1. Hand Hygiene Quick Reference Chart on the …Hand Hygiene Quick Reference Chart Hand washing/hand...

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DATE ISSUE: February 1, 2006 REVISION DATE:

Winnipeg Regional Health Authority Infection Prevention & Control Manual

1. Hand Hygiene Quick Reference Chart Hand washing/hand hygiene reduces the number of microorganisms on the hands and is the most important practice to prevent the spread of infection. WHEN Before: • Direct hands-on care with a patient • Performing invasive procedures • Handling dressings or touching open wounds • Preparing and administering medications • Preparing, handling, serving, or eating food • Feeding a patient • Shifts and breaks After: • Contact with blood, body fluids, non-intact skin, and/or mucous membranes • Contact with items known, or considered to be contaminated • Removal of gloves • Personal use of toilet or wiping nose • Shifts and breaks Between: • Procedures on the same patient where soiling of hands is likely, to avoid cross-contamination of body sites HAND WASHING/HAND HYGIENE AGENTS Alcohol-Based Hand rub: • Must contain a minimum of 60% alcohol • Use in all clinical situations, except when hands are visibly soiled • Use as an alternate when plain or antimicrobial soap is indicated, except when hands are visibly soiled Plain Soap: • For routine hand washing Antimicrobial Soap: • Before contact with invasive devices • Before performing any invasive procedures • Before contact with immunosuppressed patients • Before/after contact with patients on infection control precautions/isolation • Use in critical care areas: ICU, OR, Burn Unit, Dialysis, Intensive Care Nurseries

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2. Hand Hygiene Procedure

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3. Hand Hygiene Procedure

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4. Personal Protective Equipment Criteria for Respiratory Infections The list of items identifies the characteristics necessary to provide protection to the health care worker: Eye Protection:

Eye protection includes safety goggles, or face shields Eye protection should protect the eyes from splashes. Protection from

splashes in all directions should be considered Choose eye protection that does not impair the health care worker’s vision

and thereby interfere with patient care Masks:

In this document, the term mask is to refer to standard surgical/procedure masks for routine practices and droplet transmission

Respirators: N95 Respirators are required for airborne transmission precautions Currently, N95 respirators or equivalent are recommended by Public

Health Agency of Canada, the World Health Organization, and the Centers for Disease Prevention and Control

N95 respirators should filter out 95% of airborne particles and provide a tight facial seal (less than 10% leak). Provided that an adequate facial seal is present, respirators that are NIOSH-certified as N95 meet or exceed this minimum recommendation

There is no evidence to support the need for enhanced respiratory PPE, such as the powered air purified respirator system (PAPRS) during care of patients with SARS

Currently, N95 fluid-resistant respirators are only required in aerosol-generating procedures for patients with probable or confirmed SARS. Fluid resistance is defined as the ability of a respirator’s material construction to minimize fluids from traveling through the material and potentially coming into contact with the user of the mask. Fluid resistance helps reduce potential exposure to blood and body fluids caused from splashes, spray, or splatter

Gloves: Medical quality of gloves of appropriate size for the wearer Gloves should cover the sleeve cuffs when a gown is worn Gloves should be single use and not be reused or washed

Gowns: Long-sleeved gowns should be worn to protect the forearms and clothing

of the HCW from splashing and soiling with body substances during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids, secretions or excretions

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5. Donning Personal Protective Equipment (PPE)

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6. Removing Personal Protective Equipment (PPE) Prior to Exiting Patient Room

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7. Removing Personal Protective Equipment (PPE) Immediately After Exiting Patient Room

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8. Air Changes Per Hour and Time in Minutes Required for Removal Efficiencies of 90%, 99%, or 99.9% of Airborne Contaminants*

MINUTES REQUIRED FOR A REMOVAL EFFICIENCY OF:

Air Changes per Hour 90% 99% 99.9% 1 138 276 414 2 69 138 207 3 46 92 138 4 35 69 104 5 28 55 83 6 23 46 69 7 20 39 59 8 17 35 52 9 15 31 46 10 14 28 41 11 13 25 38 12 12 23 35 13 11 21 32 14 10 20 30 15 9 18 28 16 9 17 26 17 8 16 24 18 8 15 23 19 7 15 22 20 7 14 21

This table is prepared according to the formula t=(in C2/C1)/(Q/V)=60, which is an adaptation of the formula for the rate of purging airborne contaminants (Mutchler, 1973) with t1=0 and C2/C1=1- (removal efficiency/100). Source: Adapted from CDC (1994). Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities. MMWR 1994; 43 (RR- 13): 1-32.

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9.1 Cover Your Cough (Pamphlet) - English

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9.1 Cover Your Cough (Pamphlet) – English - Page 2

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9.2 Cover Your Cough Poster #1 - English

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9.3 Cover Your Cough Poster #2 - English

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9.4 Cover Your Cough – Bilingual

See Individual Site Specific Protocols, Policies & Information for: - Cover Your Cough Pamphlet - Bilingual - Cover Your Cough Poster #1 - Bilingual - Cover Your Cough Poster #2 - Bilingual

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10.1 Airborne Precautions

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10.2 Airborne/Contact Precautions

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10.3 Contact Precautions

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10.4 Droplet Precautions

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10.5 Droplet/Contact Precautions

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11. Additional Precautions Signs – Bilingual

See Individual Site Specific Protocols, Policies & Information for: - Airborne Precautions Sign - Bilingual - Airborne/Contact Precautions Sign - Bilingual - Contact Precautions Sign - Bilingual - Droplet Precautions Sign - Bilingual - Droplet/Contact Precautions Sign - Bilingual

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12.1 Patient and Family Airborne Precautions Information Sheet - English

Patient and Family

Airborne Precautions Information Sheet

What are Airborne Precautions? Germs can be in small airborne particles that remain in the air for long periods of time and are carried by air currents. People may breathe the germs in if they are in the same room as the patient, or even if they are some distance away. This is called Airborne Transmission. Airborne Precautions help stop the spread of germs carried by airborne transmission. What hospital procedures are used for Airborne Precautions? The patient will be given a private room. The door will be kept closed at all times,

whether he/she is in the room or not A sign will be placed on the door to let everyone know the special precautions Staff and visitors will wear special masks called respirators while in the room Staff will take the patient out of the room for medically essential purposes only Before entering or leaving the room all staff, patients and visitors will wash hands

with soap and water if visibly soiled, or use alcohol-based hand rub What can the patient do to help? Keep the door closed at all times whether in the room or not Stay in the room unless staff has approved leaving the room Put on a mask before leaving the room and keep it on at all times when out of the

room Cover the nose and mouth with a tissue when coughing or sneezing, and throw the

tissue away in the wastebasket in the room Wash hands with soap and water if visibly soiled, or use alcohol-based hand rub

