Winnipeg Regional Health Authority Acute Care Infection Prevention & Control Manual
INFECTION PREVENTION & CONTROL CHLORHEXIDINE GLUCONATE CONCENTRATION FOR HAND HYGIENE COMMUNICATION FORM
PART 1: ISSUE & RECOMMENDATIONS Issue: The WRHA Infection Prevention and Control program (IP&C) was requested to research and recommend acceptable concentrations of chlorhexidine gluconate (CHG) (2% versus 4%) for hand hygiene in all programs within WRHA sites, to ensure appropriate products are being used, and facilitate standardization. Recommendations: Use 2% CHG hand cleansers for hand hygiene when antimicrobial hand soap is indicated. Do NOT use 4% CHG for hand hygiene as the minimal improvement in efficacy (from 2%), does not warrant the increased frequency of skin irritation and breakdown, which ultimately impedes effective hand hygiene practices. PART 2: BACKGROUND: DISCUSSION OF ISSUE, OPTIONS AND ANALYSIS & REFERENCES Discussion of Issue: There are several different hand hygiene products used within and between WRHA sites. All areas should adhere to recommended hand hygiene products, as determined by available evidence. There are differences in when specific hand hygiene products are indicated. It is important to identify the appropriate product to use for the appropriate reason, as supported by evidence. Options and Analysis: 1. CHG has a cumulative effect when applied to the skin. In hand hygiene, this effect remains and is sustained, especially when hand hygiene is repeated. 2% CHG is appropriate for hand antisepsis because of the cumulative effect.1 2. Literature regarding differences between 2% and 4% CHG identifies there is minimal difference in efficacy between 2% and 4% CHG for hand antisepsis and cleansing.2 3. The frequency of skin irritation is concentration dependent, with products containing 4% most likely to cause dermatitis when used frequently for hand antisepsis. 2 4. The minimal improvement in efficacy of the 4% solution does not warrant the increased frequency of skin irritation and breakdown. References: 1. Best Practices for Hand Hygiene In all Health Care Settings, 4th Edition. Provincial Infectious Diseases Advisory Committee (PIDAC). (2014 April). Available at: http://www.publichealthontario.ca/en/eRepository/2010-12%20BP%20Hand%20Hygiene.pdf 2. WHO Guidelines on Hand Hygiene in Health Care. World Health Organization. (2009) Available at: http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf.
Review Date: January 2018 Communication Form Contacts: Davilyn Cairns and Janice Briggs, WRHA IP&C
DATE ISSUED: February 1, 2006 Page 8.1 REVISION DATE: January 2015
Winnipeg Regional Health Authority Acute Care Infection Prevention & Control Manual
INFECTION PREVENTION & CONTROL COMMUNICATION FORM CLEAN SUPPLY MOVEMENT
PART 1: ISSUE & RECOMMENDATIONS Issue: Procedures to standardize the movement of unused supplies within the Region are needed to minimize infection transmission. Note: Supplies in the Operating Room are outside the scope of this Communication Form.
Recommendations: 1. Ensure minimal supplies leave Clean Supply Room at all times. o Do not over-stock patient rooms. 2. Clean and disinfect, with a facility approved disinfectant as per manufacturer’s recommended cleaning instructions, wipeable supplies with intact packaging that have been in a patient room prior to returning them to a Clean Supply Room. 3. Supplies may be returned to Stores or the Clean Supply Room or moved to a different Clean Supply Room after being cleaned and disinfected, with a facility approved disinfectant as per manufacturer’s recommended cleaning instructions. 4. Control and monitor access to Clean Supply Rooms.4 o Take reasonable steps to enforce Policies and Procedures pertaining to Clean Supply Rooms. o Take reasonable steps to prevent unauthorized persons from entering Clean Supply Rooms. 5. Clean and disinfect supplies that have been in a patient room prior to using them for another patient. 6. Supplies that are visibly soiled and high touch areas require cleaning and disinfecting prior to being moved with a patient should their location change. 7. Clean and disinfect unused disposable supplies that are in the patient’s room and that can tolerate the process and products when a patient is discharged. o Unused disposable supplies that have been cleaned and disinfected may be returned to the unit’s Clean Supply Room. o Unused disposable supplies that have non-intact packaging or cannot tolerate cleaning and disinfection are discarded. o Supplies in resuscitation rooms or ambulatory care areas, e.g., treatment and clinic rooms do not have to be removed from the room or cleaned between patients unless visibly soiled. 8. Ensure care is used with all supplies, particularly if a patient has been on Additional Precautions, during outbreaks or if supplies are suspected to be contaminated. 9. Supplies in basket and carts, e.g., Code Blue, emergency intubation baskets, intravenous baskets shall not be returned to Clean Supply Room or Stores. o These supplies shall be managed in accordance with Code Blue Team Resuscitation in Acute Care Policy # 110.050.010.
