ࡱ> OQLMN` Jwbjbjss q<#o&,,,,,,,$PPH܈|P2dL"ҋҋҋQSSSSSS hH S,S,,ҋҋhӗӗӗ\,ҋ,ҋQӗQӗӗi,,YҋX ˅=NU~0^ ^ Y^ ,YZ@ӗG4{0SSodPPPJO$8PPPOPPP,,,,,, Model/Template Infection Control Policy for Outpatient Healthcare Facilities RationaleBasic strategies for preventing pandemic influenza are the same as those for seasonal influenza and many other infectious diseases: vaccination, early detection and appropriate treatment, and the use of infection control measures to prevent transmission during patient care. It is uncertain whether there will be time for the development of a vaccine for a pandemic; therefore, the ability to limit transmission in healthcare settings will rely heavily on exercising appropriate infection control measures. IntroductionThis policy should be read by all staff personnel. It is recognized that in an outpatient healthcare setting that office staff responsible for handling patient calls and scheduling may be the first person aware of patients that might have a highly contagious illness. Office staff should always consult the doctor or nursing staff if they have a triage/scheduling question. To prevent the spread of infection every healthcare facility should: 1. Report Communicable Diseases to Local and State Health Departments. a. Forms:  HYPERLINK "http://www.in.gov/isdh/form/communicable_forms.htm" http://www.in.gov/isdh/form/communicable_forms.htm Reporting rules: http://www.in.gov/isdh/publications/comm_dis_rule.pdf Guidelines for reporting and submitting specimens for avian influenza testing to state laboratory: http://www.in.gov/isdh/bioterrorism/PandemicFlu/LabInfo.htm 2. Orientate and provide all staff members access to a written Infection Control Policy. 3. Practice and Promote Hand Hygiene. Modes of Transmission: Seasonal and Pandemic InfluenzaEpidemiology studies indicate that transmission is generally spread through close contact (i.e. exposure to large respiratory droplets, direct contact, or near-range exposure to aerosols). Little evidence exists for airborne transmission over long distances or prolonged periods of time as seen in Tuberculosis. However, it is prudent to follow Airborne Precautions for strains of influenza exhibiting increased transmissibility during initial stages of an outbreak of an emerging or novel strain. Control of transmission for highly contagious illness and pandemic influenza in healthcare facilitiesVaccination of patients and healthcare personnel. Early detection. Antivirals to treat the ill and those indicated for prophylaxis. Limit contact between infected and non-infected persons. Confine patients to a defined area. Limit contact between nonessential personnel and ill patients with highly contagious illnesses including pandemic flu. Promote spatial separation in common areas (sit or stand at least 3 feet from potentially infectious persons) Appropriate barriers during patient care. See Use of Special Precaution Signs, page 3. Surgical mask. During pandemics and indicated illnesses, coughing person may wear either a surgical or procedure mask. N-95 masks (During initial stages of a pandemic outbreak or a highly transmissible strain; active tuberculosis) Gloves Gowns 6. Source Control Measures. a. Post signs to promote cough etiquette in common areas, e.g. elevators, waiting areas, lavatories. b. Ensure availability of tissues and no-touch receptacles for tissue disposal. c. Provide conveniently located dispensers of alcohol-based hand rubs. d. Place symptomatic patients in an exam room as soon as possible. 7. Education of staff and patients. a. Post signs for respiratory hygiene/cough etiquette. Poster available online at  HYPERLINK "http://www.cdc.gov/flu/protect/covercough.htm" http://www.cdc.gov/flu/protect/covercough.htm a. Educate all clinic personnel about infection control, especially occupational health issues related to pandemic influenza. b. Post signs in languages for populations served. c. Post instructions for patients and accompanying family to immediately report symptoms of respiratory infection as directed on signage. d. Symptomatic personnel should be sent home until they are physically ready to return to work, especially during a pandemic. Healthcare personnel who have an immune status should be prioritized for the care of patients with active infectious illnesses (e.g. varicella, rubeola). Inform staff at high risk (i.e. pregnant, immuno-compromised) about their medical risks and offer an alternate work assignment. 