Before leaving the room After coughing After going to the bathroom Before eating

What should visitors do? Read the sign on the door and discuss with staff the precautions to follow

They will be educated by staff about how to wear the respirators while in the room

Ask the staff if they have any questions Wear respirators as instructed by staff Wash their hands with soap and water if visibly soiled, or use alcohol-based hand

rub before entering and leaving the room Visitors should be limited to family members or close friends

Ask the nurse if there are any questions

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12.2 Patient and Family Airborne/Contact Precautions Information Sheet - English

Patient and Family

Airborne/Contact Precautions Information Sheet

What are Airborne Precautions? Germs can be in small airborne particles that remain suspended in the air for long periods of time and are carried by air currents. People may breathe them in either in the same room as the patients or even if they are some distance away. This is called Airborne Transmission. Airborne Precautions help stop the spread of germs carried by airborne transmission. What are Contact Precautions? Germs can be spread directly by physical contact, such as when shaking hands, or indirectly, when someone touches an item someone else may have touched such as equipment, telephone or other objects. This is called Contact Transmission. Contact Precautions help stop the spread of germs from one person to another by direct or indirect contact. Airborne and Contact Precautions help stop the spread of germs carried by airborne and contact transmission. What hospital procedures are used for Airborne & Contact Precautions?

The patient will be given a private room the door will be kept closed at all times, whether he/she is in the room or not

A sign will be placed on the door to let everyone know the special precautions Staff will wear gloves and may wear long sleeved gowns while in the room Staff and visitors will wear special masks called respirators while in the room Staff will take the patient out of the room for medically essential purposes only Before entering or leaving the room all staff, patients and visitors will wash hands

with soap and water if visibly soiled, or use alcohol-based hand rub What can the patient do to help?

Keep the door closed at all times whether in the room or not Stay in the room unless staff has approved leaving the room Put on a mask before leaving the room and keep it on at all times when out of the

room Cover the nose and mouth with a tissue when coughing or sneezing, and throw

the tissue away in the wastebasket in the room Wash hands with soap and water if visibly soiled, or use alcohol-based hand rub

Before leaving their room After coughing After going to the bathroom Before eating

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What should the visitors do?

Read the sign on the door and discuss with the staff the precautions to follow They will be educated by staff about how to wear the respirators while in

the room Ask the staff if they have any questions Wear respirators, gloves and long sleeved gowns as instructed by the staff Wash their hands with soap and water if visibly soiled, or use alcohol-base hand

rub before entering or leaving the room Visitors should be limited to family members or close friends


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12.3 Patient and Family Contact Precautions Information sheet - English

Patient and Family Contact Precautions Information Sheet

What are Contact Precautions? Germs can be spread directly by physical contact, such as when shaking hands, or indirectly, when someone touches an item someone else may have touched such as equipment, telephone or other objects. This is called Contact Transmission. Contact Precautions help stop the spread of germs carried by contact transmission. What hospital procedures are used for Contact Precautions?

The patient may be given a private room. The door can be kept open. If the patient is not placed in a private room, the curtain may be drawn around the bed.

A sign will be placed on the door or cubicle curtain to let everyone know the special precautions required.

Staff will wear gloves and may wear long sleeved gowns when they have contact with the patient or objects in the room.

Staff will take the patient out the room for medically essential purposes only. Before entering or leaving the room all staff, patients and visitors will wash their

hands with soap and water if visibly soiled, or use an alcohol-based hand rub. What can the patient do to help?

Stay in the room unless staff has approved leaving the room. Wash their hands with soap and water if visibly soiled, or use alcohol-based hand

rub: Before leaving their room After going to the bathroom Before eating


Read the sign on the door and discuss with staff the precautions they are to follow

They will be educated by staff if they are to wear long sleeved gowns and gloves while in the room

Ask the staff if they have any questions Wear gloves and long sleeved gowns as instructed by the staff Wash their hands with soap and water if visibly soiled, or used an alcohol-based

hand rub before entering or leaving the room Visitors should be limited to family members or close friends


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12.4 Patient and Family Droplet Precautions Information Sheet - English

Patient and Family Droplet Precautions Information Sheet

What are Droplet Precautions? Germs are spread by large droplets that are produced when a person coughs or sneezes. These droplets are pushed a short distance through the air and settle in the eyes, nose or mouth of another person. Droplets generally travel 1 metre (3 feet) or less in distance and can settle on surfaces. This is called Droplet Transmission. Droplet Precautions help stop the spread of germs carried by droplet transmission. What hospital procedures are used for Droplet Precautions?

The patient may be given a private room. The door can be kept open. If the patient is not placed in a private room, the curtain may be drawn around the bed

A sign will be placed on the door or cubicle curtain to let everyone know the special precautions required

Staff will wear masks when they are within 1 metre (3 feet) of the patient Staff will take the patient out the room for medically essential purposes only Before entering of leaving the room all staff, patients and visitors will wash their

hands with soap and water if visibly soiled, or use an alcohol-based hand rub What can the patient do to help?

Cover their nose and mouth with a tissue when they cough or sneeze, and throw the tissue away in the wastebasket in the room

Stay in the room unless staff has approved leaving the room Put on a mask before leaving the room and keep it on at times when out of the

room Wash hands with soap and water if visibly soiled, or use an alcohol-based hand

rub Before leaving the room After coughing or sneezing After going to the bathroom Before eating


Read the sign on the door and discuss with staff on the precautions to follow: They will be educated by staff if they are to wear and masks while in the

room Ask the staff if they have any questions Wear masks as instructed by staff Wash their hands with soap and water if visibly soiled, or use an alcohol-based

hand rub before entering or leaving the room Visitors should be limited to family members of close friends


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12.5 Patient and Family Droplet/Contact Precautions Information Sheet – English

Patient and Family

Droplet/Contact Precautions Information Sheet What are Droplet Precautions? Germs are spread by large droplets that are produced when a person coughs or sneezes. These droplets are pushed a short distance through the air and settle in the eyes, nose or mouth of another person. Droplets generally travel 1 metre (3 feet) or less in distance and can settle on surfaces. Droplet Precautions help stop the spread of germs, which can be coughed or sneezed out. This is called Droplet Transmission. What are Contact Precautions? Germs can be spread directly by physical contact, such as when shaking hands, or indirectly, when someone touches an item someone else may have touched such as equipment, telephone or other objects. This is called Contact Transmission. Contact Precautions help stop the spread of germs from one person to another by direct or indirect contact. Contact and Droplet Precautions help stop the spread of germs carried by droplet and contact transmission. What hospital procedures are used for Droplet & Contact Precautions?