PART 2: BACKGROUND: DISCUSSION OF ISSUE, OPTIONS AND ANALYSIS & REFERENCES Discussion of Issue: 1. Returning unused clean supplies that have been in a patient’s room to Stores or the Clean Supply Room potentially results in contamination of clean supplies. 2. Once reusable sterile supplies are moved into clean storage they are considered compromised, and must be reprocessed if returned to Medical Device Reprocessing (MDR). 3. Once reusable supplies are moved into an occupied patient room they are considered
8.2 DATE ISSUED: May 9, 2013 REVISION DATE: June 2015 Winnipeg Regional Health Authority Acute Care Infection Prevention & Control Manual
compromised, and require cleaning or disinfecting prior to moving. 4. Supplies moving “downstream” i.e., from MDR/Stores Clean Supply Room patient room, do not require additional cleaning or disinfecting prior to moving. 5. Supplies moving “upstream” i.e., from patient room Clean Supply Room Stores, require cleaning and disinfecting prior to moving. 6. Supplies moving “laterally” i.e., from Clean Supply Room Clean Supply Room or from patient room patient room require cleaning and disinfecting prior to moving. 7. Supplies may be cleaned and disinfected provided: o Their packaging is intact (if packaged). o The supply or packaging is wipeable. o The supply or packaging can tolerate cleaning and disinfecting with facility approved products according to manufacturer’s instructions. 8. The scope of this communication form is limited to non-operating room areas as the OR is a more controlled environment with appropriate air handling, humidity and heightened infection prevention and control measures. 9. Various baskets and carts are brought into patient rooms resulting in used supplies and unused clean supplies. Emergent circumstances may have occurred while these were in the rooms. 10. The chemistry of liquid products (e.g., intravenous solutions) left in the patient room on heaters or in direct sunlight may be compromised. Options and Analysis: 1. Discard all disposable supplies removed from patients rooms or the Clean Supply Room when no longer required, e.g., upon patient discharge or change of supply requirements; do not return any used supplies to Clean Supply Rooms. 2. Do not return any supplies to Medical Device Reprocessing, Stores or Clean Supply Rooms. 3. Only wipeable supplies with intact, wipeable packaging may be moved laterally or upstream and must first be cleaned and disinfected with a facility approved disinfectant as per manufacturer’s recommended cleaning instructions. 4. Control and monitor access to Clean Supply Rooms.4 5. Reprocess unused supplies after removing from the room of a patient on Contact, Airborne/Contact or Droplet/Contact Precautions. 6. Discard all disposable supplies after removing from the room of a patient on Contact, Airborne/Contact or Droplet/Contact Precautions. 7. Do not move supplies from one area to another area on the same level, i.e., not from patient room to patient room, not from Clean Supply Room to Clean Supply Room. 8. Use increased diligence with supplies in outbreak situations or if suspected to be contaminated.
References: 1. Code Blue Team Resuscitation in Acute Care Policy #110.050.010. Winnipeg Regional Health Authority. Available at: http://home.wrha.mb.ca/corp/policy/files/110.050.010.pdf. 2. The Chief Public Health Officer’s Report on the State of Public Health in Canada Infectious Disease-The Never-ending Threat (2013). Dr. D. Butler-Jones. Available at: http://www.phac- aspc.gc.ca/cphorsphc-respcacsp/2013/index-eng.php. 3. Effective Sterilization in Health Care Facilities by the Steam Process. Z314.3-09 (2009). Canadian Standards Association. Available at: http://shop.csa.ca/en/canada/sterilization/z3143- 09/invt/27013302009. 4. Warehousing, Storage and Transportation of Clean and Sterile Medical Devices. Z314.15-10 (2010). Canadian Standards Association. Available at: http://shop.csa.ca/en/canada/sterilization/z31415-10/invt/27019502010.
Review Date: June 2018 Communication Form Contact: Janice Briggs, WRHA IP&C Specialist
8.3 DATE ISSUED: May 9, 2013 REVISION DATE: June 2015
Winnipeg Regional Health Authority Acute Care Infection Prevention & Control Manual
INFECTION PREVENTION & CONTROL COMMUNICATION FORM CLEANING AND DISINFECTION OF JETTED TUBS
PART 1: ISSUE & RECOMMENDATIONS Issue: The purpose of this document is to standardize cleaning and disinfection practices for jetted tubs within the Winnipeg Health Region. Jetted tubs include hydrotherapy, extremity (arm, leg), as well as any other tub with jets. Note: Air jetted tubs and chlorinated tubs or pools are not within the scope of this document. Jetted tubs have the potential to act as reservoirs in the spread of infection. Agitation of water by jets increases the risk of aerosol generation and inhalation of microorganisms. There is potential for contact with, and exposure of open wounds or mucous membranes (e.g., perineum) in jetted tubs. Recommendations: 1. Clean and disinfect all jetted tubs and associated plumbing with an intermediate level disinfectant after each use.3, 4, 5, 6 Extremity jetted tubs and associated tubing, when used for patients with intact skin, are an exception and may be cleaned and disinfected with a low level disinfectant. 2. Cap unneeded jets with a manufacturer-approved cap. Jet capping includes completely removing the whirlpool system, tubing, motor and supportive components. 3. Replace jetted tubs with non-jetted tubs or showers during renovations. 4. Assess appropriateness of use of jetted tubs for patients with non-intact skin on a case-by-case basis.5 PART 2: BACKGROUND: DISCUSSION OF ISSUE, OPTIONS AND ANALYSIS AND REFERENCES Discussion of Issue: Jetted tubs require intermediate level disinfection due to increased risk for infection transmission resulting from both exposure to aerosolized water that has been in tubing which cannot be effectively cleaned and dried, as well as exposure to mucous membranes or non-intact skin. Water in jetted tubs may transmit microorganisms through ingestion, inhalation, or contact with mucous membranes or wounds.6 Literature reports indicate infections due to transmission of microorganisms such as Pseudomonas and Mycobacteria from jetted tubs2. Sources of microorganisms include patients/residents/clients, as well as tap water. Exposure of mucous membranes, open wounds, and non-intact skin increases the risk of microorganism transmission. The potential for use of extremity tanks with non-intact skin may lead to microorganism transmission, even though there may be no exposure to mucous membranes or open wounds.7 Intermediate level disinfectants kill vegetative bacteria, most viruses and most fungi but not resistant bacterial spores. Note: intermediate level disinfectants are effective against mycobacteria.4 Low level disinfection is adequate for extremity jetted tubs used for patients with intact skin. Jets in tubs may be capped to avoid: Increased risk posed by jetted tubs Need for additional cleaning and disinfection required for jetted tub plumbing. Options and Analysis: 1. Clean and disinfect all jetted tubs and associated plumbing, with an intermediate level disinfectant after each use. Additional cleaning/disinfection may be required per manufacturer’s recommendations. 2. Cover jets with a manufacturer-approved cap. Jet capping includes completely removing the whirlpool system, tubing, motor and supportive components.
