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TRANSMISSION-BASED PRECAUTIONS FOR HOSPITALIZED PATIENTS

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1 TRANSMISSION-BASED PRECAUTIONS FOR HOSPITALIZED PATIENTS
ISOLATION PRECAUTIONS TRANSMISSION-BASED PRECAUTIONS FOR HOSPITALIZED PATIENTS Based On CDC Guidelines 2007 \\Spefp01\groups1\hr dept\SRN Staff\COMPETENCIES\INITIALS\TRANSMISSION BASED PRECAUTIONS\Transmission Based Precautions-MRSA-SLM.ppt Infection Control 1

2 2003 Guidelines 2007 Guidelines
ISOLATION PRECAUTIONS 2003 Guidelines 2007 Guidelines The term “Nosocomial” Healthcare Associated (HA) Cough etiquette during flu season Respiratory Hygiene/Cough Etiquette now a part of Standard Precautions- year round Negative Pressure (TB) Rooms Airborne Infection Isolation Room (AIIR) Categories: Airborne, Droplet, Contact and RO (Resistant organism) Isolation Airborne, Droplet and Contact Precaution signs- Airborne, Droplet, Contact, RO, Stop –Childhood Illness RO sign deleted Contact sign now green Yellow “hand wash soap and water only” added All signs stay posted until terminal cleaning completed Family and visitors not encouraged to wear N95 respirator when visiting a patient in Airborne Infection Isolation Families and visitors will be offered the N95 respirator mask-nursing will offer education on the proper use as indicated Family and visitors do not wear gowns and gloves while visiting in a contact isolation room Family and visitors are encouraged to wear the appropriate PPE when assisting with direct patient care CDC Guidelines 2007 Infection Control 2

3 New Name Transmission Based Precautions for Hospitalized Patients
To emphasize the reason for precautions Method of transmission Was titled Isolation Precautions for Hospitalized Patients

4 Reasons Behind the Changes
ISOLATION PRECAUTIONS Reasons Behind the Changes healthcare delivery has moved from primarily acute care hospitals to other healthcare settings (e.g., home care, ambulatory care, free-standing specialty care sites, long-term care) the emergence of new pathogens (e.g., SARS and Avian influenza in humans) renewed concern for evolving known pathogens (e.g., C. difficile, Noroviruses, community associated MRSA) CDC Guidelines 2007 Infection Control 4

5 Visitor Requirements Airborne Droplet Contact
ISOLATION PRECAUTIONS Visitor Requirements Hand Hygiene Upon Entering and Leaving the Room. Airborne Droplet Contact …An N95 mask will be offered …Standard mask will be offered …Gown and gloves are encouraged if visitors are assisting with direct patient care Updated P&P #05300 Transmission Based Precautions Infection Control 5

6 ISOLATION PRECAUTIONS - 2000
Standard Precautions Prevents contact with blood or other potentially infectious materials. Involves Hand Hygiene and glove use as the most important procedure for prevention of infection. Wear gloves when: Handling blood, body fluids, excretions & secretions Surfaces, materials & objects are visibly soiled with them Contact with non-intact skin (includes rashes) and mucous membranes is expected. Wear facial protection when face likely to be splashed with blood or body fluids. Wear gowns when clothing may become soiled with body fluids, blood, secretions or excretions. Infection Control 6

7 ISOLATION PRECAUTIONS - 2000
Hand Hygiene Alcohol based hand gel is more effective than soap and water on most organisms Use before and after each patient Apply product to palm of one had and rub hands together Cover all surfaces of hands and fingers until hands are dry Fast acting and cause less skin irritation than soap and water Hands visibly soiled must be washed with soap and water Precautions for Clostridium difficile include: Performing handwashing with only soap and water C. Diff is a spore that is NOT killed by alcohol based hand gel Teach visitors about importance of proper hand hygiene Infection Control 7

8 Hand Hygiene: Gloves and Fingernails
ISOLATION PRECAUTIONS Hand Hygiene: Gloves and Fingernails The use of gloves does not eliminate the need for hand hygiene Likewise, the use of hand hygiene does not eliminate the need for gloves Gloves Reduce hand contamination by 70-80% Prevents cross-contamination Protects patients and health care personnel from infection Artificial fingernails or extenders are not permitted for staff having direct contact with patients Artificial fingernails are defined as “the application of a product to the nail to include but not limited to acrylic, overlay, tips, extensions, gels or silk wraps. Keep all natural nail tips less than ½ inch long. See P&P for further information. Infection Control 8