8. Special infection control procedures for patients suspected of pandemic influenza: a. Post visual alerts in appropriate languages at entrance to office instructing persons with respiratory symptoms to: Inform reception & healthcare personnel when they first register for care. Practice hygiene/cough etiquette. Triage patients calling for medical appointments during period of pandemic influenza: Discourage unnecessary visits to medical facilities. Instruct symptomatic patients about infection control measures to limit transmission in the home and when traveling to necessary medical appointments. Reduce exposure of persons at high risk for complication of influenza, i.e. postpone nonessential medical care. Occupational health issues: Healthcare personnel who have recovered from pandemic influenza should be prioritized for the care of patients with active pandemic flu. During a pandemic all symptomatic personnel should be sent home until they are physically ready to return to work. Inform staff at high risk, i.e. pregnant, immunocompromised, about their medical risks and offer alternate work assignments. Source control measures: Post signs to promote cough etiquette in common areas, (e.g. elevators, waiting areas, lavatories). Ensure availability of tissues and no-touch receptacles for tissue disposal. Provide conveniently located dispensers of alcohol-based hand rubs. Provide soap and disposable towels for hand washing at sinks. Plan for spatial separation. Encourage coughing persons to sit at least 3 feet way from other persons in common waiting room. Where possible designate separate waiting area for patients with symptoms of pandemic influenza. Post signs indicating separate waiting areas. Place symptomatic patients in an exam room as soon as possible. Offer and encourage use of procedure or surgical masks by persons with symptoms of pandemic influenza. e. Patient education for care of patients with pandemic influenza in the home: Encourage them to physically separate themselves from non-ill persons. Instruct patients not to leave the home during the period they are most likely to be infectious to others (i.e. 5 days after onset of symptoms). Wash soiled dishes and eating utensils in a dishwasher or by hand with warm water and soap. Handwashing for all persons following contact with influenza patient or environment in which care is provided. Separate laundry as usual, no special treatment. Wearing gloves and gowns not recommended for household members providing care in the home. Place tissues used by ill patient in a bag and dispose with other household waste. Place a bag for that purpose at the bedside. Keep home and environmental surfaces clean using household products.   Use of Special Precaution Signs Purpose/Policy:To prevent/control the spread of infection. To give healthcare workers a practical set of standards based on scientific principles, to follow in the care and placement of patients with potentially infectious disease or epidemiologically important pathogens. Procedure:Responsibility:Nursing personnel are responsible for determining whether a patient entering the clinic should be treated with special precautions. Nurses may place a patient suspected of a highly contagious or infective illness in an appropriate examination room and post a notice on the door to alert any staff member who might enter the room. A physicians order is not required. Notify Patients to Report Flu Symptoms: Post visual alerts (in appropriate languages) at the entrance to the clinic instructing patients and persons who accompany them (e.g., family, friends) to inform healthcare personnel of symptoms of a respiratory infection when they first register for care and to practice Respiratory Hygiene/Cough Etiquette. Standard of Care:Any patient suspected or known to have an infectious disease or an epidemiologically important pathogen will be given the same quality of care as all patients and will have total care within the specifications of their isolation needs. General:There are three types of precautions that require healthcare providers to wear personal protective equipment, PPE. Color coded signs should be attached to patient exam rooms in which PPE is needed. The reverse side of the color coded signs displays a list of possible diagnoses for the patient suspected of an infectious illness. Red sign for airborne precautions. Orange sign for droplet precautions. Yellow sign for contact precautions. White sign to caution staff for any special situations. Airborne Precautions:Airborne Precautions to be used in conjunction with Universal Precautions/Body Substance Isolation for patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (small particle residue, 5 microns or smaller in size) of evaporated droplets containing microorganisms that remain suspended in the air and that can be dispersed widely by air currents within a room or over a long distance. Droplet Precautions:Droplet Precautions to be used in conjunction with Universal Precautions/Body Substance Isolation for patients known or suspected to be infected with microorganisms transmitted by droplets (larger than 5 microns in size) that can be generated by the patient during coughing, sneezing, talking or the performance of procedures. Contact Precautions:Contact Precautions to be used in addition to Universal Precautions/Body Substance Isolation for specific patients known or suspected to be infected or colonized (presence of microorganisms in or on the patient but without clinical signs and symptoms of infection) with epidemiologically important microorganisms that can be transmitted by direct contact with the patient (hand or skin to skin contact that occurs when performing patient care activities that require touching the patients skin or indirect contact (touching) with environmental surfaces or patient care items in the patients environment.) 