1. Session 4: Standard and Transmission Based Precautions and Novel Approaches to Controlling the Spread of MDROs
Good afternoon, and welcome to Session 4 of today’s conference.
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2. Approaches to Controlling the Spread of MDROs
Our primary objectives in this session are as follows
Describe HICPAC/CDC precautions for preventing transmission
Understand literature on adherence to precaution measures
We would like to hear from you about your facility’s efforts to monitor and evaluate precaution measures and spread of infection
In this session, we will be describing HICPAC/CDC precautions and literature on preventing transmission. We are also going to conduct an exercise, whereby each person at your table will discuss efforts to implement and evaluate precautions measures, so be thinking about those topics now.
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3. Approaches to Controlling the Spread of MDROs
In this session, we are going to discuss
Standard and Transmission (including Contact) precaution guidelines
Literature on effectiveness of contact precautions, including Universal Glove and Gown
Other techniques such as Red Box Entry
Local efforts to control C. difficile or other MDROs
Some of the topics we will touch upon today include: [speaker, highlight content of slide]
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4. Precautions to Prevent Transmission of Infectious Agents
HICPAC/CDC has two tiers of precautions for preventing transmission
Standard Precautions
Intended for all patients in all healthcare settings, regardless of suspected infection
Transmission-based Precautions
Intended for patients who are known or suspected to be infected or colonized with infectious agents
There are two tiers for precautions, either Standard or Transmission based [ read definitions]
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5. Precautions to Prevent Transmission of Infectious Agents
Standard Precautions
Assume that every person is potentially infected or colonized
Hand Hygiene
Avoid unnecessary touching of surfaces in close proximity to patient
When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water
Standard precautions assume that every person is potentially infected or colonized. Standard precautions are basic common sense. And of course, there’s that Hand Hygiene again! HCWs should avoid touching surfaces in close proximity to the patient, and when your hands are visibly soiled, either a non-antimicrobial or an antimicrobial soap with water can be appropriate, if hands are washed properly.
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6. Precautions to Prevent Transmission of Infectious Agents
Standard Precautions
Hand Hygiene
If hands are not visibly soiled, or after removing visible material with non-antimicrobial soap and water, decontaminate hands
The preferred method of hand decontamination is with an alcohol - based hand rub
Alternatively, hands may be washed with an antimicrobial soap and water.
Frequent use of alcohol - based hand rub immediately following hand-washing with non-antimicrobial soap may increase the frequency of dermatitis
If hands are not visibly soiled [speaker, highlight content of slide]
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7. Precautions to Prevent Transmission of Infectious Agents
Standard Precautions
Perform hand hygiene:
Before having direct contact with patients
After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings
After contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure or lifting a patient)
If hands will be moving from a contaminated - body site to a clean – body site during patient care.
After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient
After removing gloves
Hand hygiene is necessary [ read the bullet points]
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8. Precautions to Prevent Transmission of Infectious Agents
Standard Precautions
Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile or Bacillus anthracis) is likely to have occurred
The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores
Soap and water are the preferred method of cleaning hands when you may have had contact with spores such as c. difficile or bacillus antracis. This is because [read last bullet]
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9. Precautions to Prevent Transmission of Infectious Agents
Standard Precautions
Do not wear artificial fingernails or extenders if duties include direct contact with patients at high risk for infection and associated adverse outcomes (e.g., those in ICUs or operating rooms)
Develop an organizational policy on the wearing of non – natural nails by healthcare personnel who have direct contact with certain patients
HCW workers should not wear artificial finger nails or extenders and facilities should have written policies on such. How about these nails for a beach vacation?
Summer décor?
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10. Precautions to Prevent Transmission of Infectious Agents
Personal Protection Equipment
When close to, or are handling, blood, body fluid, body tissues, mucous membranes, or areas of open skin, HCWs must use personal protective equipment, depending on the anticipated exposure, such as:
Gloves
Mask and goggles
Apron, gown, and shoe covers
Personal Protection Equipment include gloves, masks, goggles, gowns, and shoe covers. Some or all of these should be worn when a HCW is close to or handling blood, body fluid, tissues, mucous membranes, open skin.
