door knobs Regular housekeeping practices. Need to clean before disinfection occurs –True for equipment & environmental surfaces

17. Hierarchy of Precautions Routine Practices Additional Precautions DropletContact Droplet/ Contact Airborne Airborne/ Contact ARO (MRSA) Contact

18. Contact Direct Indirect Vehicle Droplet Less than 2 metres Airborne Greater than 1 metre

19. Contact Precautions Refers to both direct and indirect contact. Patient care equipment/surfaces in direct contact with patient or infective materials require cleaning between patients. Handled equipment can become indirectly contaminated. Stool, respiratory secretions, drainage from lesions are common infective materials. PPE?

20. Droplet Precautions

21. Generated by the respiratory tract i.e coughing, sneezing etc. Droplets heavier and larger; can only be propelled a short distance. Maintain a minimum distance of 2 meters. Croup, Pneumonia, Colds, RSV, influenza, meningitis. PPE?

22. Airborne Precautions Remain suspended in the air for long periods of time. Widely dispersed by air currents & inhaled by susceptible hosts at a far distance from the source (such as a different unit!). Examples: Chicken pox, TB, Measles, Smallpox!

23. Let’s Talk AGMPs! Aerosol-generating medical procedures. –Endotracheal intubation –Bronchoscopy –CPAP/ BIPAP –Mechanical ventilation –Respiratory/ airway suctioning –Tracheostomy care –Aerosolized or nebulized medication administration Can produce aerosols and be a risk in respiratory infected patients i.e. with influenza.

24. Airborne Precautions Negative pressure room or single room with door closed. Fit tested N95 mask. Consider immunity or risk of exposure to airborne diseases, conducting AGMPs.

25. Get the Gear

26. Get the Gear! Gloves –Gloves provide an additional protective barrier between the HCW’s hands and blood, body fluids, secretions, excretions and mucous membranes. –Removed immediately after completion of care, before touching clean environmental surfaces. –Turn inside out when removing. –Hands must be washed immediately after removing gloves. –Vinyl, latex, nitrile.

27. Get the Gear! Gowns/Aprons –put on with the opening at the back, with edges overlapping. –tied at the waist and neck. –Remove wet gowns immediately as this allows microorganisms to pass through. used to protect uncovered skin and prevent soiling of clothing during procedures and activities likely to generate splashes or sprays. uniforms should be changed if soiled.

28. Get the Gear! Masks & eye protection –worn if within 2 metres of a patient with a respiratory infection –Whenever a mask is required, the HCW should also wear eye or face protection (i.e. goggles, safety glasses or face shield). Mask manners! –worn once and discarded. –changed if mask becomes wet. –always discarded into an appropriate receptacle. –covering both mouth and nose; both straps tied! –avoid touching mask while being worn. –NEVER dangle mask around neck, this practice causes contamination. All PPE should be removed before leaving the room and hand hygiene performed!

29. Donning & Removal What goes on first? –Gown –Mask –Goggles –Gloves What comes off first? –Untie gown in back –Remove gloves –Remove eye protection ( if wearing) –Remove mask using ties –Remove gown –Perform hand hygiene!

30. Precautions for the Flu Gloves –Gloves on room entry of patients/residents suspected or confirmed to have influenza. Gowns –Not required for the routine care of patients/residents suspected or confirmed to have influenza. –Gowns/aprons should only be used to protect uncovered skin and prevent soiling of clothing during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids, secretions or excretions. Masks/Eye Protection –Should be worn if within 2 metres of a resident with ILI –Whenever a mask is required, the HCW should also wear eye or face protection (i.e. goggles, safety glasses or face shield). All PPE should be removed before leaving the room Hand Hygiene –wash your hands, wash your hands, wash your hands!!! Meticulous hand washing with soap and water or waterless alcohol hand sanitizers will inactivate the virus.

31. In the Office….. Make Routine Practices truly routine! Screening: –signage posted outside the entrance asking that any patient with a fever and/ or new cough or other respiratory symptoms to perform hand hygiene and put on a surgical mask. –Can also occur when doing reminder calls.

32. In the Office….. Source control measures –Having a physical barrier between the receptionist and the patient. –Maintaining a 2 metre distance. –Educating the patient on hand and respiratory hygiene practices. –Placing the patient in a separate area of the office (e.g.: examination room). –Scheduling the appointment for the ILI patient at the end of the day, if possible.

33. Toys Soft toys should be removed. Hard non-porous toys should be clean and disinfected at the very least daily. To minimize risk associated with toys, remove and have parents bring in their childs own.

34. Ask Yourself These Questions….. Do I need protection because there is a risk of exposure to…..? Do I need protection because of the resident’s symptoms? Does my office or clinic have policies stipulating what I must do to provide patient care?

35. Resources Infection Prevention and Control Best Practices for Long Term Care, Home and Community Care including Health Care Offices and Ambulatory Clinics: http://www.chica.org/pdf/IPAC_best_practices_CCAR.p df http://www.chica.org/pdf/IPAC_best_practices_CCAR.p df Ontario Best Practice Manual : Cleaning, Disinfection and Sterilization In All Health Care Settings: http://www.health.gov.on.ca/english/providers/program/i nfectious/diseases/ic_cds.html http://www.health.gov.on.ca/english/providers/program/i nfectious/diseases/ic_cds.html Provincial Centre for IP &C: –Suzanne.Rhodenizer-Rose@gov.ns.ca 722-1244Suzanne.Rhodenizer-Rose@gov.ns.ca –Patsy.Rawding@gov.ns.ca 424-8254Patsy.Rawding@gov.ns.ca

36. Any Questions for Us?