Document Number: GNAH Guideline xx_xx Intensive Care Infection Control Guidelines Sit es where Guidelin e\ applies: J ohn Hunt er Intensive Care Serv ices Tar get audience: All He alth Care Wo r k er s Description: Guideline for infection prevention and control in the int ensive care Keywor ds: Stan dard P recaut ions, Hand Hygiene, Additional Precautions Replaces Existing Guidelin e / P rocedure\: Yes Registration Number(s) and/or name and of Superseded Documents: Relevant or related Documents, Australian Standards, Guidelines etc: P olicy Direct ive P D200 7_036 Inf ect ion Cont rol P olicy P olicy Directive PD2007_084 Infection Control Policy: P revent ion and Managem ent of Multi- Resistant Organisms (MRO) P olicy Direct ive PD2010_028 Influen za Pandemic- P rov idin g Crit ical Care P olicy Directive PD2005_387 Children and Infant s with Bronchiolit is- Acute Managem ent Policy Compliance Procedure PD2007_36:PCP1 Hand Hygiene by Healthcare Staff P olicy Dire ct ive P D20 10_058 Hand Hyg iene P olicy Guideline GL2010_007 Influenza-Guidelines for the Intensive Care Unit 2010 P rerequisites (if required ): Health Care Worker ’s m ust annually com plete th e Hand Hygiene on lin learning program accessed via the mylink portal at http://mylink.hnehealth.nsw.gov.au/ P rocedure Summary: This Guideline sets out t he steps to be followed when providin g care for all patient s adm itt ed to J ohn Hunt er Hospit al Int ensive Care Services. The procedural components of the document such as, Preparation of patient, P reparat ion of equipment , T echnique, Cleaning up and Documentation are considered mandatory. Guideline Note : This docum ent reflects what is current ly regarded as safe and appropriate practice. However in any clinical situation t here m ay be many factors that cannot be covered by a single document and therefore does not replace the need for the application of clinical ju d gment in respec t t o ea ch in d iv id u al pat ie n t . For assistance with any matter relating to infection prevention and contr ol call I P CU on 13129/554 5 or page 204 8/287 8 Outside office hours cont act J ohn Hunt er Hospit al swit chboard and ask for assistance IPCU intranet site address is http://intranet.hne.health.nsw.gov.au/hne_infection_prevention_and_co ntrol Date first authorised: May 2010 Aut hori sed by : J HH ICU Execu t ive Team Guideline \ Page 1
Sites where Guideline\ applies: J ohn Hunter Intensive Care Services
Target audience: All Health Care Workers
Description: Guideline for infection prevention and control in theintensive care
Keywords: Standard Precautions, Hand Hygiene, AdditionalPrecautions
Replaces Existing Guideline / Procedure\: Yes
Registration Number(s) and/or name and
of Superseded Documents:Relevant or related Documents, Australian Standards, Guidelines etc:
Policy Directive PD2007_036 Infection Control Policy
Policy Directive PD2007_084 Infection Control Policy: Prevention and Management of Multi-Resistant Organisms (MRO)
Policy Directive PD2010_028 Influenza Pandemic- Providing Critical Care
Policy Directive PD2005_387 Children and Infants with Bronchiolitis- Acute Management
Policy Compliance Procedure PD2007_36:PCP1 Hand Hygiene by Healthcare Staff
Policy Directive PD2010_058 Hand Hygiene Policy
Guideline GL2010_007 Influenza-Guidelines for the Intensive Care Unit 2010
Prerequisites (if required): Health Care Worker’s must annually complete the Hand Hygiene onlinlearning program accessed via the mylink portal athttp://mylink.hnehealth.nsw.gov.au/
Procedure Summary: This Guideline sets out the steps to be followed when providing carefor all patients admitted to J ohn Hunter Hospital Intensive CareServices. The procedural components of the document such as,Preparation of patient, Preparation of equipment, Technique, Cleaningup and Documentation are considered mandatory.
Guideline Note : This document reflects what is currently regarded as safe and
appropriate practice. However in any clinical situation there may bemany factors that cannot be covered by a single document andtherefore does not replace the need for the application of clinical judgment in respect to each individual patient.
For assistance with any matter relating to infection prevention andcontrol call IPCU on 13129/5545 or page 2048/2878
1 All Health Care Workers must adhere to standard precautions, including the hand hygienepolicy and the use of Personal Protective Equipment
2All Health Care Workers must adhere to additional precautions including contact, droplet andairborne precautions
3 All Health Care Workers must adhere to environmental management including the disposal of contaminated waste, handling of linen, handling of laboratory specimens, equipment disposal,patient care area cleaning and re-stocking and patient hygiene, to ensure a safe environmentfor Health Care Workers, patients and visitors.