The patient may be given a private room. The door can be kept open. If the patient is not placed in a private room, the curtain may be drawn around the bed

A sign will be place on the door or cubicle curtain to let everyone know the special precautions required

Staff will wear masks when they are within 1 metre (3 feet) of the patient Staff will wear gloves and may wear long sleeved gowns when they have contact

with the patient or objects in the room Staff will take the patient out the room for medically essential purposes only Before entering of leaving the room all staff, patients and visitors will wash their

hands with soap and water if visibly soiled, or use an alcohol-based hand rub What can the patient do to help?

Cover their nose and mouth with a tissue when they cough or sneeze, and throw the tissue away in the wastebasket in the room

Stay in the room unless staff has approved leaving the room Put on a mask before leaving the room and keep it on at times when out of the

room Wash hands with soap and water if visibly soiled, or use an alcohol-based hand

rub Before leaving the room After coughing or sneezing After going to the bathroom Before eating

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Read the sign on the door and discuss with staff on the precautions to follow They will be educated by staff if they are to wear long sleeved gowns, gloves and masks while in the room

Ask the staff if they have any questions Wear gloves, long sleeved gowns and masks as instructed by staff Wash their hands with soap and water if visibly soiled, or use an alcohol-based

hand rub before entering or leaving the room Visitors should be limited to family members of close friends


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13. Patient and Family Information Sheets for Additional Precautions - Bilingual

See Individual Site Specific Protocols, Policies and Information for: - Airborne Precautions - Bilingual - Airborne/Contact Precautions - Bilingual - Contact Precautions - Bilingual - Droplet Precautions - Bilingual - Droplet/Contact Precautions - Bilingual

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DATE ISSUE: February 1, 2008 REVISION DATE: January 7, 2010


14.1 Wash Your Hands Sign – 4.25” x 5.5”

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14.2 Please Use the Hand Rub Provided Sign – 4.25” x 5.5”

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14.3 Please Use the Hand Rub Provided Sign – 8.5” x 11”

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14.4. Hand Hygiene Signs - Bilingual

See Individual Site Specific Protocols, Policies and Information for: - Wash Your Hands Sign – 4.25” x 5.5” - Please use the Hand Rub Provided Sign – 4.25” x 5.5” - Please use the Hand Rub Provided Sign – 8.5” x 11”

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DATE ISSUE: January 7, 2010 REVISION DATE:


15.1 Extended Spectrum Beta Lactamase (ESBL) Producing Bacteria Fact Sheet for Patient, Family & Visitors

One of the test results shows you or your family member have a germ or bacteria called Extended Spectrum Beta Lactamase (ESBL).

What is Extended Spectrum Beta Lactamase (ESBL)? Extended Spectrum Beta Lactamases (ESBLs) are enzymes produced by some bacteria or germs that can make them resistant to certain antibiotics. These bacteria or germs may be found in the bowel of many people. Usually these people are completely healthy and don’t know they have it. This is called colonization. ESBLs may cause wound or bladder infections, or less often, more serious infection of the blood or other body sites. When it causes an infection, it is usually treated with antibiotics.

What does antibiotic resistance mean? Antibiotics are drugs used to treat infections caused by germs. Sometimes these drugs will no longer kill the germs as the germs have changed. These germs are called antibiotic resistant. How does a person get an ESBL? ESBLs may be found in patients in the hospital. ESBLs can be found on people’s hands, especially after using the bathroom. Because ESBLs may be found in the bowels, not washing the hands after using the bathroom can spread them. ESBLs can spread in a facility by touching a patient who has an ESBL or by the hands of staff. Who gets an ESBL? Patients who have open wounds, catheters, or drainage tubes and those who are very sick are most likely to get an ESBL. The general public living in the community who are in good health is at low risk of getting an ESBL. There is generally no need for special precautions in the home.

Why are special precautions needed? Special precautions are to stop the ESBL from spreading to other sick patients.

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What are the special precautions? Some of the precautions may include: The patient will be placed in a private room or with another ESBL positive

patient. A sign will be placed on the door of the room to alert every one of the

precautions needed. Staff members will wear gowns and gloves when caring for the patient or if

they have contact with equipment or surfaces in the room. Everyone must wash their hands or use alcohol based hand rub (sanitizer)

when entering or leaving the room. If the patient has to leave their room, their hands must be washed well or

an alcohol based hand rub (sanitizer) used. Wounds must be covered. The patient may not be able to go to other areas of the hospital or to the

cafeteria.

What about family and visitors? Family and friends may visit. They will be asked to wash their hands or use an alcohol based hand rub (sanitizer) before entering or leaving the room. Family members may still have close contact such as hugging, kissing and handholding with the patient. Family members rarely get an ESBL. If they do, it does not usually cause a problem. Patients with an ESBL do not pose a risk to their families or to other healthy people.

What about at home? There are no special precautions at home, except people should wash their hands often. Hands should be washed after going to the bathroom, coughing, sneezing or touching their nose or any wound. This is the best way to prevent the spread of germs, not just because someone has ESBL. How can the patient with ESBL help? Remind all staff and visitors to wash their hands or use an alcohol based

hand rub (sanitizer) when they come in the room and before and after they touch the patient.

The patient who has an ESBL should wash their hands well or use an alcohol-based hand rub (sanitizer) often. When washing their hands, they should turn off the taps with a paper towel to avoid getting their hands dirty again.

If another doctor, hospital or clinic is visited or you receive home care, it is important for you to tell staff you have an ESBL.

Hand washing or using alcohol based hand rub (sanitizer) is the best way to prevent the spread of these germs.

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15.2 Methicillin Resistant Staphylococcus aureus (MRSA) Fact Sheet for Patient, Family & Visitors

One of the test results shows you or your family member has a germ or bacteria called Methicillin Resistant Staphylococcus aureus (MRSA).

What is Staphylococcus aureus? Staphylococcus aureus (S. aureus) is a bacteria or germ that normally lives on the skin or in the nose of many people. Usually, these people are completely healthy and don’t know they have it. This is called colonization. It is normal to be colonized with bacteria in many parts of our bodies. If S. aureus gets “inside” the body, for example, under the skin or into the lungs, it may cause an infection. When it causes an infection, it is usually treated with antibiotics.