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11. Precautions to Prevent Transmission of Infectious Agents
Transmission-based Precautions
Three categories
Contact Precautions
Airborne Precautions
Droplet Precautions
Now Transmission-based Precautions: There are three categories and they are: [read bullets]
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12. Precautions to Prevent Transmission of Infectious Agents
Transmission-based Precautions
Should be initiated when illness is first suspected, and discontinued only when the illness has been treated or ruled-out and the room has been cleaned
Contact precautions may be needed
Wear a gown and gloves
CRE, MDR-Ab, C. difficile and norovirus, and respiratory syncytial virus (RSV)
Transmission based precautions should be initiated when illness is first suspected and d/c’d only when the illness is resolved or ruled out AND the room has been cleaned.
Contact precautions include gown and gloves, airborne precautions such as negative pressure rooms and secure respiratory masks are initiated with airborne transmitted illnesses such as chicken pox, measles, and TB
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13. Precautions to Prevent Transmission of Infectious Agents
Transmission-based Precautions
Patients may need to wear a mask if they must leave their room
Droplet precautions are used to prevent contact with mucus and other secretions from the nose and sinuses, throat, airways, and lungs.
Influenza (flu), pertussis (whooping cough), and mumps
Wear surgical mask
Airborne precautions may be needed
Chicken pox, measles, and active tuberculosis (TB)
Patients should be in a negative pressure room
Secure respiratory mask before entering the room
And similarly, droplet precautions, such as surgical masks should be initiated when mucus and other secretions are a concern (w/ illnesses such as flu and whooping cough)
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14. Discontinuation of Contact Precautions
Per HICPAC 2006 guidelines: Unresolved “In general, it seems reasonable to discontinue Contact Precautions when three or more surveillance cultures for the target MDRO are repeatedly negative over the course of a week or two in a patient who has not received antimicrobial therapy for several weeks, especially in the absence of a draining wound, profuse respiratory secretions, or evidence implicating the specific patient in ongoing transmission of the MDRO within the facility.”
According to HICPAC, Contact Precautions, once instituted, should not be discontinued until three or more surveillance cultures are normal over a week or two after discontinuation of antimicrobial therapy for several weeks.
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15. Time for a movie quiz!
Hint: Zombie movie Answer: Dawn of the Dead

16. How well do we adhere to contact precautions?
Okay, so how well do you think healthcare facilities adhere to contact precautions?
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17. Contact Precautions for Multidrug Resistant Organisms (MDROs): Current Recommendations and Actual Practice
This study by Clock et al. was conducted in a network of three hospitals in New York City and sought to assess availability of contact precautions equipment and adherence to protocol by staff and visitors
A study by Clock et al, published in 2010, assessed 3 hospitals in NYC and adherence to protocol by staff & visitors
Clock SA et al. Am J Infect Control 2010;38(2):
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18. Contact Precautions for Multidrug Resistant Organisms (MDROs)
Results
January – June 2008, 424 patients observed
67% positive MDRO cultures for one organism
33% positive for 2 to 6 organisms
Most common VRE and MRSA
Provision of supplies
85.4% of room observations in the 60 day study period indicated contact precautions with a sign display
Approximately 95% of rooms with sign display had isolation carts
They observed over 400 patients in 2008, of which 67% were positive for MDROs, primarily VRE and MRSA. Adherence to sign display and isolation cards was pretty good, but not perfect.
Clock SA et al. Am J Infect Control 2010;38(2):
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19. Contact Precautions for Multidrug Resistant Organisms (MDROs)
Patient Care Staff had higher adherence rates for all contact precautions behavior, compared with other staff (52 to 70%)
Visitors wore a gown 43 to 64% of the time
Direct patient care staff had higher adherence to all contact precautions, but required gowning only occurred between 52 and 70% of the time. That could be considered poor adherence. Visitors were observed in the adult tertiary and community hospitals, and only 43-64% wore gowns. Again, this could be considered poor adherence.
Clock SA et al. Am J Infect Control 2010;38(2):
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20. Contact Precautions for Multidrug Resistant Organisms (MDROs)
Overall adherence rates on room entry and exit, respectively, were
19.4% (entry) and 48.4% (exit) for hand hygiene
67.5% and 63.5% for gloves
67.9% and 77.1% for gowns
Conclusions: Findings support the recommendation that methods to monitor contact precautions and identify and correct non-adherent practices should be a standard component of infection prevention and control programs
Looking at the hospitals in aggregate, adherence upon room entry was 19.4% for hand hygeine, 67.5% for gloving, and 67.9% for gowning. At exit, hand hygiene adherence across all three hospitals was 48.4%, adherence to de-gloving procedures was 63.5% and adherence to de-gowning procedures was 77.1%. The researchers concluded that measures to correct non adherence are very much needed.