9 Initiation of Transmission-Based Precautions
ISOLATION PRECAUTIONS Initiation of Transmission-Based Precautions Physician’s responsibility: indicate infectious disease that is known or suspected Nurse responsibility: initiates appropriate precautions as indicated by laboratory or clinical results or physician diagnosis notifies admitting physician if not already informed. Infection Prevention personnel: may be consulted for clarification when appropriate has authority to supersede the patient's physician decision regarding need for precautions when the safety of patients, personnel, or visitors is a concern. Infection Control 9

10 Patient Placement When possible, patients with highly transmissible or epidemiologically important microorganisms are placed in a private room with hand washing and toilet facilities. If private room not available and the patient does not use a bedpan: patient not to use a community bathroom place dedicated commode at bedside if commode must be used for another patient, clean it thoroughly with approved hospital disinfectant (arms, seat, bucket, legs) and allow to dry A private room for source patient: has poor hygienic habits cannot assist in maintaining infection control precautions When a private room is not available: may be placed with appropriate roommates: i.e. patients infected or colonized with the same microorganism can share a room staff use appropriate barriers between patient contacts. postoperative patient should not share a room with a patient who has a draining wound

11 Airborne Precautions Airborne precautions sign
ISOLATION PRECAUTIONS Airborne Precautions Airborne precautions sign Childhood diseases stop sign Place on door if patient has a childhood illness, e.g. measles, mumps or chicken pox Infection Control 11

12 Airborne Precautions Diseases
ISOLATION PRECAUTIONS Airborne Precautions Diseases Tuberculosis, confirmed infectious case - diagnosed with pulmonary or laryngeal TB by positive culture. Tuberculosis, suspected infectious case - a respiratory specimen is positive for AFB, or the physician indicates TB is highly possible. Large draining tuberculosis wounds with culture swabs that are positive for AFB, or the physician indicates TB is highly possible. Rubeola virus (Measles), confirmed or suspected. Chickenpox, confirmed or suspected. Disseminated Varicella zoster, confirmed or suspected. (Disseminated zoster is diagnosed when the patient has 30 or more lesions out side of the affected dermatome.) Infection Control 12

13 Airborne Precautions Diseases
ISOLATION PRECAUTIONS Airborne Precautions Diseases Localized Varicella zoster in immunocompromised patient. SARS (Severe Acute Respiratory Syndrome) confirmed or suspected infectious case. (See Attachment A) Viral Hemorrhagic Fevers Other unusual viruses or bacteria suspected of being transmitted via airborne route. Infection Control 13

14 Specifications of Airborne Precautions
ISOLATION PRECAUTIONS Specifications - ROOM Room will have negative air pressure in relation to corridor. Keep door closed. (See Attachment D for specific rooms). Nursing unit personnel should notify Engineering department that the negative air pressure room needs to be monitored daily, unless the nursing unit already monitors routinely. In the event negative air pressure is lost, contact Engineering to initiate back-up support to sustain negative air pressure in Airborne Infection Isolation Room. When no Airborne Infection Isolation Room is available, contact Infection Prevention for further assistance and place a standard mask on the patient. Infection Control 14

15 Specifications of Airborne Precautions
ISOLATION PRECAUTIONS Specifications - SIGN Post Airborne Precautions sign outside of the room. When Airborne Infection Isolation precautions are discontinued, the room should remain closed with the sign posted until the air inside is totally exchanged. Specifications - MASK/Hood Masks for Airborne precautions (N95 Particulate Filter Respirator) are specially designed to filter particles the size of the TB organism. This mask is to be worn by all health care workers. The N95 mask must be fit tested annually to ensure mask fits properly. Those who fail the fit testing will wear a hood/PAPR (personal powered air-purifying respirator with a HEPA filter). The N95 mask may be worn more than once as long as the mask is clean, dry and intact. The mask must be worn each time the room is entered and removed after leaving the room. Place a regular mask on patient during transport (N95 mask is not necessary) Infection Control 15

16 Duration of Airborne Precautions
ISOLATION PRECAUTIONS Suspected TB patient may be removed from precautions if the respiratory specimen fails to show AFB and the physician rules out active TB. For confirmed cases of TB, precautions are maintained until three (3) sputum AFB smears, taken at least 8 hours apart, with at least one being an early a.m. specimen, are negative. For confirmed cases of Chickenpox, precautions are maintained until lesions are crusted over. Infection Control 16

17 Droplet Precautions Diseases
ISOLATION PRECAUTIONS Droplet Precautions Diseases Infection Control 17

18 Droplet Precautions Diseases
ISOLATION PRECAUTIONS Mumps Rubella* Parvovirus Meningococcal disease (meningitis) Pertussis Mycoplasma pneumoniae Pneumonic plague Diphtheria, pharyngeal Respiratory Syncytial Virus (RSV) Rhinovirus SARS-associated coronavirus Streptococcus Influenza, confirmed or strongly suspicious * = childhood illness. Infection Control 18