ABBREVIATIONS & GLOSSARY
Abbreviation/Word Definition
Additional(transmission based)precautions
Are designed for patients known or suspected to be infected withpathogens for which additional precautions beyond standard precautionsare needed to interrupt transmission in health organizations. Additionalprecautions are also designed to protect immunocompromised patientsfrom acquiring healthcare associated infections whilst in protectiveisolation
Alcohol-based handrub/gel
An alcohol-containing preparation designed for reducing the number of viable micro-organisms on the hands
Droplets Small particles of moisture (e.g. spatter) generated when a person coughsor sneezes, or when water is converted into a fine mist by an aerator orshowerhead. These particles, intermediate in size between drops anddroplet nuclei, can contain infectious micro-organisms and tend to quicklysettle from the air such that risk of disease transmission is usually limitedto persons in close proximity of the droplet source
Hand hygiene General term that applies to hand washing, antimicrobial hand wash,antimicrobial hand rub or surgical hand antisepsis
HCW’s Health Care Workers. This includes Medical Staff, Nursing Staff, AlliedHealth and Housekeeping
ICU Intensive Care Unit
IPCU Infection Prevention and Control Unit
PPE Personal Protective Equipment, refers to a variety of infection controlbarriers and respirators, used alone, or in combination, to protect mucousmembranes, skin, and clothing from contact with recognized andunrecognized sources of infectious agents in health care settings
Standard Precautions Precautions designed to reduce the risk of transmission of micro-organisms from both recognized and unrecognized sources of infection inhealthcare settings.
Standard precautions are standard operating procedures that apply to the care and treatment of allpatients, regardless of their diagnosis or perceived infectious risk. These precautions includeaseptic technique, hand hygiene, use of personal protective equipment, appropriate reprocessingof instruments and equipment and implementation of environmental controls.
Standard precautions are work practices required to achieve a basic level of infection control. Theyare pivotal to infection control in the health care environment and recommended for the treatmentand care of all patients.
Adoptions of standard precautions is the primary strategy to prevent the transmission of healthcare associated infections and are used in conjunction with additional precautions (AustralianCommission on Safety and Quality in Healthcare, 2010).
Standard precautions must be adhered to by all HCW’s within the ICU.
Standard precautions apply to all patients receiving care, regardless of their diagnosis orpresumed infection status.
They also apply to the handling of or when contact is likely with;
Blood
All body substances, including secretions and excretions
Non intact skin
Mucous membranes including eyes
Standard precaution items of PPE are donned in the patient care area when;
Providing direct patient care
Cleaning equipment
Standard precaution items of PPE are doffed before leaving a patient care area. They are onlyworn outside this area when;
Transporting blood and bodily substances to a disposal receptacle (if possible this shouldoccur in the patient care area)
Transporting a patient outside the ICU
All items of standard precautions PPE are removed and discarded appropriately once thisactivity is complete and before undertaking another activity or caring for another patient
Standard precautions are the use of Safe Work practices and PPE. This includes;
1. Hand hygiene
2. Use of Items of PPE (including fluid repellent masks, protective eyewear, sleeveless plasticaprons and medical examination gloves)
All HCW’s must comply with the hand hygiene policy. This includes the “5 moments of handhygiene” and hand care.
Hand Care
This integral aspect of hand hygiene is performed by
Checking your skin integrity using alcohol based hand rub on commencement of duty
Covering cuts or other non-healed skin lesions with an occlusive dressing
Reporting skin conditions to Staff Health and Line Managers and getting treatment
Applying moisturiser to your hands at least 5 times per shift
Keeping your nails short and clean and not wearing artificial nails or polish
Avoiding picking your nails
“ 5 Moments of Hand Hygiene”
This includes the use of alcohol based hand rub if hands are not soiled or the use of liquid soapand hand hygiene sinks with running water if hands are soiled.
Policy Compliance Procedure PD2007_36:PCP1 Hand Hygiene by Healthcare Staff
Are used in addition to standard precautions and are designed to interrupt the transmission of pathogens within Intensive Care. There are three categories of additional precaution;
Contact Precautions
Droplet Precautions
Airborne Precautions
Additional Precautions may be applied separately or in combination depending on the pathogeninvolved or the procedure being performed on a patient. The need for additional precautions isindicated by a coloured hand sign placed on the patient care area door. This sign outlinesprecautions that need to be implemented.
Regardless of the type of additional precautions required the following steps must be taken
Display the correct hand sign on the door of the patient care area
The patient care area door is to remain fully closed
All notes are to remain outside the patient care area
Clean all equipment that is moved in or out of the patient care area
Notification of Additional Precautions
During office hours
IPCU will notify staff when additional precautions are required.