What does antibiotic resistance mean? Antibiotics are drugs used to treat infections caused by germs. Sometimes these drugs will no longer kill the germs as the germs have changed. These germs are called antibiotic resistant.

What is Methicillin Resistant Staphylococcus aureus or MRSA? The usual treatment for S. aureus infections is a group of antibiotics related to penicillin, which include methicillin, oxacillin and cloxacillin. Some S. aureus are no longer killed by methicillin and they are called MRSA. When this happens a different antibiotic is needed to treat the infection. Individuals can have an infection caused by MRSA or they can just carry the germ on their skin or in their nose. How does a person get MRSA? MRSA may be found in the community and hospital, on people and objects. MRSA can be passed from a person who is either sick with MRSA or just carrying the bacteria harmlessly on their skin or in their nose or by the hands of healthcare workers. MRSA can also live on things such as doorknobs, water taps, and equipment touched by a person with MRSA. MRSA can spread from one person to another by directly or indirectly touching something the MRSA bacteria are on. Who gets MRSA? Anyone can get MRSA. However patients who have open wounds, catheters or drainage tubes, and those who are very ill, are most likely to get MRSA. The general public living in the community is at low risk of getting MRSA. At home, people should wash their hands often. There is generally no need for special precautions in the home.

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Why are special precautions needed? Special precautions are taken to stop MRSA from spreading to other sick patients. What are the special precautions? Some of the precautions may include: The patient will be placed in a private room or with another MRSA positive






cafeteria. Tests (swabs) may be done on a regular basis to see if the patient still

carries MRSA.

What about family and visitors? Family and friends may visit. They will be asked to wash their hands or use an alcohol based hand rub (sanitizer) when entering or leaving the room. Family members may still have close contact such as hugging, kissing and handholding with the patient. Family members rarely get MRSA. If they do, it does not usually cause a problem. Patients with MRSA do not pose a risk to their families or to other healthy people.

What about at home? There are no special precautions at home, except people should wash their hands often. Hands should be washed after going to the bathroom, coughing, sneezing or touching your nose or any wound. This is the best way to prevent the spread of germs, not just because someone has MRSA.

How can the patient with MRSA help? Remind all staff and visitors to wash their hands or use an alcohol based


The patient who has MRSA should wash their hands well or use an alcohol based hand rub (sanitizer) often. When washing their hands, they should turn off the taps with a paper towel to avoid getting their hands dirty again.

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If another doctor, hospital or clinic is visited or you receive home care, it is important for you to tell staff you have MRSA.


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15.3 Vancomycin Intermediate Resistant Staphylococcus aureus (VISA) and Vancomycin Resistant Staphylococcus aureus (VRSA) Fact Sheet for Patient, Family & Visitors

One of the test results shows you or your family member has a germ or bacteria called Vancomycin Intermediate Resistant Staphylococcus aureus (VISA) or Vancomycin Resistant Staphylococcus aureus (VRSA)

What is Staphylococcus aureus? Staphylococcus aureus (S. aureus) is a bacteria or germ that normally lives on the skin or in the nose of many people. Usually, these people are completely healthy and don’t know they have it. This is called colonization. It is normal to be colonized with bacteria in many parts of our bodies. If S. aureus gets “inside” the body, for example, under the skin or into the lungs, it can cause infections. When it causes an infection, it is usually treated with antibiotics. What does antibiotic resistance mean? Antibiotics are drugs used to treat infections caused by germs. Sometimes these drugs will no longer kill the germs as the germs have changed. These germs are called antibiotic resistant. What are VISA and VRSA? The usual treatment for S. aureus infections is a group of antibiotics related to penicillin, which include methicillin, oxacillin and cloxacillin. Over the past 50 years, S. aureus has become resistant to many antibiotics including this group of antibiotics. This led to increased use of another antibiotic called vancomycin. While most S. aureus are killed by vancomycin, a few have developed resistance and cannot be killed by vancomycin. This group of S. aureus is called either VISA or VRSA.

How does a person get VISA/VRSA? VISA/VRSA can be passed from a person who is either sick with VISA/VRSA or just carrying the bacteria harmlessly on their skin or in their nose or by the hands of healthcare workers. VISA/VRSA can also live on things such as doorknobs, water taps, and equipment touched by a person with VISA/VRSA. VISA/VRSA can spread from one person to another by directly or indirectly touching something the VISA/VRSA bacteria are on.

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Who gets VISA or VRSA? People most likely to get VISA/VRSA are those who are receiving a lot of antibiotics especially vancomycin, those with previous VISA/VRSA infections who have open wounds, catheters or drainage tubes and those who are very ill. A long hospital stay or contact with an individual or equipment that has VISA/VRSA might increase the risk of getting VISA/VRSA. The general public living in the community is at very low risk of getting VISA/VRSA.

Why are special precautions needed? Special precautions are taken to stop VISA/VRSA from spreading to other sick patients. What are the special precautions? Some of the precautions may include: The patient will be placed in a private room. A sign will be placed on the door of the room to alert every one of the

precautions needed. Staff members will wear gowns and gloves when caring for you or your

family member or if they have contact with equipment of surfaces in the room.

Everyone must wash their hands or use alcohol based hand rub (sanitizer) when entering or leaving the room.

Patients, staff and visitors must avoid touching their noses and mouths with their hands.

If the patient has to leave their room, their hands must be washed well or an alcohol based hand rub (sanitizer) used. Wounds must be covered.

The patient may not be able to go to other areas of the hospital or to the cafeteria.

Tests (swabs) may be done on a regular basis to see if the patient still carries VISA/VRSA.

What about family and visitors? Family and friends can visit. They will be asked to wash their hands or use an alcohol based hand rub (sanitizer) before entering or leaving the room. Family members may still have close contact such as hugging, kissing and handholding with the patient. Family members rarely get VISA/VRSA. If they do, it does not usually cause a problem. Patients with VISA/VRSA do not pose a risk to their families or to other healthy people.

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What about at home? There are no special precautions at home, except people should wash their hands often. Hands should be washed after going to the bathroom, coughing, sneezing, touching your nose or any wound. This is the best way to prevent the spread of germs, not just because someone has VISA/VRSA. How can the patient with VISA/VRSA help? Remind all staff and visitors to wash their hands or use an alcohol based


The patient who has VISA/VRSA should wash their hands well or use an alcohol based hand rub (sanitizer) often. When washing their hands, they should turn off the taps with a paper towel to avoid getting their hands dirty again.