Clock SA et al. Am J Infect Control 2010;38(2):
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21. Contact Isolation Precautions: More is not Necessarily Better
Kaye et al found a negative relationship between contact isolation precautions and compliance
Conclusions: Compliance with CIP was low across multiple hospitals.  Increased indications for CIP and burden of MDROs were associated with decreased HCW compliance.  Hospitals should weigh the implications of decreased HCW compliance when implementing widespread CIP, and consider targeting CIP practices towards MDROs that pose particular threats to their patient populations.
Kaye, et. al., Oral abstract presentation Decennial Saturday, March 20, 2010
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22. Why might HCWs not be adherent to precautions?
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23. Adverse outcomes associated with contact precautions: A review of the literature
Four main adverse outcomes related to Contact Precautions
Less patient-health care worker contact
Delays and more noninfectious adverse events
Increased symptoms of depression and anxiety
Decreased patient satisfaction with care
Morgan, et al. American Journal of Infection Control - March 2009 (Vol. 37, Issue 2, Pages 85-93)
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24. Local Example of Isolation Precautions Tool
Here is an example of an Isolation precautions checklist from one of our Texas facilities. This checklist helps identify potential gaps in adherence.
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25. Novel Approaches to Transmission Prevention
Now let’s talk about novel approaches to transmission prevention
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26. Taking Off the Gloves: Toward a Less Dogmatic Approach to the Use of Contact Isolation
Conclusion:
…..Most importantly, there is good evidence that a less restrictive alternative exists that has the advantage of being universally applicable and acting at multiple sites in the chain of events leading to HAI. For this reason, efforts to improve hand hygiene should be prioritized by all hospitals. If those efforts are successful, the role for contact isolation will be limited.
The is a movement in Infection Prevention and Epidemiology to de-escalate Contact Precautions. Kathryn Kirkland concluded this in her presentation to the Society of Epidemiology (SHEA) and her published article.
Kirkland; Clin Infect Dis. (2009) 48 (6):
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27. New Rules for Contact Precautions
Contact Precautions will be instituted for patients who have:
Diarrhea known or suspected to be infectious or toxin-mediated (e.g. C-diff), or diarrhea in a patient who is incontinent of stool, as detailed below:
Known infectious cause of diarrhea, even if patient is continent of stool or stool is contained in a diaper or device.
Patient is being tested for C. difficile or other form of infectious diarrhea
Patient is incontinent of stool regardless of cause unless the the stool is effectively contained in an incontinence brief or fecal collection device.
2.Draining wound that is not, or cannot be completely covered with a sealed dressing that contains the drainage (regardless of organism or infection)
3.Uncontrolled uncontained respiratory secretions (most commonly in trached patients, regardless of organism)
4.Selected specific infectious diseases (See “Isolation Guidelines 2007 for Specific Diseases” on the Infection Prevention Intranet Site)
5. Emerging MDROs that are defined by IP and ID
A Central Texas IP took Dr. Kirkland’s advice to heart and trialed her Contact Precautions policy for a year. These were the policy rules:
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28. Patient must be in a private room (door may be left open)
Contact Precautions require all of the elements of Standard Precautions, and in addition require the following:
Patient must be in a private room (door may be left open)
Gloves must be worn by staff whenever they enter the room.
Gowns must be worn by staff when they enter the room unless there will be NO contact with the patient or the patient’s environment.
Dedicated patient care equipment must be used when available. If dedicated equipment is not available, equipment must be disinfected between patients.
Limit transport and movement of patients outside of the room to medically necessary purposes.
***Contact Precautions may be discontinued when signs and symptoms have resolved for at least 24 hours or according to disease-specific recommendations, whichever is later.
Note: According to Standard Precautions gloves and gown are required for any contact with stool or items contaminated with stool.
Rules continued. They did continue to isolate “Emerging Resistant Organisms” which included CRE and MDR-A, as well as MDR pseudomonas.
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29. New Rules for Contact Precautions
No increase in MDR HAIs
3623 Nursing hours saved in one year
$291, 316 saved (if compliance was perfect before)
These were the results of the year’s trial. In light of the positive results, they made the new rules permanent and spread throughout their network.
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30. Red Box Entry
A hospital in Illinois created a 3 foot square area, marked by red duct tape at the entrance to patient rooms placed on contact precaution due to risk of infection spread.