DATE ISSUED: October 22, 2015 Page 8.3.1 REVIEW DATE: October 2018
Winnipeg Regional Health Authority Acute Care Infection Prevention & Control Manual
3. Replace jetted tubs with non-jetted tubs or showers during renovations. 4. Assess appropriateness of use of jetted tubs for patients/residents/clients with non-intact skin on a case- by-case basis.6 5. Manitoba Health5, Public Health Agency of Canada3, and the Centers for Disease Control and Prevention6 recommend intermediate level disinfection for jetted tubs and associated tubing although PIDAC has recommended low level disinfection1. Evidence regarding the level of disinfection required is not strong5. References: 1. Best Practices for Cleaning, Disinfection and Sterilization of Medical Equipment/Devices in All Health Care Settings, 3rd edition. (2013 May) Provincial Infectious Diseases Advisory Committee (PIDAC). Public Health Ontario. Available at: http://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013. pdf. 2. Budgell, S., Thompson, B. Hydrotherapy Tub Usage. Infection Risks - Cleaning and Disinfecting. Environmental Health Review. (2002 Spring) pp 5-10. Canadian Institute of Public Health Inspectors (CIPHI) Available at: http://brainmass.com/file/27899/EHR02.1-5-9.pdf. 3. Canada Communicable Disease Report Supplement. Infection Control Guidelines Hand Washing, Cleaning, Disinfection and Sterilization in Health Care. (1998 December). Volume 24S8. Available at: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/98vol24/index.html. 4. Morbidity and Mortality Weekly Report (2003). Appendix A: Regulatory Framework for Disinfectants and Sterilants. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a2.htm#fig 5. Personal Service Facility Guidelines. (2013 November). Manitoba Health. Available at: http://www.gov.mb.ca/health/publichealth/environmentalhealth/protection/docs/psf_guideline.pdf 6. Water Use in Hydrotherapy Tanks. (2009) Centers for Disease Control and Prevention. Available at: CDC - Hydrotherapy Tanks - Medical Water - Other Uses of Water - Healthy Water 7. Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings. (2012) Public Health Agency of Canada. Available at: http://www.ipac- canada.org/pdf/2013_PHAC_RPAP-EN.pdf.
Review date: October 2018 Communication Form Contacts: Janice Briggs, Dana Male, WRHA Infection Prevention & Control Program
DATE ISSUED: October 22, 2015 Page 8.3.2 REVIEW DATE: October 2018
Winnipeg Regional Health Authority Acute Care Infection Prevention & Control Manual
INFECTION PREVENTION & CONTROL COMMUNICATION FORM MANAGEMENT OF SHARED READING MATERIALS IN
HOSPITAL WAITING ROOMS
PART 1: ISSUE & RECOMMENDATIONS
Issue: Should shared reading materials in hospital waiting rooms be removed in efforts to control organism transmission?
Recommendations: 1. Discard reading materials in hospital waiting rooms if visibly soiled or damaged. 2. Remove reading materials from hospital waiting rooms during outbreaks of Severe Acute Respiratory Illness, emerging illnesses and when directed by the WRHA Infection Prevention & Control Program. 3. Ensure all hospital waiting rooms have the following: Hand hygiene products Procedure or surgical masks Respiratory etiquette signage Processes to ensure movement of patients with respiratory symptoms, draining wounds or incontinence directly to exam rooms rather than waiting rooms.
PART 2: BACKGROUND - DISCUSSION OF ISSUE, OPTIONS AND ANALYSIS AND REFERENCES Discussion of Issue: The risk of organism transmission from reading materials in hospital waiting rooms has not been recognized in published Infection Prevention & Control guidelines however, there are published studies indicating these materials carry low levels of bacteria.
Options and Analysis: 1. A study published in the British Journal of General Practice suggests there are low levels of bacteria on magazines, and concludes these items can routinely be used in waiting rooms. 2. A review article published in the Canadian Medical Association Journal suggests transmission of antibiotic resistant bacteria in ambulatory care is infrequent. Emphasized prevention measures include: Accessibility of hand hygiene products for patients on arrival to and exit from the area/facility. Timely movement of patients with draining wounds or incontinence from waiting rooms to exam rooms. Routine cleaning of the environment and equipment, including furniture. 3. The Canadian Committee on Antibiotic Resistance recommends routine cleaning of equipment with an emphasis on triaging patients with respiratory symptoms, posting respiratory etiquette signage, and ensuring access to hand hygiene products on arrival to and exit from the area/facility.
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Winnipeg Regional Health Authority Acute Care Infection Prevention & Control Manual
References: 1. Control of antibiotic-resistant bacteria in the office and clinic. Matlow, A. & Morris, S. Canadian Medical Association Journal vol 180 no 10, pp 1021-1024. (2009 May). Control of antibiotic- resistant bacteria in the office and clinic 2. Infection control in paediatric office settings. Moore, D. Pediatrics and Child Health, 13 (5), pp 408-419. (2008 May). Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532878/#b42-pch13408. 3. Infection Prevention and Control Best Practices for Long Term Care, Home and Community Care including Health Care Offices and Ambulatory Clinics. (2010 July ). Public Health Agency of Canada. Available at: http://www.phac-aspc.gc.ca/amr-ram/ipcbp-pepci/infection- eng.php#basic. 4. Routine practices and additional precautions for preventing transmission of infections in Healthcare facilities. (2012 April). Manitoba Health. Available at: http://www.gov.mb.ca/health/publichealth/cdc/docs/ipc/rpap.pdf. 5. Swabbing of waiting room magazines reveals only low levels of bacterial contamination. Charnock C. British Journal of General Practice, 55, pp 37-39. (2005 January). Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1266241/.