If another doctor, hospital or clinic is visited or you receive home care, it is important for you to tell staff you have VISA/VRSA.


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15.4 Vancomycin-Resistant Enterococci (VRE) Fact Sheet for Patient, Family & Visitors

One of the test results shows you or your family member has a germ or bacteria called Vancomycin-Resistant Enterococci (VRE).

What are Enterococci? Enterococci are bacteria or germs that are normally found in the bowel of many people. Usually these people are completely healthy and don’t know they have it. This is called colonization. Enterococci may cause wound or skin infections, or less often, more serious infection of the blood and other body sites. When it causes an infection, it is usually treated with antibiotics.

What does antibiotic resistance mean? Antibiotics are drugs used to treat infections caused by germs. Sometimes these drugs will no longer kill the germs as the germs have changed. These germs are called antibiotic resistant. What is Vancomycin-Resistant Enterococci or VRE? Vancomycin is an antibiotic used to treat Enterococci. Some Enterococci are no longer killed by vancomycin and they are called Vancomycin Resistant Enterococci or VRE. How does a person get VRE? VRE may be found in the hospital, on people and objects. VRE can be passed from a person who is either sick with VRE or just carrying the bacteria harmlessly or by the hands of healthcare workers. VRE can be found on people’s hands, or on things that are touched such as toilet seats, door handles, call bells or equipment. VRE can spread from one person to another by directly or indirectly touching something the VRE bacteria are on. Who gets VRE? Patients who have open wounds, catheters or drainage tubes and those who are very sick are most likely to get VRE. The general public living in the community who are in good health are at low risk of getting VRE. Why are special precautions needed? Special precautions are taken to stop VRE from spreading to other patients.

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What are the special precautions? Some of the precautions may include: The patient will be placed in a private room or with another VRE positive






cafeteria.

What about family and visitors? Family and friends may visit. They will be asked to wash their hands or use an alcohol based hand rub (sanitizer) when entering or leaving the room. Family members may still have close contact such as hugging, kissing and handholding with the patient. Family members rarely get VRE. If they do, it does not usually cause a problem. Patients with VRE do not pose a risk to their families or to other healthy people. What about at home? There are no special precautions at home, except people should wash their hands often. Hands should be washed after going to the bathroom, coughing, sneezing or touching your nose or any wound. This is the best way to prevent the spread of germs, not just because someone has VRE. How can the patient with VRE help? Remind all staff and visitors to wash their hands or use an alcohol based


The patient who has VRE should wash their hands well or use an alcohol-based hand rub (sanitizer) often. When washing their hands, they should turn off the taps with a paper towel to avoid getting their hands dirty again.

If another doctor, hospital or clinic is visited or you receive home care, it is important for you to tell staff you have VRE


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15.5 Extended Spectrum Beta Lactamase (ESBL) Producing Bacteria Fact Sheet for Healthcare Workers

What are Extended Spectrum Beta Lactamases (ESBLs)? Extended spectrum beta lactamases (ESBLs) are enzymes produced by some gram negative bacteria that can inactivate a wide range of antibiotics particularly penicillins and cephalosporins. E. coli and Klebsiella are the organisms most frequently associated with ESBLs. The gastrointestinal tract is the most common site of colonization and less frequently the respiratory tract. The sites most frequently infected with ESBLs are the urinary tract and wounds; more serious infection of the blood or other body sites are less common. ESBLs have been present in Europe and the USA since 1983. These bacteria have only recently been detected in Canada in low, but increasing numbers.

What to look for (signs and symptoms of ESBLs)? Most people with ESBLs have no symptoms (asymptomatic). For the few people who develop symptoms of infection, antibiotics should be used. Infections caused by ESBLs present in the same way as non-ESBL producing organisms. These infections can be serious; therefore, knowing a person has ESBL is important to ensure the most appropriate treatments are prescribed.

How are ESBLs transmitted (spread)? Lack of hand hygiene, especially after using the washroom, can spread these bacteria. The spread of ESBLs in a facility occurs most commonly through direct contact with someone who has ESBL, contaminated environment, or on the hands of healthcare providers. Careful cleaning of frequently touched surfaces is important to reduce the spread of these organisms in a facility.

How is ESBL detected? The laboratory can identify ESBLs in a clinical specimen obtained from an infected patient. Screening cultures are not routinely required. The need for screening cultures will be determined by Infection Prevention and Control. Laboratories perform tests to determine which antibiotics will be effective (sensitive) or not effective (resistant) for treatment.

Who is at risk? Patients: Some patients are at higher risk for acquiring an ESBL. Some risk factors are:

Prolonged stay in a healthcare facility where ESBL cases have been reported

Treatment with antibiotics, especially cephalosporins

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Recent surgery Instrumentation (IV and urinary catheters) Open wounds Prolonged hospitalization and/or admission to a high-risk unit

Healthcare worker/staff: Healthcare workers are not usually at risk for ESBL colonization/infection. The chances of colonization/infection with ESBL do not increase even if you have been in contact with an individual with ESBL, e.g. at work. Healthcare workers/staff including pregnant healthcare workers are at minimal risk of acquiring ESBL colonization/infection provided they adhere to Routine Practices and Additional Precautions for the specific situation. If you are immunocompromised the risk is also very small. Please contact Occupational & Environmental Safety & Health if you have concerns about working with patients who are colonized/infected with an ESBL.

How is ESBL treated? Treatment is only necessary for people with symptomatic infections. Consultation with an Infectious Disease Specialist is recommended for those with symptoms of infection with ESBL. There is no effective way to “treat” asymptomatic colonization with eradication therapy. Carriers can frequently clear this organism without any treatment.

What are the infection prevention and control considerations? Routine Practices are required for all patient care activities to limit the spread of microorganisms. Key points include: Hand hygiene with soap and water or alcohol based hand rub before and

after contact with every patient. Thorough environmental cleaning, including reusable patient care

equipment between patients. When gloves are used, they must be changed and hand hygiene

performed, between procedures and patients. Special attention to environmental cleaning is required as ESBLs can live in the environment for long periods (days to months) if cleaning is not performed adequately.

To reduce the risk of ESBL transmission in a healthcare facility, known ESBL positive patients are placed on Contact Precautions as outlined in the WRHA Infection Prevention and Control Manual.