19 Specifications & Duration of Droplet Precautions
ISOLATION PRECAUTIONS Specifications & Duration of Droplet Precautions Specifications Private room, door closed. Standard mask is worn when in the room. Post "Droplet Precautions" sign outside patient room. Post Childhood Illness ("Stop") sign when a patient has any disease in the list that is preceded by an *. Personnel who are immune to the * diseases do not need to wear a mask. Duration of Precautions Refer to table in Attachment A in policy #05300. Infection Control 19

20 CONTACT PRECAUTIONS GOWN GLOVES
ISOLATION PRECAUTIONS CONTACT PRECAUTIONS GOWN GLOVES REQUIRED UPON ENTRY BY ALL HEALTHCARE WORKERS VISITORS SHOULD CHECK WITH THE NURSE BEFORE ENTERING ___________________________________________________ VISITANTES DEBEN DE REPORTARSE CON LA ENFERMERA ANTES DE ENTRAR Infection Control 20

21 ISOLATION PRECAUTIONS - 2000
Contact Diseases or Colonization/Infection with Microorganisms Requiring Precautions Diseases may be transmitted via direct and indirect contact With direct contact microorganisms are transferred from one infected person to another person (without a contaminated intermediate object or person) Examples of Direct contact transmission between patients and healthcare personnel include: blood or other blood-containing body fluids from a patient directly entering a caregiver’s body through contact with a mucous membrane or breaks (i.e., cuts, abrasions) in the skin. Infection Control 21

22 Contact Precautions Diseases
ISOLATION PRECAUTIONS Contact Precautions Diseases Scabies Pediculosis Shingles, localized Congenital Rubella Diphtheria, cutaneous Furunculosis, Staphylococcus Rotavirus Impetigo RSV Major draining wounds (Staph/Strep) not contained in dressing Hemorrhagic fevers* Clostridium difficile* MRSA* VRE* ESBL* and organisms labeled MDRO* *lab will notify the nursing unit when these organisms are identified Infection Control 22

23 Contact Precautions Private room door may be open
ISOLATION PRECAUTIONS Contact Precautions Private room door may be open Contact Sign will be posted In addition “Clean Hands with Soap and Water Only” sign may be posted for patients with C difficile Patients with the same resistant organism during current admission may be cohorted in the same room Gown/gloves will be worn upon entering the room Please contact the AL for appropriate placement Infection Control 23

24 Contact Precautions The patient may leave the room to ambulate, but must clean their hands using the waterless alcohol-based hand sanitizer or wash their hands with soap and water before ambulating. Patients infected with Clostridium Difficile must wash their hands with soap and water. a) Patient should limit contact with the environment when outside the transmission-based precautions room. b) Patient must wear a clean hospital gown over the gown they are wearing. c) Failure to comply with policy will restrict patient to their room

25 Patient Equipment & Supplies
ISOLATION PRECAUTIONS Patient Equipment & Supplies Use disposable (single patient) BP cuff, stethoscope and thermometer. Keep the equipment in the patient room during use, and send home with patient when discharged. Send single use items and any items that cannot be wiped with hospital approved disinfectant home with the patient or discard the items upon discharge (gauze dressings, etc.) If patients are being cohorted one patient may use the bathroom toilet and the other will use a bedside commode dedicated to the patient Infection Control 25

26 Isolation Supplies-”PPE Supply Stations”
ISOLATION PRECAUTIONS Isolation Supplies-”PPE Supply Stations” Personal Protection Equipment (PPE) Supply Containers are placed outside rooms of patients requiring transmission based precautions Unit will be stocked appropriately with hospital items (not magazines, books, etc.) and not overstocked Following patient discharge the supplies will be removed and the holder will be cleaned with hospital approved disinfectant and will be stored in the designated area (determined by each patient care unit) Infection Control 26

27 Please Clean Hands with Soap and Water only
ISOLATION PRECAUTIONS For rooms in which the patient requires Contact Precautions due to C diff this sign will be posted and left in place until terminal cleaning performed Please Clean Hands with Soap and Water only Infection Control 27

28 Duration of Contact Precautions-MRSA
ISOLATION PRECAUTIONS Duration of Contact Precautions-MRSA MRSA – Maintain precautions for positive culture or swab during current hospitalization. If an attempt has been made to eradicate colonization/ infection, the patient may be screened for continued colonization/infection at the physician’s discretion. Culture/swab must be taken after patient has completed antibiotic therapy for MRSA and the first culture/swab must be obtained no sooner than 48 hours after completion of therapy. Infection Prevention will review these cases on an individual basis. Infection Control 28