1. Airborne Precautions: Red Stop Sign Respirator-mask, gloves, and gown Procedure:Patients known or suspected to have the following illnesses should be placed on Airborne Precautions in addition to Universal Precautions/Body Substance. Isolation: a. Measles (Rubeola) for nonimmune staff. b. Varicella (including disseminated zoster) for nonimmune staff. Chicken Pox (NOT Shingles) Discussion: Shingles is due to reactivation of previously latent Varicella zoster virus infection. Shingles is a cutaneous eruption and unless disseminated (which only rarely occurs in immunocompromised patients) does NOT produce pulmonary infection. Shingles DOES NOT require Airborne Precautions. c. Tuberculosis d. Severe Acute Respiratory Syndrome (SARS) e. Smallpox f. During the initial stage of a pandemic outbreakPatient Placement:a. Door to room should be closed at all times. b. Place a Red Stop Sign on the door of the exam room to alert healthcare workers of the need for supplemental precautions. c. Eye protection must be worn when caring for a patient with SARS. d. Shoe covers must be worn when caring for a patient with Smallpox. Respiratory Protection:a. NIOSH (National Institute of Occupational Safety and Health) approved fit-tested respirator is to be worn by all healthcare workers when entering the room of a patient with known or suspected tuberculosis, SARS, and Smallpox. b. If the caregiver is not immune to varicella or rubeola, contact with the patient with known or suspected varicella or rubeola should not be made unless the caregiver is wearing a NIOSH approved fit-tested respirator. It is preferable to assign immune caregivers to these patients. Immune caregivers need not wear respiratory protection. Cleaning and Disinfection:a. The room should be left empty for a minimum of one hour for adequate air exchange to occur to remove any potentially infectious droplet nuclei. b. If cleaning is done prior to the aforementioned hour, respiratory protection must be worn. When coding a patient that is in Airborne Precautions: a. Place crash cart at the foot of the exam table. b. Designate a clean staff member to get items out of the cart. c. When code is terminated, the clean staff member will close all drawers of the crash cart. d. Remove cart from room. e. Wipe down the outside of the cart, backboard, and monitor/defibrillator with a hospital approved tuberculocidal disinfectant. f. Return crash cart to its designated place: ___________________________ Additional Precautions for Preventing Transmission of Tuberculosis:CDC website:  HYPERLINK "http://www.cdc.gov/nchstp/tb/pubs/dtbefax.htm" www.cdc.gov/nchstp/tb/pubs/dtbefax.htm  Additional Precautions for Preventing Transmission of SARS, and Smallpox:  Gloves and Handwashing: a. Gloves are to be worn when entering the room. b. Change gloves after having contact with infected material that may contain high concentrations of microorganisms. c. Gloves are to be removed prior to leaving the patients room and hands are to be washed immediately. d. After glove removal and handwashing ensure that hands do not touch potentially contaminated environmental surfaces. Gown: a. A gown is to be worn when entering the room. b. Gown should be removed before leaving the patients environment. c. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environment. Patient Care Equipment: a. Dedicate the use of non-critical patient care equipment to a single patient: Stethoscope, BP, thermometer, etc.  2. Droplet Precautions: Orange Stop Sign Gloves, gown, face mask (surgical or procedure masks) Procedure:Patients known or suspected to have any of the following illnesses should be placed on Droplet Precautions in addition to Universal Precautions/Body Substance Isolation/Separation:a. Haemophilus Influenza (meningitis or epiglottis) b. Neisseria Meningiditis (meningitis or sepsis) c. Pharyngeal Diphtheria (Corynebacterium dipthereae) d. Mycoplasma Pneumonia e. Pertussis (Bordella pertussis) f. Pneumonic Plague (Yersina pestis) g. Group A Streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children h. Rubella i. Mumps j. Methicillin resistant Staphyloccus Aureus (MRSA) Infection in the respiratory tract (sputum or sore/infection in mouth) or nasal colonization. k. Avian Influenza Patient Placement:Place an ORANGE STOP SIGN on the exam room door to alert healthcare staff of the need for supplemental precautions. PPE: Masks: surgical or procedure mask is indicated when working within three feet of the patient or when the performance of a task might cause the splash of bodily fluids. During a pandemic, one mask may be worn if multiple patients are visited within a short time. Other PPE (gloves and gown) must be changed between patients and hand hygiene performed. Gloves: a. For contact of body fluids and respiratory secretions (e.g. oral care, handling soiled tissues) b. Remove and dispose after use on patient, do not wash gloves. c. Perform hand hygiene after glove removal. d. If gloves are in short supply, establish priorities for glove use (i.e. during a pandemic). Use other barriers such as disposable paper towels and hand hygiene. Gowns: a. Most patient interactions do not necessitate the use of gown. Use during activities in which splash of bodily fluids