Screening of patient contacts and/or environmental culturing, if required, will be directed by Infection Prevention and Control. If necessary, screening of healthcare workers will be directed by Occupational & Environmental Safety &

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Health. Healthcare Workers are not screened for ESBL unless a worker is linked to patient transmission. Hand washing or using alcohol-based hand rub is the best way to prevent the spread of these organisms.

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15.6 Methicillin Resistant Staphylococcus aureus (MRSA) Fact Sheet for Healthcare Workers

What is Staphylococcus aureus? Staphylococcus aureus (S. aureus) is a bacteria or germ that normally lives on the skin or in the nose of many people. Usually, these individuals are not aware of it and are completely healthy. This is called colonization. It is normal to be colonized with bacteria in many parts of our bodies. S. aureus is capable of causing infections from mild skin irritation to severe systemic infections such as pneumonia and bacteremias. S. aureus is one of the most common causes of community and hospital acquired infections, and affects individuals of all ages.

What is Methicillin Resistant Staphylococcus aureus (MRSA)? The usual treatment for S. aureus infections is a group of antibiotics related to penicillin, which include methicillin, oxacillin and cloxacillin. Over the past 50 years, S. aureus has become resistant to multiple antibiotics including this specific group of antibiotics. These resistant bacteria are called Methicillin Resistant Staphylococcus aureus, or MRSA. MRSA causes colonization and/or infections similar to antibiotic sensitive S. aureus strains. Infections causes by MRSA are sometimes more difficult and expensive to treat because the usual antibiotics cannot be used.

What to look for (signs and symptoms of MRSA)? For most people, MRSA causes no harm. If symptoms of infection develop, antibiotics should be used in consultation with an Infectious Disease Specialist. Infections caused by MRSA present in the same way as infections caused by non-MRSA. Symptoms will depend on the site of infection. For example, MRSA can cause an infection in a wound, lung or in the blood, etc.

How is MRSA transmitted (spread)? MRSA is spread by direct contact with an MRSA positive individual or by indirect contact, e.g. equipment contaminated with MRSA. MRSA can be spread from one person to another by healthcare workers’ hands or by sharing contaminated equipment.

How is MRSA detected? The laboratory can identify MRSA either by a screening swab of the nose or wound or by a clinical specimen obtained from an infected individual. Laboratories perform tests to determine which antibiotics will be effective (sensitive) or not effective (resistant) for treatment. If S. aureus is identified as resistant to oxacillin, additional tests are done to confirm the resistance. MRSA are often resistant to multiple commonly used antibiotics.

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Who is at risk? Patients: Some patients are at higher risk for acquiring MRSA. Some risk factors are:

Prolonged hospital stay. Receiving extended antibiotic therapy. Hospitalization in an intensive care or burn unit. Exposure to patients with MRSA. Exposure to MRSA contaminated equipment.

Healthcare worker/staff: Healthcare workers are not usually at risk for MRSA colonization/infection. The chances of colonization/infection with MRSA do not increase even if you have been in contact with an individual with MRSA, e.g. at work. Healthcare workers/staff including pregnant healthcare workers are at minimal risk of acquiring MRSA colonization/infection provided they adhere to Routine Practices and Additional Precautions for the specific situation. If you are immunocompromised the risk is also very small. Please contact Occupational & Environmental Safety & Health if you have concerns about working with patients who are colonized/infected with MRSA.

How is MRSA treated? Colonized individuals do not routinely need treatment. Treatment of MRSA infections will be directed by the individual’s doctor in consultation with an Infectious Diseases Specialist.

What are the infection prevention and control considerations? Routine Practices are required for all care activities to limit the spread of microorganisms. Key points include:

Hand hygiene with soap and water or alcohol based hand rub before and after contact with every patient.

Good environmental cleaning including reusable patient care equipment.

If gloves are used they must be changed and hand hygiene performed between procedures and patients.

Special attention to environmental cleaning is required as MRSA can live in the environment for long periods (days to months) if adequate cleaning is not performed.

To reduce the risk of MRSA transmission in a healthcare institution, known MRSA positive patients are placed on Contact Precautions as outlined in the WRHA Infection Prevention and Control Manual. Known MRSA positive

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patients on readmission will be screened for MRSA and placed on Contact Precautions.

Screening of patient contacts and/or environmental culturing if required, will be directed by Infection Prevention and Control. If necessary, screening of healthcare worker contacts will be directed by Occupational & Environmental Safety & Health. Healthcare workers are not screened for MRSA unless a worker is linked to patient transmission. Hand washing or using alcohol-based hand rub is the best way to prevent the spread of these organisms.

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15.7 Vancomycin Intermediate Staphylococcus aureus (VISA) and Vancomycin Resistant Staphylococcus aureus (VRSA) Fact Sheet for Healthcare Workers

What is Staphylococcus aureus? Staphylococcus aureus (S. aureus) is a bacteria or germ that normally lives on the skin or in the nose of many people. Usually, these individuals are not aware of it and are completely healthy. This is called colonization. It is normal to be colonized with bacteria in many parts of our bodies. S. aureus is capable of causing infections from mild skin irritation to severe systemic infections such as pneumonia and bacteremias. S. aureus is one of the most common causes of community and hospital acquired infections, and affects individuals of all ages.

What are VISA and VRSA? The usual treatment for S. aureus infections is a group of antibiotics related to penicillin that include methicillin, oxacillin and cloxacillin. Over the last 50 years, some strains of S. aureus have become resistant to multiple antibiotics including this specific group of antibiotics. This led to increased use of vancomycin. While most S. aureus are susceptible to vancomycin, a few have developed resistance and cannot be successfully treated with vancomycin. These highly antimicrobial resistant S. aureus are classified as either VISA or VRSA based on laboratory tests that determine the degree of resistance. In the late 1990’s initial cases of VISA and VRSA were reported. VISA and VRSA isolated to date are also methicillin resistant. All VRSA isolates have been identified in individuals with Vancomycin Resistant Enterococcus (VRE) colonization/infection isolated in addition to MRSA. It is likely the resistance from VRE was transferred to the MRSA strain, resulting in VRSA. The identification of VISA/VRSA constitutes a “crisis” and requires immediate response. What to look for (signs and symptoms of VISA/VRSA)? The signs and symptoms of infection/colonization with VISA/VRSA are similar to other types of S. aureus infections but are very difficult to treat because of limited effective antibiotics. How is VISA/VRSA transmitted (spread)? VISA/VRSA is spread by direct contact with a VISA/VRSA positive individual or by indirect contact, e.g. equipment contaminated by a VISA/VRSA positive person. VISA/VRSA can be spread from one person to another by healthcare workers’ hands or by sharing contaminated equipment.