29 Duration of Contact Precautions-VRE
ISOLATION PRECAUTIONS Duration of Contact Precautions-VRE Isolation precautions should remain in use until there are VRE negative culture results on at least three consecutive occasions, at least a week apart. Cultures are to be obtained from the original body site(s) if possible, and from stool or rectal swab. Infection Control 29

30 Duration of Contact Precautions- Other Organisms
ISOLATION PRECAUTIONS Duration of Contact Precautions- Other Organisms Precaution for other resistant organisms may be discontinued on a case by case basis Infection Control 30

31 Readmission of a Patient With Resistant Organisms
ISOLATION PRECAUTIONS Readmission of a Patient With Resistant Organisms Check face sheet under “IC section” for MRSA VRE Gram negative rods Infection Control 31

32 ISOLATION PRECAUTIONS - 2000
Readmission of the patient with a known history of resistant organism colonization/infection- MRSA MRSA known patients who are not on antibiotics specific for treatment of MRSA may be candidates for screening to see if colonization exists Swab nares and perineum (Refer to the Decision Tree for patients Re-admitted with the IC: MRSA.) Swabs will be submitted for rapid molecular diagnostic testing or traditional culture, depending upon specific entity procedures and the results will be reviewed by the lab If results are negative the nurse can contact Infection Prevention who will remove the MRSA coding on the admit facesheet IC code field Patients with wounds will be cleared on an individual basis by Infection Prevention. Note: at this time (2008) PCR testing is only performed on MRSA readmissions. Other organisms are screened via cultures Infection Control 32

33 Readmission of the patient with a known history of VRE
ISOLATION PRECAUTIONS Readmission of the patient with a known history of VRE Patients with a history of VRE place them in Contact Precautions and obtain orders for VRE screening cultures and off antibiotic If VRE culture results on at least three consecutive occasions, at least a week apart are negative the nurse will notify Infection Prevention to remove the patient from precautions Cultures are to be obtained from the original body site(s) if possible, and from stool or rectal swab. Infection Control 33

34 Visitors Visitors in the Transmission-Based Precautions Rooms
ISOLATION PRECAUTIONS Visitors Visitors in the Transmission-Based Precautions Rooms All visitors should be instructed to perform hand hygiene before and after patient contact. Visitors in rooms of patients with Clostridium difficile should be instructed to wash their hands with soap and water. Airborne Precautions for the TB patient: For visitors, offer a TB mask and instruct on its use prior to the visitor entering the negative pressure room. The patient will need to wear a standard mask in the presence of children. The patient will wear a standard mask when outside the negative pressure room. Droplet Precautions: Visitors should wear the standard mask. Contact Precautions: Gowns and gloves are encouraged if participation in direct patient care is anticipated. If the patient has Lice or Scabies, the patient’s physician should be alerted to the need to assess the household members for the need for treatment of the same condition. Animals are not permitted in transmission-based precautions rooms except as stipulated in The SHC policy #05625, Animals in the Workplace. Infection Control 34

35 Airborne Infection Isolation and Room Exchanges
ISOLATION PRECAUTIONS Airborne Infection Isolation and Room Exchanges Following Discharge of a Patient Requiring Airborne Precautions, the door must be left closed for the period of time indicated below Regular Patient Room 90 minutes Regular Patient Treatment room Airborne Designated Patient Room (AIIR) 30 minutes Medical Air Unit OR Suite Infection Control 35

36 MRSA Screening of the Previously Positive Patient
January 2008

37 Objectives Identify patients with a previous history of Methicillin-resistant Staphylococcus Aureus (MRSA) colonization Perform the screening procedures for obtaining appropriate specimens prior to or upon admission to the hospital admission hospital Demonstrate proper specimen collection technique

38 Brief History of MRSA Over the last decade, MRSA has increased from 38% of Staph aureus infections to greater than 60% of infections Penicillin became available in the 1940Penicillin 1940’’ Within ten years, Staph aureus began to develop resistance 90% of community acquired and hospital acquired Staph aureus infections are resistant to the penicillin infections class drugs Methicillin is the test for penicillin resistance

39 Isolation Utilization
Appropriate use of isolation is an important tool to help decrease transmission of MRSA between patients and staff Isolation impacts patients and staff through: Increased financial costs (supplies, blocked beds) High emotional costs (to patient) Workflow disruption (donning isolation gear)

40 MRSA Statistics Patients with MRSA infections have:
Double the mortality rate of other blood stream infections Longer hospital length of stay Annual cost of treatment of MRSA infections in US hospitals is $3.2 – 4.2 billion