Communication Form Contacts: Janice Briggs, Specialist, Infection Prevention & Control Program Janis Kennedy, Infection Control Professional, St. Boniface Hospital
8.5 DATE ISSUED: June 2015 REVIEW BY: June 2018 REVISION DATE:
Winnipeg Regional Health Authority Acute Care Infection Prevention & Control Manual
INFECTION PREVENTION & CONTROL COMMUNICATION FORM PORTABLE FANS – CLEANING AND USE RESTRICTIONS
PART 1: ISSUE & RECOMMENDATIONS Issue: Portable fans are currently used in some sites across the region to assist in patient comfort or to regulate a patient’s body temperature. Other sites have chosen to disallow the use of fans in patient care areas. Staff also use fans in their work areas, which may be near patients. This communication form does not supersede any existing site specific policy which bans the use of fans, nor does it include High-Efficiency Portable Air (HEPA)-filtered fans. Fans have the potential to disperse dust and airborne-transmitted microorganisms1, create airborne Clostridium difficile spores3, and alter airflow patterns. While use of portable fans has not been proven to transmit infection3, these issues, as well as lack of appropriate cleaning procedures, are infection control concerns. Recommendations: 1. Prohibit fans in Airborne Infection Isolation Rooms or any other pressurized room (e.g., Protective Precautions) due to pressure differentials between the room and external spaces that may disrupt the designed air flow pattern. 2. Do not use fans for patients who have been placed on Droplet or Droplet/Contact Precautions, including Contact Precautions for Methicillin Resistant Staphylococcus aureus (MRSA) or confirmed or suspected C. difficile or Norovirus infection, due to the risk of microorganism dispersal. If avoiding fans is not possible in these circumstances, close door of room or pull curtain. 3. Do not use fans in high risk areas where immunocompromised patients receive care. Immunocompromised refers to patients with congenital or acquired immunodeficiency or immunodeficiency due to therapeutic agents or hematologic malignancies. 4. Do not use fans in areas where sterile supplies are stored. 5. Do not use fans in facilities that have banned their use. 6. Perform a risk assessment on a case by case basis for patient use of fans6. 7. Adjust heating, ventilation and air-conditioning (HVAC) system in order to achieve comfortable humidity, temperature, and fresh air thus avoiding the need for the fan. 8. Perform an HVAC (facilitated by the area’s supervisor) and an air quality (facilitated by the site’s Occupational Health Nurse) assessment on a case by case basis for staff use of fans near patient care areas (e.g., at a nursing station). 9. If fans are approved for use: Ensure airflow is into patient’s bed space and not across patient to roommate or hallway Direct airflow within the area in non-patient care areas (e.g., nursing station) Position at patient’s bed level or higher. Placement of table fans on floors is not acceptable; fans must be positioned such that airflow is level with the surface of the bed (i.e., place table fans on a surface at bed level; telescoped floor fans may be acceptable if this can be accomplished). 10. For facility-owned fans, establish cleaning and disinfection frequency; add to the area’s equipment cleaning schedule. 11. Disassemble and thoroughly clean and disinfect facility-owned fans according to manufacturer’s recommendations, in accordance with the Cleaning of Non-Critical, Reusable Equipment/Items for Patients in Hospital Operational Directive in the Infection Control Manual, at http://www.wrha.mb.ca/extranet/ipc/files/manuals/ManualHospital_Full.pdf Responsibility for this task is a site-based decision. 12. Fans owned by patients or families: May be used when the family is aware of, and in agreement with, their responsibility to ensure cleaning is performed on a regular schedule (frequency of cleaning to be determined in discussion with unit staff). Should be disassembled and thoroughly cleaned by the family according to manufacturer’s recommendations. PART 2: BACKGROUND: DISCUSSION OF ISSUE, OPTIONS AND ANALYSIS & REFERENCES Discussion of Issue: 1. Use of fans may be a requirement included in the care plan for specific patients. 2. Fungal spores in dust have been shown to cause serious infections in immunocompromised patients.2 3. Fans may alter the directed airflow pattern in Airborne Infection Isolation and Protective Precautions rooms. Such alteration may result in microorganism transmission and possible infection.