might occur or there is a need to hold the patient close, ie pediatric setting. b. Disposable gown of synthetic fiber or washable cloth, full coverage. c. Worn only once and then placed in receptacle. Perform hand hygiene. d. If gowns are in short supply (i.e. during a pandemic) priorities should be established. Consider other coverings (e.g.. patient gowns) e. It is doubtful that disposable aprons would provide desired protection. PPE for special circumstances:N-95 mask for strains of influenza exhibiting increased transmissibility during initial stages of an outbreak of an emerging or novel strain. Also consider immune status of personnel and availability of antivirals. Staff wearing N-95 masks need to be fit-tested, received medical clearance, and trained. Room Cleaning:Follow routine policy. When coding a patient that is in Droplet or Contact Precautions: a. Place crash cart at the foot of the exam table. b. Designate a clean staff member to get items out of the cart. c. When code is terminated, the clean staff member will close all drawers of the crash cart. d. Remove cart from room. e. Wipe down the outside of the cart, backboard, and monitor/defibrillator with a hospital approved disinfectant. f. Return crash cart to its designated place:______________________ Additional Precautions for Preventing Transmission of Pandemic influenza:CDC website: www.cdc.gov/ncidod/hip/ppe/default.htm 3. Contact Precautions: Yellow Stop Sign Gloves and gown. Procedure:Patients known or suspected to have a serious illness easily transmitted by direct patient contact or by contact with items in the patients environment should be placed on Contact Precautions in addition to Universal Precautions/Body Substance Isolation. Infections for which Contact Precautions are appropriate are: a. Clostridium Difficile b. Enterohemorrhagic E. coli 0157:H7 c. Shigella d. Salmonella e. Hepatitis A f. Rotavirus g. Respiratory Syncytial Virus h. Pediculosis i. Scabies j. Vancomycin resistant Enterococcus (VRE) k. Methicillin resistant Staphylococcus Aureus (MRSA) (Orange sign for coughing patient with MRSA infection of respiratory tract.) l. Any multi-drug resistant organism m. Adverse Event Due to Smallpox Vaccine Ocular Vaccinia Blepharitis, Conjunctivitis, Iritis, and Keratitis Eczema Vaccinatum Generalized Vaccinia Progressive Vaccinia (Vaccinia Necrosum) Fetal VacciniaPatient Placement:Place a YELLOW STOP SIGN on the exam room door to alert healthcare staff of the need for supplemental precautions.Mask:a. A mask is indicated when working within three feet of the patient who has a MRSA infection or colonization of the respiratory tract or if the colonization status is unknown. Gloves and Handwashing:a. Gloves are to be worn when entering the room. They are not necessary for non- contact activities. b. Change gloves after having contact with infected material that may contain high concentrations of microorganisms (i.e.wound drainage). c. Gloves are removed prior to leaving the patients room and hands are washed immediately with antimicrobial soap or a waterless antiseptic agent. As always, it is important to turn the faucets off with paper towels to avoid recontamination of the hands. d. After glove removal and handwashing ensure that hands do not touch potentially contaminated environmental surfaces or items in the exam room to avoid transfer of microorganisms to other patients or environments. It is necessary to open the exam room door to exit by using a paper towel on the door handle. (Remember that anything that has been touched with a gloved hand will be contaminated.) e. Use soap and water to wash hands when caring for a patient with C-difficile. Do not use alcohol hand cleanser. Gown:a. A gown is to be worn when entering the room if it is anticipated that the healthcare workers clothing will have substantial contact with the patient or environmental surfaces. b. Gown should be removed before leaving the room. c. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients, staff, or environments. Patient-Care Equipment:a. Dedicate the use of non-critical patient care equipment for the exam room. (Examples: tourniquets, stethoscopes, thermometers, blood pressure cuffs). If it is absolutely necessary to use common equipment is imperative that the equipment be cleaned and disinfected with the appropriate agent:__________________________ Infectious Waste:a. Handle according to the clinics policy. Site: ___________________ b. Carefully place other waste into designated receptacle. Cleaning and Disinfection:a. Follow normal policy with the following supplements: i. Special attention should be made to environmental surfaces such as exam table, faucet handles, door knobs, drawer handles. ii. Dedicate cleaning materials/equipment to this area. It is important not to use the mop or mop water in another room or area. If it is not possible to dedicate a mop to the area then clean this area last and dispose of the mop in the normal method. When coding a patient that is in Droplet or Contact Precautions: a. Place crash cart at the foot of the exam table. b. Designate a clean staff member to get items out of the cart. c. When code is terminated, the