IPCU will provide an infection control care plan to place in the patient notes, indicating thetype of precautions required
Intensive Care staff will place the appropriate hand sign on the patient care area door
Outside office hours
Notification will be provided by Hunter Area Pathology Microbiology
Any HCW who becomes aware that additional precautions are required must notify;
The Intensive Care Medical Team
The Nurse In Charge of Intensive Care
The Nurse caring for the patient
Intensive Care staff will place the appropriate hand sign on the patient care area door
This indicates infectious enteric disease from pathogens. They most commonly include
Clostridium Difficile
Gastroenteritis
But can also include
Hepatitis A and E
Rotavirus
Action Required
Immediately after entering the patient care area, standard precautions must be “donned”. Thisincludes
Fluid repellent mask (if the need is anticipated)
Protective eyewear
Sleeveless plastic aprons
Medical examination gloves
Important additional information to effective containment of Clostridium Difficle
Clostridium Difficile produces resistant spores that widely contaminate the environmentaround a colonised or infected patient
Alcohol based hand rub is not effective at killing these spores
HCW’s hands must be washed with 4% chlorhexidine®solution and water. This is stored inthe clean utility room in zone B. Washing hands with liquid soap and water is also effective.
This indicates actual or suspected infection with pathogens that can be transmitted by the dropletroute. They most commonly include,
Seasonal Influenza including H1N1 (contact and droplet precautions)
Haemophilus Influenzae
Niseria Meningitidis - Meningococcal Disease
Pertussis - Whooping Cough
But can also include
Streptococcal and Adenovirus Pneumonia (contact and droplet precautions)
Rubella (contact and droplet precautions)
Paravirus B19
Action Required
Immediately before entering the patient care area, standard precautions must be “donned”. Thisincludes
Fluid repellent mask (must be donned)
Protective eyewear
Sleeveless plastic aprons
Medical examination gloves
Important additional information for effective droplet transmission containment
Escalation of droplet precautions to airborne precautions must be adhered to when HCW’s performor anticipate performing an aerosol producing procedure.
Ai rborne Precautions – The Pink hand with an “ A”
This indicates actual suspected infection with pathogens that can be transmitted by the airborneroute. This is by dissemination of small droplets, evaporated droplets or dust particles containingthe infectious agent. They most commonly include
Avian Influenza (airborne, droplet and contact precautions)
Pandemic Influenza (airborne, droplet and contact precautions)
SARS (airborne, droplet and contact precautions)
Varicella (airborne and contact precautions)
Norovirus (airborne and contact precautions)
Measles
Tuberculosis
Action Required
Immediately before entering the patient care area, standard precautions must be “donned”. Thisincludes
A P2/N95 mask
Protective eyewear
A disposable long sleeve impervious gown
Medical examination gloves
Visiting by the general public during droplet and airborne precautions
Any member of the general public visiting patients must adhere to the same precautions asHCW’s. This includes adherence with standard precautions. In addition
Visitors should be restricted to essential only
Visitors should be asked to leave the patient care area during aerosol producing procedures
High risk persons including children, the elderly and pregnant women should not visit
Immunocompromised Protective Precautions – The Purple Hand
This indicates that a patient is susceptible to infection from micro-organisms and requiresprotective precautions. They most commonly include
A patient with a neutrophil count of <0.5 109/L (neuropenia)
Febrile neutropenia
The decision to utilise immunocompromised protective precautions is made by the Intensive CareMedical Team in conjunction with the Medical Specialty the patient is admitted under.
Action Required
The patient care area door must remain closed at all times.
Immediately before entering the patient care area, standard precautions must be “donned”. Thisincludes
Fluid repellent mask (if the need is anticipated)
Protective eyewear
Sleeveless plastic aprons
Medical examination gloves
Important additional information to effective Immunocompromised Protective Precautions
These precautions do not indicate the need for cytotoxic precautions
Equipment must be cleaned immediately prior to moving it into the patient care area
Flowers or pot plants are not permitted in the patient care area due to risk of bacterialexposure
For further information regarding cytotoxic management access the following links
Infants who are diagnosed with or suspected of having bronchiolitis may be infected withpathogens that are transmitted by the respiratory route. They most commonly include
Respiratory Syncitial Virus (RSV)
But can also include
Metapneumovirus
Adenovirus
Parainfluenza
Due to an infants reduced ability to generate droplets or aerosolise pathogens via spontaneouscoughing the precautions required differ from those mentioned previously.