DATE ISSUED: October 22, 2015 Page 8.5.1 REVIEW DATE: October 2018
Winnipeg Regional Health Authority Acute Care Infection Prevention & Control Manual
4. Environmental contamination due to MRSA shedding4, 7, may be increased with fan use. 5. Norovirus may be spread through droplets and aerosols while a patient is vomiting7. Fan use may facilitate spread. 6. Activities that contribute to microorganism dispersal may contribute to aerosolization and spread of C. difficile3. Fan use may lead to such dispersal. 7. Fans are considered non-critical reusable equipment.5 Through indirect transmission, microorganisms from such equipment may spread to patients, and lead to infection. 8. Fans require cleaning and disinfection as per regional guidelines. Options and Analysis: 1. Prohibit fan use in areas with directed airflow, to prevent altering the required airflow. 2. Prohibit fan use when patients are on Additional Precautions, including Contact Precautions for a patient with suspected or confirmed C. difficile, due to possible dispersal risk of infectious microorganisms. 3. Prohibit fan use for immunocompromised patients due to the increased risk of infection caused by dust. “Immunocompromised” refers to patients with congenital or acquired immunodeficiency or immunodeficiency due to therapeutic agents or hematologic malignancies. 4. Prohibit use in sterile supply areas to avoid risk of contaminating supplies from dust dispersal. 5. Prohibit fan use completely. 6. Consider an adjustment of the HVAC system for optimal humidity, temperature and fresh air. 7. Consider performing a risk assessment on a case by case basis to determine the need for a fan. 8. Consider an HVAC and air quality assessment for staff fan use in or near patient care areas. 9. Consider written physician orders when medical conditions warrant use of portable fans. 10. Position fans in such a way to avoid dust dispersal, as well as blowing particles outside the patient’s bed space. 11. Ensure fans are cleaned according to manufacturer’s instructions. For facility-owned fans, this would be the responsibility of staff; if patient/family owned, the family would be requested to do the cleaning. References: 1. Bartley, J. and Olmsted, R. Construction and Renovation: A Toolkit for Professionals in Infection Prevention and Control; 3rd Ed. Association for Professionals in Infection Control and Epidemiology (APIC) (2007): pp 324-326. 2. Bartley, J. et al. Heating, Ventilation, and Air Conditioning. APIC Text of Infection Control and Epidemiology (2014). Association for Professionals in Infection Control and Epidemiology (APIC).Heating, Ventilation, and Air Conditioning 3. Best, E. et al. The Potential for Airborne Dispersal of Clostridium difficile from symptomatic patients. Clinical Infectious Diseases (2010); 50 (11): 1450-1457. Available at: http://cid.oxfordjournals.org/content/50/11/1450.short 4. Boswell, T.C et al. Reduction in Methicillin Resistant Staphylococcus aureus environmental contamination with a portable HEPA-filtration unit. Journal of Hospital Infection (2006 May); 63(1): 47-54. Available at: http://www.sciencedirect.com/science/article/pii/S0195670105005074 5. Cleaning and Disinfection of Non-Critical, Reusable Equipment/Items for Patients in Hospitals Operational Directive. Winnipeg Regional Health Authority. Infection Prevention and Control Manual. (2013) IP&C Manual 6. The Joint Commission. Environment of Care (CAMH/Hospitals); Use of Fans. (2008, November 24). Available at: Environment of Care; Fan Use 7. Kowalski, W. Airborne Nosocomial Microorganisms. Hospital Airborne Infection Control. CRC Press (2011). Chapter 4.
Review Date: October 2018 Communication Form Contact(s): Jen Tomlinson and Dana Male, WRHA Infection Prevention & Control Program
DATE ISSUED: October 22, 2015 Page 8.5.2 REVIEW DATE: October 2018
Winnipeg Regional Health Authority Acute Care Infection Prevention & Control Manual
INFECTION PREVENTION & CONTROL REUSE OF RAZORS COMMUNICATION FORM PART 1: ISSUE & RECOMMENDATIONS Issue: There are instances when razors are being shared between patients/residents/clients (p/r/c) across the continuum of care. Safe practices are required to ensure shaving equipment is managed appropriately to prevent transmission of hospital-acquired infections among p/r/c. Recommendations: The WRHA Infection Prevention and Control Program provides the following recommendations: 1. Do not share straight-blade razors (disposable or re-useable) between p/r/c. 2. When a p/r/c is unable to provide his/her own razor, provide a disposable single-person use razor, OR allow use of an electrical razor with disposable or replacement heads. 3. Label each p/r/c razor (whether personal or provided from the facility; whether straight blade or electrical) with his/her name as appropriate and store at bedside or other designated area specific to the individual p/r/c. 4. If electric razors with disposable or replacement heads are used, prior to use on a new p/r/c: a. Remove the previously used head. b. Clean/ disinfect the body of the electrical razor per the manufacturer’s instructions. c. Attach a new disposable or replacement head. PART 2: BACKGROUND: DISCUSSION OF ISSUE, OPTIONS AND ANALYSIS AND REFERENCES Discussion of Issue: Shaving is well known to cause abrasions and small cuts. Blades can become contaminated with blood. The Centers for Disease Control and Prevention caution against sharing razors because razors cause microscopic cuts in the skin as they remove hair. These nicks are large enough to allow viruses and bacteria into the skin. Blood borne diseases, such as HIV and hepatitis are the largest concerns. The buildup of epithelial cells in razors blades (electrical or straight blades) could contaminate a cut and transmit infection. Electric razors are considered single p/r/c, multi-use devices. Routine Practices indicate single p/r/c multi-use devices are to be assigned to only one p/r/c, and must be properly cleaned/ disinfected between uses. Options and Analysis: 1. Provide disposable, single p/r/c-use razors to those who do not have their own. 2. Provide each p/r/c with his/her own electrical razor which is not shared with others. 3. Use electric razors with disposable or replacement heads. This requires appropriate cleaning/disinfection of the razors between each use.