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How is VISA/VRSA detected? The laboratory can identify VISA/VRSA either by a screening swab of the nose or wound or by a clinical specimen obtained from an infected individual. Laboratories perform tests to determine which antibiotics will be effective (sensitive) or not effective (resistant) for treatment. If S. aureus is identified with reduced susceptibility to vancomycin and is called VISA, while S. aureus identified as fully resistant to vancomycin is called VRSA.

Who is at risk? At present VISA/VRSA infections are rare. Antibiotic use is a major risk factor for emergence of antibiotic resistant organisms (ARO’s). Reduction of overuse and misuse of antibiotics will decrease the risk of emergence of S. aureus with reduced susceptibility to vancomycin. Patients: Some patients are at higher risk for acquiring VISA/VRSA. Some risk factors are:

Colonization/infection with MRSA and/or VRE. Underlying health conditions, e.g. diabetes, kidney disease. Previous infection with VISA/VRSA. Presence of IV catheters or other invasive devices. Recent hospitalization, especially if prolonged. Recent exposure to vancomycin or other antimicrobial agents.

Healthcare worker/staff: Healthcare workers are not at risk for VISA/VRSA colonization/infection. The chances of colonization/infection with VISA/VRSA do not increase even if you have been in contact with an individual with VISA/VRSA, e.g. at work. Healthcare workers/staff including pregnant healthcare workers are at minimal risk of acquiring VISA/VRSA colonization/infection provided they adhere to Routine Practices & Additional Precautions for the specific situation. If you are immunocompromised the risk is also very small. Please contact Occupational & Environmental Safety & Health if you have concerns about working with patients who are colonized/infected with VISA/VRSA. How is VISA/VRSA treated? Colonized individuals do not routinely need treatment. Treatment of VISA/VRSA infections will be directed by the individual’s doctor in consultation with an Infectious Diseases Specialist. Options for treatment may be very limited and costly.

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What are the infection prevention and control considerations? There is significant concern about the spread of VISA/VRSA among individuals because of limited treatment options. If a VISA/VRSA is suspected, specific infection prevention and control precautions need to be initiated immediately to decrease the risk of transmission to others. Infection Prevention and Control must be notified immediately when VISA/VRSA is suspected. To reduce the risk of VISA/VRSA transmission, known VISA/VRSA positive patients are placed on enhanced Contact Precautions as outlined in the WRHA Infection Prevention and Control manual. Screening of patient contacts if required, will be directed by Infection Prevention and Control and possibly Public Health Authorities. If necessary, screening of healthcare worker contacts will be directed by Occupational & Environmental Safety & Health in consultation with Public Health Authorities. Hand washing or using alcohol-based hand rub is the best way to prevent the spread of these organisms.

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15.8 Vancomycin Resistant Enterococci (VRE) Fact Sheet for Healthcare Workers

What are Enterococci? Enterococci are bacteria found in the bowel of healthy people and usually do not cause illness. This is called colonization. Enterococci are capable of causing wound and skin infections, and less often, more serious infections of the blood or other body sites.

What is Vancomycin Resistant Enterococci (VRE)? The antibiotic Vancomycin is sometimes the only antibiotic that is effective in treating serious infections caused by enterococci. VRE is a type of enterococcus that has become resistant to the antibiotics normally used to kill it, including vancomycin. When vancomycin can no longer kill enterococci this means they have become resistant. VRE does not cause more severe infections than other enterococci.

What to look for? (signs and symptoms of VRE): For most people, VRE causes no harm. Infections rarely develop; usually only seriously ill individuals get infections. Symptoms will depend on the site of infection. For example, VRE can cause an infection in the bladder, a wound or in the blood stream.

How is VRE transmitted (spread)? Enterococci, including VRE, are found in the human bowel and are passed from the body through feces. Enterococci can be found on people’s hands, or on things that are touched such as toilet seats, door handles, call bells, or equipment. VRE is passed from one person to another by direct contact with feces, or indirectly through equipment or items that have become contaminated. VRE can live in the environment for days or even months.

How is VRE detected? The laboratory can identify VRE either by a screening swab of the rectum/ostomy or by a clinical specimen obtained from an infected individual.

Who is at risk? Patients: Some patients are at higher risk for acquiring VRE. Some risk factors are:

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Prolonged stay in a healthcare facility where VRE cases have been reported.

Treatment with frequent doses of vancomycin in the past Hospitalization in an intensive care unit Treatment in a dialysis unit Has an indwelling device, e.g. foley catheter Open wounds Major surgery Exposure to patients with VRE or VRE contaminated equipment

Healthcare worker/staff: Healthcare workers are not usually at risk for VRE colonization/infection. The chances of colonization/infection with VRE do not increase even if you have been in contact with an individual with VRE, e.g. at work. Healthcare workers/staff including pregnant healthcare workers are at minimal risk of acquiring VRE colonization/infection provided they adhere to Routine Practices and Additional Precautions for the specific situation. If you are immunocompromised the risk is also very small. Please contact Occupational & Environmental Safety & Health if you have concerns about working with patients who are colonized/infected with VRE.

How is VRE treated? Healthy people, who are carriers (colonized) with no symptoms of infection do not need treatment. Consultation with an Infectious Disease Specialist is recommended for treatment of individuals who have infection with VRE.

What are the infection prevention and control considerations? Routine Practices are required for all patient care activities to limit the spread of microorganisms. Key points include:

Hand hygiene with soap and water or alcohol based hand rub before and after contact with every patient.

Good environmental cleaning, including reusable patient care equipment

When gloves are used, they must be changed and hand hygiene performed between procedures and patients.

Special attention to environmental cleaning is required as VRE can live in the environment for long periods (days to months) if adequate cleaning is not performed.

To reduce the risk of VRE transmission in a healthcare institution, known VRE positive patients are placed on Contact Precautions as outlined in the WRHA Infection Prevention and Control Manual. Known VRE positive patients on readmission will not be screened for VRE. These patients will be placed on

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Contact Precautions or Modified VRE Precautions. VRE positive patients can be placed on Modified VRE Precautions (VRE Alert) in consultation with Infection Prevention and Control if they are continent and have good hygiene. Screening of patient contacts and /or environmental culturing, if required, will be directed by Infection Prevention and Control. If necessary, screening of healthcare worker contacts will be directed by Occupational & Environmental Safety & Health. Healthcare workers are not screened for VRE unless a worker is linked to patient transmission. Hand washing or using alcohol-based hand rub is the best way to prevent the spread of these organisms.