Action Required
Immediately after entering the patient care area, standard precautions must be “donned”. Thisincludes
Fluid repellent mask (if the need is anticipated)
Protective eyewear
Sleeveless plastic aprons
Medical examination gloves
Situations where a fluid repellent mask may be required include
Intubation
Extubation
Disconnection of the ventilator circuit
Changing the expiratory filter of the ventilator circuit
Admission and discharge for adults and paediatrics
This includes nose and peri-anal swabs with a “blue” bacterial swab stick and is performedafter dipping this into transport medium.
The peri-anal swab is attained using the “swipe card” method
If the patient is transferred from ICU to HDU, the discharge swabs are obtained in HDU
Tick Intensive care unit box on form
Addi tional Environmental Management
Contaminated Waste
Each patient care area contains a general waste receptacle lined with a clear plastic bag and aclinical waste receptacle lined with a reinforced plastic yellow contaminated waste bag.
Contaminated waste is material that has the potential to cause injury, infection, or offence. Itincludes dressings and disposable items that are heavily soiled with blood
For disposal purposes, saliva, CSF, tears, sweat, urine and faeces are not classified ascontaminated unless they are visibly contaminated with blood
Any items that are not contaminated with blood are to be disposed in the general wastereceptacle
Linen
Each patient care area contains a double linen skip for the disposal of all linen. This skip housestwo disposal bags
A bag with no plastic lining for the disposal of non-contaminated linen
A bag with an impermeable lining for the disposal of linen contaminated with blood or bodysubstances
All linen bags must only be ¾ filled then are changed by contacting the Intensive Care wards-person
All specimens must be handled as potentially infectious and transported in leak proof bags/containers
Alcohol based hand rub must be used after contact with specimens and after utilising thepneumatic transport system tubes
Non- Disposable
Contaminated reusable equipment may be rinsed at the point of use, and then deposited in theleak proof CSSD containers found in the dirty utility rooms in zones A, B, C and D.
Room Stock
Patient care area stock of disposable items should be kept to minimal
Upon patient discharge non used disposable stock is retained
If the patient has required protective precautions any non used disposable stock should be
placed in a plastic bag and transferred to the receiving ward with the patient or disposed of if not required
Patient Hygiene
All patients are washed with generic brand liquid soap stored in the clean utility room inzones A, B, C and D
Any patients identified with an MRO must have a daily wash with 1% Triclosan®using thecomplete tube of solution
Any patient attending operating theatres must have a 1% Triclosan®using the complete tubeof solution
Any patient attending Intensive Care for an invasive procedure must have a % Triclosan® using the complete tube of solution in the ward area
Environmental Cleaning Patient Care Area
Nursing staff are to attend routine cleaning of all equipment in the patient care area every 24hours using undiluted Viraclean®.
A container of this solution is stored in every patient care area
The solution is changed every 24 hours by cleaning staff
Large alcohol wipes are used to clean protective eyewear, ventilator screens and monitorscreens
On patient discharge cleaning staff attend mopping of floors, cleaning of walls and ceilingswith Viraclean®solution diluted to 1:10 with tap water
HCW’s must adhere to standard precautions during direct contact with Viraclean®solutions
Australian Commission on Safety and Quality in Healthcare (2010) Australian Guidelinesfor the prevention and Control of Infection in Healthcare. Retrieved 14th October 2010 fromhttp://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/CD33_InfectionControlGuidelines2010.pdf
Policy Directive PD2007_036 Infection Control Policy
Policy Directive PD2007_084 Infection Control Policy: Prevention and Management of Multi-Resistant Organisms (MRO)
Policy Directive PD2010_028 Influenza Pandemic- Providing Critical Care
Policy Directive PD2005_387 Children and Infants with Bronchiolitis- Acute Management
Policy Compliance Procedure PD2007_36:PCP1 Hand Hygiene by Healthcare Staff
Policy Directive PD2010_058 hand Hygiene Policy
Guideline GL2010_007 Influenza-Guidelines for the Intensive Care Unit 2010
Hunter New England Area health Service Infection Prevention and Control webpage. Retrieved
26th
February 2010 fromhttp://intranet.health.nsw.gov.au/hne_infection_prevention_and_contol/infection_control_manual_best+practice_standards
Hunter New England Area Health Service Infection Prevention and Control Manual (2004)Retrieved 26th February 2010 fromhttp://intranet.hen.health.nsw.gov.au/hne_infection_prevention_and_control/infection_control_manual_best_practice_standards
Hunter New England Area Health Service Intensive Care Infection Control Practice Guidline (2007)Retrieved 3rd March 2010 fromhttp://intranet.hne.health.nsw.gov.au/_data/assests/pdf_file/0008/55961/Infection_control_policy.pd