References: 1. Fact Sheet - Community-Acquired Methicillin-Resistant Staphylococcus aureus (CA-MRSA). Public Health Agency of Canada (PHAC) (2008 June). Available at: http://www.phac-aspc.gc.ca/id-mi/camrsa-eng.php 2. Hepatitis B - Get The Facts, Bloodbourne Pathogen Section. Public Health Agency of Canada (PHAC) (2014 September). Available at: Hepatitis B - Get the Facts - Bloodborne Pathogens Section - Public Health Agency of Canada 3. Routine Practices and Additional Precautions: Preventing the Transmission of Infection in Health Care. Manitoba Health (2012 April) Available at: http://www.gov.mb.ca/health/publichealth/cdc/docs/ipc/rpap.pdf 4. Electric Razors as a Potential Vector for Viral Hepatitis. Kelly, C. New England Journal of Medicine (2000 March) pp 744-745. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJM200003093421017 5. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention. (2011 May) Available at: http://www.cdc.gov/hicpac/SSI/004_SSI.html 6. Recommended Practices: skin preparation of patients. AORN Journal 2002. Vol 75, Issue 1, pp 184-187. Available at: Recommended Practices for Skin Preparation of Patients - AORN Journal
Review Date: January 2018 Communication Form Contacts: Roxane Estrada and Janice Briggs, WRHA IP&C
DATE ISSUED: February 1, 2006 Page 8.6 REVISION DATE: January 2015 Winnipeg Regional Health Authority Infection Prevention & Control Manual
Infection Prevention & Control (IP & C) Communication Form
PART 1 Issue Submitted By Brenda Dyck Issue Number 3, 2006 Date May 18, 2006 Date Directed To: WRHA Sr. Mgt Subject: Date Directed To: Sharing of personal items Med Advisory Cte Date Directed To: Nursing Leadership Indicate whether the issue is for: Date Directed To: CEOs Date Directed To: May 18, 2006 Information WRHA IP&C Committee X Date Directed To: Discussion WRHA Prog teams X Date Directed To: Decision Others
PART 2 Review Date Reviewed By:
Action By Distribution
8.7
DATE ISSUED: November 30, 2006 REVISION DATE: Winnipeg Regional Health Authority Infection Prevention & Control Manual
Follow-up Requirements
Issue Sharing of personal items including but not limited to shampoo, lotions, soaps, mouthwash, deodorant, nail care items is being done in some sites across the region. Sharing of these items can transmit infections between patients, residents and clients.
Discussion of Issue Public Health Agency of Canada (Health Canada) Routine Practices recommends personal items should not be shared.
Options and Analysis
Recommendation 1. Personal items cannot be shared between patients, residents and clients 2. Single use personal items should be used. 3. If large quantity bottles/containers of personal hygiene solutions/products are used they must be decanted into a single use disposable container for each patient, resident or client.
References: 1. Public Health Agency of Canada. Routine Practices & Additional Precautions for Preventing the Transmission of Infection in Health Care. Canada Communicable Disease Report. Volume 25S4. July 1999.
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DATE ISSUED: November 30, 2006 REVISION DATE: Winnipeg Regional Health Authority Infection Prevention & Control Manual
Infection Prevention & Control (IP & C) Communication Form
PART 1 Issue Submitted By Brenda Dyck Issue Number 1, 2004 Date Directed To: January 3, 2005 Date December 2, 2004 WRHA Sr. Mgt Subject: String cords and call bells in patient Date Directed To: January 2005 care areas within hospitals. Med Advisory Cte This issue was raised by infection control practitioners Date Directed To: April 6, 2005 and discussed with facility managers. This communication details the actions to date and need for Nursing Leadership future review. Indicate whether the issue is for: Date Directed To: January 2005 CEOs Date Directed To: December 2, 2004 Information WRHA IP&C September 23, 2004 Committee. Date Directed To: Facilities Managers Group Discussion X WRHA Prog teams September 30, 2004 Date Directed To: Decision Others
PART 2 Review Date April 1, 2005 Reviewed By WRHA IP&C Program Discussion 1.) Ensure call bells are being cleaned routinely and on patient transfer and discharge. 2.) Standardized guideline for replacement of call bells. 3.) Plan for replacement of string cords is developed.
Action By Distribution
Follow-up Requirements
8.9
DATE ISSUED: February 1, 2006 REVISION DATE: Winnipeg Regional Health Authority Infection Prevention & Control Manual
Issue Push button call bells have been linked to transmission of infection and outbreaks. String cords become visually contaminated in a hospital environment and therefore are a major Infection Prevention and Control concern because they cannot be cleaned between patients. Discussion of Issue Microorganisms and contaminated material migrate under the button and contaminate the inside of push button call bells. An outbreak of VRE in Toronto was linked to push button call bells. The call bells were taken apart and there was evidence of heavily contaminated fecal material inside. The fecal material inside was epidemiological linked to the same strain of VRE that was the cause of the outbreak. The majority of call bells in hospitals in WRHA are the push button type. String cords cannot be cleaned between patients. Improper cleaning of the physical environment has been related to transmission of many types of pathogenic organisms, i.e. C. difficile, VRE. The majority of string cords in hospitals within WRHA are not cleanable and are not changed between patients. Options and Analysis Push button call bells will be more difficult to implement as they are usually built into the nurse call system and cannot be readily changed. The changing of the calls bells would require significant funding for implementation. As this will be a more long term goal, it is important to ensure all call bells are routinely cleaned as well as when patient is discharged or transferred.