41 Setting for Screening Screening occurs at initial point of entry to our system: Emergency Department Pre-anesthesia Admission Evaluation Service (PAES) for elective surgical patients Triage Any other nursing unit

42 Scope of Supervision MRSA Screening is a Procedure that is implemented by a physician order. All patients with a history of MRSA are screened on entry to the hospital

43 PCR Technology vs. Cultures
PCR (polymearase chain reaction) identifies DNA fragments of a specific bacteria; in this case, MRSA. The test results can be obtain very quickly i.e. within hours. Cultures are specimens placed in a media which feeds a specific bacteria allowing it to grow and usually takes up to 3 days to identify MRSA.

44 Screening Procedure Step One: Determine history of MRSA by asking the patient if: They have ever had MRSA If so, have they received treatment for MRSA within the past 48 hours Step Two: Determine history of MRSA by: Review the Infection Control (IC) field on patient’s face sheet

45 Screening Procedure Bactrim Vancomycin Doxycycline Linezolid Tetracycline Daptomycin Rifampin Clindamycin Mupirocin Tigarcycline Step Three: Inquire whether the patient has received any of the following antibiotics within the past 48 hours If the patient has received any of the above medications, NO further screening is required & place patient in Contact Precautions.

46 MRSA Screening Exclusion Criteria
MRSA Screening Not Indicated if the patient has a(n): Active infection with MRSA Previous MRSA infection (within the past 48 hours) treated with antibiotics NO FURTHER screening is necessary

47 MRSA Specimen Collection
Prior to obtaining, verify if specimens were collected pre--admission (ED,PAES, Physicians office) Collect specimens from nares and perineum if no open wounds are present.

48 Appearance of MRSA

49 MRSA Specimen Collection
If the patient has an open wound, swab: Nares Perineum Wound Lesions Abscesses If the patient has a tracheostomy or tubes/drains, swab: Tube exit sites Notify the Infection Control Practitioner by phone or mail that specimens have been collected

50 Collecting Nares Specimen
Educate patient Have the patient sit facing you Use both swabettes provided One per nostril Swab UP TO the anterior fold only Gently swab in a circular fashion FIVE times

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

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

53 Specimen Labeling and Disposition
Label specimen bag with the patient identification sticker Send specimen to lab

54 How to Order in Carecast
Go to Orders in Carecast & enter “MRSA” in the Non Med Orders field Then Select “MRSA mol”

55 How to Order in Carecast
Select “perineum” under Source; “nares” also available for selection

56 How to Order in Cerner Enter required fields as appropriate.
Add an order & search for “MRSA”. Select “MRSA Molecular Amp”. Enter required fields as appropriate.

57 Prescheduled Surgery Screening
Prior to prescheduled surgery, the PAES nurses screen patients who are able to come to the PAES clinic and collect specimens from the nares, and perineum when indicated. If unable to collect all needed specimens, the PAES nurse places a Physician Order Sheet on the patient’s chart indicating which sites still need a specimen collected.

58 Patient Education on Screening
If the specimen is obtained prior to hospital admission, the PAES RN will notify the surgeon of all positive results if results are available prior to the day of surgery If the final results are unavailable upon admission, the patient is placed in isolation, pending results of screening

59 Screening Results The Infection Control Practitioner reviews the results of all screens If all PCR or culture results are negative, the MRSA designation is removed from the patient face sheet by the Infection Control Practitioner The patient will no longer require isolation Only 1 negative culture/PCR from each site is necessary If the results return on the weekend, notify the Infection Control Practitioner so that the designation can be removed from the face sheet

60 Further Tests During Hospitalization
If the results are positive, the patient remains in isolation Infection Control Practitioner may order additional specimens to further assess colonization

61 Contact Precaution Guidelines
Patients are to be placed in a private room Patients can ambulate in the halls, however they must perform hand hygiene before and after leaving the room and not be allowed in other patient care areas. For mother/baby isolation, the mother and infant will remain in isolation together.

62 Benefits of Screening Current screening of patients with a history of MRSA results in % clearance rate – meaning these patients are no longer infected or colonized and do not need isolation Screening makes a difference for our patients and the care they receive

63 References/Credits Submitted:
Gina Newman, RN, Infection Control Practitioner, SMH Shannon Oriola, RN, CIC Infection Control Practitioner, SMMC Joan Ausloos, RN, PAES, SMH Bobbie Bochichio, RN, PAES, SMH Susan Moore, RN, Senior Specialist, SMH Monee Gagliardo, RN, Infection Control Practitioner, SMBHW


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