Referred to as ‘safe zone’ where healthcare workers can interact with patients without donning personal protective equipment
Saves time donning clothing
Improved patient satisfaction
Increased staff productivity
No negative impact on HAI rate
One approach considered innovative to infection prevention is called the Red Box Entry. This comes from a facility in Illinois that created [read slide]. Has anyone here today tried this approach? What did you find?
Source: Accessed June 30, 2014
Webinar available at :
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31. 20 medical and surgical ICUs in 20 hospitals were randomized
Universal Glove and Gown Use and Acquisition of Antibiotic Resistant Bacteria in the ICU: A randomized trial
This study by Harris et al. sought to determine whether wearing gloves and gowns for all patient contact in the ICU decreased MRSA or VRE compared to usual care
20 medical and surgical ICUs in 20 hospitals were randomized
In the intervention group, all healthcare workers were required to glove and gown for all patient contact and when entering any patient room
Primary Outcome:
Acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from ICU
Now lets talk about the impact of instituting universal glove and gown use on MRSA and VRE rates. One study looked at 20 critical care units and randomly assigned units to either continue on as they were doing, or to universally require glove and gown for all patient contact when entering any room.
Harris AD et al. JAMA 2013;310(15):
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32. Universal Glove and Gown Use and Acquisition of Antibiotic Resistant Bacteria in the ICU: A randomized trial
Results
No differences in MRSA/VRE acquisition rates were seen between universal glove and gown and ‘usual care’
There were fewer MRSA acquisitions: 40.2% relative reduction in intervention vs. 15% reduction in control
Universal glove and gown
Decreased HCW room entry
Increased room-exit hand hygiene compliance
Had no effect on rates of adverse events
Adverse events were randomly sampled using the IHI Global trigger tool
The researchers found that while universal glove and gown did not reduce overall acquisition rates, the protocol did appear to reduce MRSA acquisitions in particular. There were some mixed consequences of universal glove/gown precautions as well. HCWs entered patient rooms less frequently but appeared to improve their hand hygiene compliance. There was no impact on adverse event rates, although this seems to be expected.
Harris AD et al. JAMA 2013;310(15):
Griffin F, Ressar R. IHI global trigger tool for measuring adverse events IHI Innovation Series White Paper (second ed)
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33. Session 4

34. Core Measures for All Acute and Long-term Care Facilities
Hand Hygiene
Promote hand hygiene
Monitor hand hygiene adherence and provide feedback
Ensure access to hand hygiene stations
Contact Precautions Acute care
Place CRE colonized or infected patients on Contact Precautions (CP)
Preemptive CP might be used for patients transferred from high-risk settings
Educate healthcare personnel about CP
Monitor CP adherence and provide feedback
No recommendation can be made for discontinuation of CP
Develop lab protocols for notifying clinicians and IP about potential CRE
Long-term care
Place CRE colonized or infected residents that are high-risk for transmission on CP (as described in text); for patients at lower risk for transmission use Standard Precautions for most situations
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35. Core Measures for All Acute and Long-term Care Facilities
Patient and staff cohorting
When available cohort CRE colonized or infected patients and the staff that care for them even if patients are housed in single rooms
If the number of single patient rooms is limited, reserve these rooms for patients with highest risk for transmission (e.g., incontinence)
Minimize use of invasive devices
Promote antimicrobial stewardship
Screening
Screen patient with epidemiologic links to unrecognized CRE colonized or infected patients and/or conduct point prevalence surveys of units containing unrecognized CRE patients
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36. Supplemental Measures for Healthcare Facilities with CRE Transmission
Conduct active surveillance testing
Screen high-risk patients at admission or at admission and periodically during their facility stay for CRE. Preemptive CP can be used while results of admission surveillance testing are pending
Consider screening patients transferred from facilities known to have CRE at admission
Chlorhexidine bathing
Bathe patients with 2% chlorhexidine
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37. Dealing with an Outbreak of C. difficile in a Children’s Hospital
Increase noted in high-risk frequent visit population
Cases mapped throughout affected patients' stays and clinic visits
Some common locations noted
Remedial education for care-givers and staff regarding proper hand hygiene, isolation, cleaning, etc.
One physician reported not knowing he was supposed to use soap and water for hand-hygiene
EVS reminded to use bleach for cleaning of isolation rooms
Took an estimated 2 months to see significant drop, but levels returned to baseline and remain
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38. Questions and Discussion
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39. What novel approaches to prevention have you implemented in your facility?
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