Some of the hospitals within the WRHA have started replacing the string cords with a cleanable type while others still maintain these string cords on their patient care units. In discussion with Gord Trann, Regional Director, Facilities Management the string cords must be constructed of a material that does not conduct electricity. The Facilities Managers Group wish to strive for standardization of the string cords taking into account there maybe differences at some facilities as not all systems are compatible. The speed at which the cords will be changed is also an issue. Funding must be identified at each of the facilities and secured to purchase and change all of these cords. Funding may be an issue at some of the facilities and may cause delay in implementation. An interim measure would be to change string cords when visibly soiled or on patient discharge or transfer. This would be only an option for a short period of time until the string cords can be changed to a cleanable type. Recommendation At the September 23, 2004 WRHA Infection Prevention and Control Committee the Infection Prevention and Control concerns regarding call bells and string cords were discussed. The following are the recommendations for call bells and string cords: 1. Call bells should be replaced with a sealed, flat surface type where necessary, i.e. during renovations, when in need of repair. The changing of call bells will require long term implementation. It is therefore important to ensure call bells be cleaned as part of routine cleaning of patient rooms as well as upon patient transfer or discharge. 2. Replace the string cords with cords that can be easily cleaned. i.e. coated wire Brenda Dyck notified Gord Trann on of the WRHA Infection Prevention and Control Committee recommendation. The recommendations were presented at the regional Facility Management Group. The Facility Management Group acknowledges string cords and call bells are a concern. There is work in progress by the Facility Management Group to ensure there is standardization of the call bells and string cords across WRHA. The decision at the facility management group was for the Facility Management individuals to go back to their hospitals and address funding and implementation to change the string cords. Call bells and string cords were again discussed at the December 2, 2004 WRHA IP&C Committee. The IP&C members will also go back to their hospitals to address the issue of call bells and string cords. Facility Management and Infection Prevention and Control under the direction and guidance of Gord Trann and Brenda Dyck will develop a policy and guideline for string cords and for upgrades and replacements of suitable call bells when they need to be replaced.
8.10
DATE ISSUED: February 1, 2006 REVISION DATE:
Winnipeg Regional Health Authority Infection Prevention & Control Manual
Infection Prevention & Control (IP & C) Communication Form
PART 1 Issue Submitted WRHA Hospital IP&C Issue Number By Working Group Date May 14, 2012 Date Directed To: WRHA Sr. Mgt Subject: Date Directed To: Topping up bottles and reusing trigger Med Advisory Cte spray nozzles Date Directed To: January 13, 2012 Note: This does not apply to bottles Nursing containing gels, which are addressed Leadership under: Gels, Ultrasound and Medical Policy #90.00.070.
Indicate whether the issue is for: Date Directed To: CEOs Date Directed To: April 19, 2012 Information WRHA IP&C Committee X Date Directed To: May 14, 2012 Discussion WRHA Program teams X Date Directed To: Decision Others
PART 2 Review Date Reviewed By:
Action By Distribution
8.11 DATE ISSUED: May 14, 2012 REVISION DATE:
Winnipeg Regional Health Authority Infection Prevention & Control Manual
Infection Prevention & Control (IP & C) Communication Form
Follow-up Requirements Issue Topping up any type of solution, lotion or cream (e.g., disinfectants, cleansers, and soaps) has the potential to encourage microbial growth in the solutions which may result in transmission of microorganisms. Discussion of Issue 1. Topping up includes the addition of liquid to a partially used bottle and the refilling of empty bottles that have not been cleaned, disinfected and thoroughly air dried before refilling. 2. Topping up of solutions has historically been discouraged from an IP&C perspective as outbreaks have been attributed to contaminated containers of product supporting microbial growth. 3. According to WRHA Routine Practices: Hand lotion bottles shall not be reused Soap or hand rub may not be added to partially empty dispensers Dispensers must be emptied, washed and dried prior to refilling if reused. 4. Outbreaks in ophthalmology have been linked to topping up disinfectants/cleansers. 5. Reusable bottles, where permitted may be cleaned and disinfected in an instrument washer or, washed in hot soapy water in a clean separate basin (e.g., dishpan), rinsed and air dried prior to refilling. 6. Reusing trigger spray nozzles can lead to microbial growth in the solution, lotion or cream because the spray nozzles cannot be adequately cleaned and/or air dried. 7. Inhalation of aerosol particles is a potential during product spraying.
Options and Analysis 1. Use ready to use solution, lotion or cream, discard bottle/dispensing mechanism (flip-top lid or trigger spray nozzle) when empty. 2. Use dilutable solution, lotion or cream and purchase new bottles, discard bottle/dispensing mechanism when empty. Option 1 & 2 increase cost, however facilities without the physical space or infrastructure to clean, disinfect and thoroughly air dry bottles may not be able to resolve the issue without disposing of each bottle. 3. Use dilutable solution, lotion or cream and clean, disinfect and thoroughly air dry the bottles, dispose of the trigger spray nozzle; use a new nozzle on each bottle before each refill. The use of sprays is also discouraged due to the potential of product aerosolization when using spray nozzles. 4. Use dilutable solution, lotion or cream and bottles equipped with flip top dispensing mechanisms, clean, disinfect and thoroughly air dry the bottles and flip top nozzle before each refill. Option 4 may be the most economical solution and it avoids potential 8.12 DATE ISSUED: May 14, 2012 REVISION DATE:
Winnipeg Regional Health Authority Infection Prevention & Control Manual
Infection Prevention & Control (IP & C) Communication Form
aerosolization however, physical space and infrastructure are required to clean, disinfect and air dry. Recommendation(s) 1. Do not top up bottles. 2. Discard bottle and dispensing mechanism when empty. The entire bottle and flip top nozzle may be cleaned, disinfected and thoroughly air dried before each refill if physical space permits. Consult your site ICP to help determine adequate space for this task. 3. Use bottles equipped with flip top dispensing mechanisms. Do not reuse trigger spray nozzles.