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15.9 Testing for Methicillin-Resistant Staphylococcus aureus (MRSA) Fact Sheet for Patient & Family

During this admission, a prior admission or follow-up visit, you or your family member may have been in contact with a person who was found to have an uncommon germ called Methicillin-Resistant Staphylococcus aureus (MRSA). Testing for antibiotic resistant germs is an important part of the Infection Prevention and Control Program to reduce the risk of spreading these germs to other patients.

What is Staphylococcus aureus? Staphylococcus aureus (S. aureus) is a bacteria or germ that normally lives on the skin or in the nose of many people. Usually, these people are completely healthy and don’t know they have it. This is called colonization. It is normal to be colonized with bacteria in many parts of our bodies. If S. aureus gets “inside” the body, for example, under the skin or into the lungs, it may cause an infection. When it causes an infection, it is usually treated with antibiotics.

What does antibiotic resistant mean? Antibiotics are drugs used to treat infections caused by germs. Sometimes these drugs will no longer kill the germs as the germs have changed. These germs are called antibiotic resistant.

What is Methicillin Resistant Staphylococcus aureus or MRSA? The usual treatment for S. aureus infections is a group of antibiotics related to penicillin, which include methicillin, oxacillin, and cloxacillin. Some S. aureus are no longer killed by methicillin and they are called MRSA. When this happens a different antibiotic is needed to treat the infection. Individuals can have an infection caused by MRSA or they can just carry the germ on their skin or in their nose.

Why is testing needed? Hospitals are places where germs may be passed from one patient to another. Testing is required to prevent the spread of this germ to other patients.

How do we test for MRSA? One way to help us find this germ is to swab your nose and wounds. Results are usually available within 24 – 48 hours. If you test positive, you will require special precautions for preventing the spread of MRSA. The doctor will be notified if the test is positive for MRSA.

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What about patients, family and visitors? You and your family members should always wash your hands or use

alcohol-based hand rub (sanitizers) while in hospital. If you or your family are concerned about MRSA, you should speak with

staff or contact Infection Prevention and Control. Remind all staff to wash their hands or use alcohol based hand rub

(sanitizer) before and after they touch a patient.

Hand washing or using alcohol-based hand rub (sanitizer) is the best way to prevent the spread of these germs. Please contact Infection Prevention & Control if you have any questions.

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15.10 Testing for Vancomycin-Resistant Enterococci (VRE) Fact Sheet for Patient and Family

During this admission, a prior admission or follow-up visit, you or your family member may have been in contact with a person who was found to have an uncommon germ called Vancomycin-Resistant Enterococci (VRE). Testing for antibiotic resistant germs is an important part of the Infection Prevention and Control Program to reduce the risk of spreading these germs to other patients. What are Enterococci? Enterococci are bacteria or germs that are normally found in the bowel of many people. Usually these people are completely healthy and don’t know they have it. This is called colonization. Enterococci may cause wound or skin infections, and less often, more serious infections of the blood and other body sites. When it causes an infection, it is usually treated with antibiotics. What does antibiotic resistance mean? Antibiotics are drugs used to treat infections caused by germs. Sometimes these drugs will no longer kill the germs as the germs have changed. These germs are called antibiotic resistant. What is Vancomycin-Resistant Enterococci (VRE)? Vancomycin is an antibiotic used to treat Enterococci. Some Enterococci are no longer killed by vancomycin and they are called Vancomycin Resistant Enterococci or VRE. Why is testing needed? Hospitals are places where germs may be passed from one patient to another. Testing is required to prevent the spread of this germ to other patients. How do we test for VRE? One way to help us find this germ is to swab your rectum. Results are usually available within 72-96 hours. If you test positive, you will require special precautions for preventing the spread of VRE. The doctor will be notified if the test is positive for VRE. What about patients, family and visitors? You and your family members should always wash your hands or use

alcohol-based hand rub (sanitizers) while in hospital. If you or your family are concerned about VRE, you should speak with staff or

contact Infection Prevention and Control. Remind all staff to wash their hands or use alcohol based hand rub (sanitizer)

before and after they touch a patient.

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Hand washing or using alcohol-based hand rub (sanitizer) is the best way to prevent the spread of these germs. Please contact Infection Prevention & Control if you have any questions.

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16.1 Infection Prevention & Control Signs – Price List

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16.2 Infection Prevention & Control Signs – Ordering Process The following process can be followed to order the Infection Prevention & Control signs: 1. Orders can be sent to:

HSC Printing Services MH210A – 59 Pearl Street Winnipeg, MB R3E 3L7 Fax: (204) 787-2086 E-mail: [email protected]

2. Cost of signs – please see the price list. 3. Please specify on the purchase order which signs you wish, the Print

Shop order number and the quantity required. For non-HSC customers a PO number is required. Print Shop Work Orders can be found on the WRHA intranet side under the Finance section. Please call Rod Sherwin @ 787-3555 if you have questions.

4. There is no minimum order. If you require specific information on how to order these signs, please contact Infection Prevention & Control at 833-1750.

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DATE ISSUED: February 1, 2006 REVISION DATE:


References

1. American Academy of Pediatrics. Red Book. Report of the Committee on Infectious Diseases. 25th Edition.

2. Association for Professionals in Infection Control and Epidemiology, Inc.

APIC Text of Infection Control and Epidemiology, 2nd Edition. January 2005.

3. Canada Communicable Disease Report. Public Health Agency of Canada.

Canadian Contingency Plan for Viral Hemorrhagic Fevers and Other Related Diseases. January 1997.


Guidelines for the Prevention and Control of Occupational Infections in Health Care. March 2002.


Guidelines for Preventing the Transmission of Tuberculosis in Canadian Health Care Facilities and Other Institutional Settings. April 1996.

6. Canada Communicable Disease Report. Infection Control Guidelines for

Classic Creutzfeldt-Jakob Disease in Canada. November 2002.

7. Canada Communicable Disease Report, Public Health Agency of Canada. Handwashing, Cleaning and Sterilization in Health Care. December 1998.


Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care. July 1999.

9. Canadian Standards Association. Selection, Use and Care of Respirators.

October 2002.

10. Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for Environmental Infection Control in Health-Care Facilities. 2003.

11.Electronic formats recommended by Johns Hopkins Medicine. Baltimore,

Maryland. Retrieved July 21, 2005 from the World Wide Web: http://www.hopkinsmedicine.org/heic/index.html

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