clean staff member will close all drawers of the crash cart. d. Remove cart from room. e. Wipe down the outside of the cart, backboard, and monitor/defibrillator with a hospital approved disinfectant. f. Return crash cart to its designated place._______________________ For Additional Information: CDCs Recommendations for Care of Patients with Pandemic Influenza http://www.cdc.gov/ncidod/hip/ISOLAT/std_prec_excerpt.htm References: Bloomington Hospital and Healthcare System, Environment of Care, Infection Control Policy & Employee Health Manual. CDC Supplement 4 Infection Control 2006 CDC Update Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Health Care Settings during an Influenza Pandemic October 17, 2006  HYPERLINK "http://www.pandemicflu.gov/plan/maskguidancehc.html" http://www.pandemicflu.gov/plan/maskguidancehc.html CRITERIA FOR DISCONTINUING AIRBORNE PRECAUTIONS DISEASE CRITERIA COMMENTS Measles (Rubeola)  4 days after onset of rashVirus usually only isolated for up to 48 hours after onset of rash. Tuberculosis  3 sputum smears negative for AFBRisk of transmission decreases markedly after 2 weeks of effective anti-TB treatment. Varicella (Chickenpox or disseminated zoster) 5 days after onset of rash, and all vesicles crusted Dermatomal shingles does not require airborne isolation CRITERIA FOR DISCONTINUING DROPLET PRECAUTIONS DISEASE CRITERIA COMMENTSHaemophilus influenzae (meningitis or epiglottitis)After 4 days of Rifampin to clear pharyngeal carriage. (Usually given toward end of therapeutic antibiotic treatment)Pneumonia, sinusitis in adults usually due to non-typable strains which are less virulent and do not require isolation. The patient may remain a carrier despite successful treatment of infection.Neisseria meningitidis (meningitis and sepsis)After effective antibiotic treatment for 48 hours.Penicillin may not eradicate pharyngeal carriage of Meningicoccus. Consider Rifampin or Cipro treatment to clear pharyngeal carriage.Diphtheria (Corynebacterium diphtheriae)After antibiotic treatment completed and 3 negative pharyngeal cultures at least 24 hours apart obtained following treatment.Mycoplasma pneumonia4 days after onset of illnessTransmission decreases markedly 2 - 4 days after onset of clinical symptoms. (Low level excretions for 10 - 14 weeks.)Pertussis (Bordetella pertussis)After 5 days of erythromycin treatment, or when cough resolved, or with negative nasopharyngeal DFA for Bordetella pertussis.Culture usually positive during catarrhal (URI symptoms) stage and becomes negative during paroxysmal stage.Plague (Yersinia pestis)48 hours after initiation of effective antibiotics, or negative sputum culture.Strict isolation.Group A streptococcal (pharyngitis, scarlet fever, pneumonia)After effective antibiotics for greater than 24 hours.Organisms rapidly decrease in number with convalescence. Low level carriage may persist.Rubella15 days after onset of rash.Prolonged excretion in many cases.Mumps7 days after onset of parotitis.Virus usually detectable for 4 - 5 days after onset of parotitis.InfluenzaWhen symptoms are resolved. Typically in 5-7 days after onset. CRITERIA FOR DISCONTINUING CONTACT PRECAUTIONS DISEASECRITERIACOMMENTSClostridium difficile colitisNegative stool culture for C. Difficile toxin obtained 24 hours after antibiotics are discontinued.E. Coli 0157 (EHEC) infectionNegative stool culture for enterohemorrhagic E. coli.ShigellaNegative stool culture Fecal excretion usually lasts 1-4 weeks if illness untreated. Long term carriage is rare.Salmonella2 negative stool cultures at least 24 hours apart.Fecal excretion usually lasts a few weeks post illness. Number of organisms in stools of chronic carriers is usually large. Chronic carriage associated with gallbladder disease.Hepatitis A2 weeks post onset of jaundice or peak in LFTsMaximum infectivity in late incubation and at onset of symptoms. With onset jaundice infectivity as warning. No transmission documented after 2 weeks from onset of icteric liver disease.RotavirusNegative antigen test for Rotavirus in stool.Maximum viral shedding 2-5 days post onset of diarrhea.Respiratory syncytial virus infection (RSV)Until Ribavirin treatment completed (usu 2-5 days). If untreated, until respiratory symptoms resolve (usu 7-21 days).Ribavirin is virustatic. Studies suggest viral shedding ceases within 24 hours of treatment, but may relapse.PediculosisFollowing completion of treatment.ScabiesFollowing completion of treatment.Vancomycin resistant enterococcus (VRE)3 negative rectal cultures and 3 negative site cultures at least one week apart. Cultures are to be obtained 24 hours after antibiotics are discontinued.Report to health department.Methicillin resistant staphylococcus aureus (MRSA)1 negative nasal culture and 1 negative site culture. Cultures are to be obtained 24 hours after antibiotics are discontinued. Blood cultures do not need to be repeated as long as patient has completed course of antibiotics and patient has been afebrile (<100.0) for 24 hours after antibiotics are discontinued.Droplet precautions indicated if respiratory tract infection. Report to the health department.     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