8.13 DATE ISSUED: May 14, 2012 REVISION DATE:
Winnipeg Regional Health Authority Infection Prevention & Control Manual
Infection Prevention & Control (IP & C) Communication Form
References: 1. American Academy of Ophthalmology. Infection Prevention in Eye Care Services and Operating Areas and Operating Rooms. December 2009. Retrieved January 31, 2011 from: http://onetext.aao.org/CE/PracticeGuidelines/ClinicalStatements_Content.aspx?cid =bfa87dce-adc9-4450-94a2-e49493154238. 2. Bello, A., Quinn, M., Perry, M., Milton, D. Characterization of occupational exposures to cleaning products used for common cleaning tasks-a pilot study of hospital cleaners. Environmental Health. 08/03/2009. Retrieved March 21, 2011 from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2678109/?tool=pubmed. 3. CHICA-Canada Position Statement. Medical Gels. March 2005. Retrieved July 22, 2011 from: http://www.chica.org/pdf/medgels.pdf. 4. Dix, K & Schraag, J. Environmental Surface Cleaning: First defense against infectious agents. Infection Control Today. 12/01/2005. Retrieved January 31, 2011 from: http://www.infectioncontroltoday.com/articles/2005/12/infection-control- today-environmental-services.aspx#. 5. Health Canada. Infection Control Guidelines: Hand washing, cleaning, sterilization and disinfection in healthcare. December 1998. Retrieved July 22, 2011 from: http://www.dantaylor.com/files/handwashing.pdf 6. Verani, J., Suchita, A., Yoder, J., Beach, M., Braden, C., Roberts, J., Conover, C., Chen, S, McConnell, K., Chang, D., Roy, L. National Outbreak of Acanthamoeba Keratitis Associated with Use of Contact Lens Solution, United States. August 2009, 15(8). Retrieved January 31, 2011 from http://www.cdc.gov/parasites/acanthamoeba/resources/Verani_JR_2009_Nat_Out break_of_AK_Associated_with_CL_Solution_EID-508c.pdf. 7. WRHA Regional Ultrasound and Medical Gels Policy – 90.00.070, December, 2007. Available on page 3.10 at: http://home.wrha.mb.ca/prog/ipc/files/hospitalmanual/ManualHospital_Full.pdf. 8. WRHA Regional Routine Practices Policy – 90.00.060, December 2007. Available on page 3.5 at: http://home.wrha.mb.ca/prog/ipc/files/hospitalmanual/ManualHospital_Full.pdf.
8.14 DATE ISSUED: May 14, 2012 REVISION DATE:
Winnipeg Regional Health Authority Infection Prevention & Control Manual
Infection Prevention & Control (IP & C) Communication Form
PART 1 Issue Submitted Janice Briggs Issue Number By Date October 21, 2010 Date Directed To: WRHA Sr. Mgt Subject: Date Directed To: Urinary catheter change frequency Med Advisory Cte Date Directed To: Nursing Leadership Indicate whether the issue is for: Date Directed To: CEOs Date Directed To: October 21, 2010 Information WRHA IP&C Approved November Committee 23, 2010 X Date Directed To: Approved December Discussion WRHA IP&C 13, 2010 Program Team Reapproved January 9, 2012 X Date Directed To: Decision Others
PART 2 Review Date Reviewed By:
Action By Distribution
8.15 DATE ISSUED: January 2012 REVISION DATE:
Winnipeg Regional Health Authority Infection Prevention & Control Manual
Infection Prevention & Control (IP & C) Communication Form
Follow-up Requirements Issue Routine changing of indwelling urinary catheters increases the incidence of urinary tract infections in patients/residents/clients therefore can become an Infection Prevention and Control issue.
Discussion of Issue There is inconsistency in the frequency of indwelling urinary catheter changes throughout the region. Manufacturers’ recommendations are written to comply with licensing requirements of indwelling devices. In order to avoid the requirement of an implantable device license, manufacturers recommend changing indwelling urinary catheters when clinically indicated and routinely every 30 days. This is in contradiction to evidence informed practice and Infection Prevention and Control published literature, standards and guidelines, which support changing urinary catheters based on clinical indications such as infection, obstruction, or when the closed system is compromised not routinely in order to reduce the incidence of urinary tract infections.
Options and Analysis 1. Follow evidence informed practice to change urinary catheters only when medically indicated OR 2. Follow manufacturers’ recommendations to change urinary catheters when medically indicated and routinely every 30 days. 3. Consider other long-term devices. 4. Carefully evaluate need for urinary catheter.
Recommendation 1. Use urinary catheter only when necessary. 2. Reevaluate continued need for urinary catheter on a regular basis. 3. Prompt removal of urinary catheter when no longer clinically indicated. 4. Follow evidence informed practice, which concludes indwelling urinary catheters should be changed only when medically indicated.
8.16 DATE ISSUED: January 2012 REVISION DATE:
Winnipeg Regional Health Authority Infection Prevention & Control Manual
Infection Prevention & Control (IP & C) Communication Form
References: 1. Gould, C. V., MD, MSCR; Umscheid, C. A., MD, MSCE ; Agarwal, R. K., MD, MPH ; Kuntz, G, MSW, MSLIS; Pegues, D. A., MD and the Healthcare Infection Control Practices Advisory Committee (HICPAC) Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009. Retrieved March 2, 2010 from the World Wide Web: http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf. 2. Lo E, Nicolle L, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Kaye KS, Klompas M, Marschall J, Mermel LA, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol 2008 Oct 29 Suppl 1:S41-50. Retrieved April 15, 2010 from the World Wide Web: Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. 3. Victor Senese, RN, CURN, Chairperson Mary Beth Hendricks, RN, CUNP Melissa Morrison, RN Janelle Harris, MSN, RN, GNP Society of Urologic Nurses and Associates Clinical Practice Guidelines 2005 Care of the Patient with an Indwelling Catheter. Retrieved March 2, 2010 from the World Wide Web: http://www.suna.org/resources/indwellingCatheter.pdf. 4. Saint ,S, MD, MPHa,b,c,*, Chenoweth, C E., MDd (2003) Biofilms and catheter-associated urinary tract infections. Infectious Disease Clinics of North America (2003) 411–432 Ann Arbor VA Medical Center, Ann Arbor, MI, USA
8.17 DATE ISSUED: January 2012 REVISION DATE: