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Entire Infection Control Manual PDF
Entire Infection Control Manual PDF
PREVENTION
&
CONTROL
MANUAL
Updated: November 2016
Infection Prevention and Control
Disclaimer
Disclaimer
The Interior Health Infection Prevention & Control Manual (the Manual) is intended as a reference document
only. The Manual represents Interior Health’s guidelines and does not imply directly or indirectly that non
Interior Health programs or facilities are bound by the guidelines. While non IH users are encouraged to
develop their own infection prevention and control guidelines, these individual groups may choose to adopt
the guidelines in the Manual as their iown provided all references to Interior Health are removed.
The most up-to-date version of the Manual is the electronic copy on the website. If a paper copy is being
maintained it is the responsibility of the users to ensure they have the most current best practise information
to guide their treatments and interventions.
The Manual (paper or electronic version) and all the information it contains is provided “as is” without
warranty of any kind, whether expressed or implied. All implied warranties, including, without limitation,
implied warranties of merchantability, fitness for a particular purpose, and non-infringement, are hereby
expressly disclaimed.
Limitation of Liabilities
Under no circumstances will the Interior Health Authority be liable to any person or business entity for any
direct, indirect, special, incidental, consequential, or other damages based on any use of the Manual,
including, without limitation, any lost profits, business interruption, or loss of programs or information, even if
the Interior Health Authority has been specifically advised of the possibility of such damages.
Infection Prevention and Control
Summary of Changes to Infection Prevention and Control Manual
IF0200 Hand Hygiene R 3.6 When Clostridium difficile infection is suspected or diagnosed:
Wash hands with soap and water (preferred).
If no sink is in close proximity, clean hands with alcohol hand rub and
wash with soap and water at first opportunity.
Do not perform hand hygiene at a patient sink, as this may cause
recontamination of the health care provider’s hands. Use a dedicated staff
hand washing sink
IH0300 Droplet R Updated signs including Point of Care Risk Assessment, Droplet Precautions and
Precautions Droplet & Contact Precautions
IH0400 Contact R Updated signs including Point of Care Risk Assessment, Contact Precautions and
Precautions Contact Plus Precautions
Assist patients with cleaning their hands, especially after toileting and
before meals
TABLE OF CONTENTS
MANUAL INTRODUCTION
IB0100: Interior Health Infection Prevention & Control Program
ROUTINE PRACTICES
IF0100: Routine Practices for All Care Areas
IF0200: Hand Hygiene Guidelines
IF0300: Waste Management
ADDITIONAL PRECAUTIONS
IH0100: Additional Precautions For
All Care Areas
IH0200: Airborne Precautions
IH0300: Droplet Precautions
IH0400: Contact Precautions
SPECIFIC DISEASES
IS0100: Reportable Communicable Diseases
IS0200: Clostridium difficile
IS0300: Antibiotic Resistant Organisms (ARO)
IS0300A: Carbapenemase Producing Organisms (CPOs)
IS0400: Scabies/Lice
IS0500A: Tuberculosis
IS0500B Tuberculosis Risk Screening – Residential Facilities
IS0600: Chickenpox (Varicella-Zoster) and Herpes Zoster (Shingles)
IS0700: Invasive Group A Streptococcal Infections (IGAS)
IS0800: Meningococcal Infection
IS0900: Creutzfeldt-Jakob Disease
IS1000: Respiratory Syncytial Virus (RSV)
IS1100: Rabies
IS1200 Measles
IS1300 Mumps
IS1400 Bed Bugs
IS1500 Pertussis
BEST PRACTICES
IX0100: Microbiology Specimen Collection
IX0200: Prevention & Control of Catheter Associated Urinary Tract Infections (CAUTI)
IX0300: Pneumococcal Vaccine for Residential Care
IX0400: Pet Therapy and Visitation
IX0500: Soiled Utility Rooms
IX0600: Equipment Cleaning
IX0700: Toy Management
IX0800: Personal Care Supplies Best Practice Guidelines
IX0900: Construction Projects
IX1000: Construction & Renovation Guidelines
Infection Prevention and Control
Cross Reference to Infection Prevention and Control Manual
CROSS REFERENCE
A
Acute Care Plan for (ARO’s) IS0300 Acute Care Admission Screening Form #807910
Acute Care Plan for Clostridium difficile IS0200
Additional Precautions for all Care Areas IH0100
Table 6: Transmission
Characteristics and Empiric
Precautions by Clinical
Presentation: Recommendations
for Acute Care Centres
Table 7: Transmission
Characteristics and Precautions by
Specific Etiology:
Recommendations for Acute Care
Centres
C
CCARO (Community Care Antibiotic IS0300
Organisms)
Carbapenemase Producing Organisms IS0300A
Care Plan – Resident with CDI IS0200
Care Plan – Acute Care with CDI IS0200
Care Plan – Acute for AROs IS0300
Care Plan – Residential for AROs IS0300
Care Plan – Community for AROs IS0300
Chickenpox and Herpes Zoster (Shingles) IS0600
Catheter Associated Urinary Tract IX0200
Infections (CAUTI)
Clostridium difficile IS0200 Clostridium difficile Contact Precautions Sign
#807914
Infection Prevention and Control
Cross Reference to Infection Prevention and Control Manual
D
Definitions of Health Care Associated IV0200
Infections
Droplet Precautions for Acute Care IH0300 Droplet Precautions Sign #807903
Droplet / Contact Precautions #807904
E
Equipment Cleaning
Exposure – Blood and Body Fluid
(see IH Policy AV0300)
G
Gastroenteritis Illness Outbreak guidelines IV0400
H
Hand Hygiene Guidelines IF0200
Herpes Zoster IS0600
HIV Exposure (see IH Policy AV0300)
I
Interior Health Infection Prevention & IB0100
Control Program
Influenza Immunization Policy for
Employees
(See IH Policy AV1300)
Influenza Like Illness Outbreak IV0500
L
Lice/Scabies IS0400
Infection Prevention and Control
Cross Reference to Infection Prevention and Control Manual
M
Meningococcal Infection IS0800
Microbiology Specimen Collection IX0100
N
Needlestick Exposure
(see IH Policy AV0300)
O
Outbreak Facility Sign IV0400 Form #807909
P
Personal Care Supplies Best Practice IX0800
Guideline
Pet Therapy and Visitation IX0400
Pneumococcal Vaccine for Residential IX0300
Care
Prevention & Control of Catheter IX0200
Associated Urinary Tract Infections
(CAUTI)
Q
Quick Reference Guide – Respiratory IV0500
Illness Outbreak
Quick Reference Guide for GI Outbreaks IV0400
R
Rabies IS1100
Reference guide – Respiratory Illness IV0500
Outbreak
Reference Guide for GI Outbreaks IV0400
Renovation Guidelines, Construction and IX0900
Reportable Communicable Diseases IS0100 Schedule A - List of Reportable Communicable
Diseases in BC
Residential Care Plan ARO IS0300
Residential Care Plan Clostridium difficile IS0200
Respiratory Infection (RI) Outbreak IV0500
Respiratory Syncitial Virus (RSV) IS1000
Routine Practices for all Care Areas IF0100
Routine Screening for Antibiotic Resistant IS0300
Organisms (AROs) form
Infection Prevention and Control
Cross Reference to Infection Prevention and Control Manual
S
Scabies/Lice IS0400
Schedule A (Reportable Communicable IS0100
Diseases)
Shingles IS0600
Soiled Utility Rooms IX0500
Specimen, Collection of Gastroenteritis IV0400
Outbreak
Specimen, Transport of IV0400
Surgical Site Infections IV0300
Surveillance of Health Care Associated IV0100
Infections
T
Toy Management IX0700
Transmission Characteristics and Empiric IH0100
Precautions by Clinical Presentation:
Recommendations for acute Care
Centres (Table 6)
Transmission Characteristics and IH0100
Precautions by Specific Etiology:
Recommendations for Acute Care
Centres (Table 7)
Transportation of Patients on Isolation or IH0100
Additional Precautions
Tuberculosis IS0500A
IS0500B
U
Urinary Tract Infections (Prevention of) IX0200
W
Waste Management IF0300
Infection Prevention and Control
Introduction to Infection Prevention and Control Manual
MANUAL INTRODUCTION
1.0 PURPOSE
The Manual has been prepared to assist healthcare providers in implementing infection prevention
and control best practice strategies across the continuum of care. The principles and guidelines set
out in the Manual are based on published best practices, national and international, which have been
modified to reflect the specific needs of Interior Health (IH). The Manual will be updated as best
practices evolve, and the most current edition will be posted on the INFECTION PREVENTION &
CONTROL WEBSITE.
This document covers acute, residential, and community care settings and programs. Note: In this
document the term “patient” is inclusive of patient, resident & client. The implementation of
routine infection control principles applies to all healthcare providers and patients in all healthcare
settings all the time.
The goal of infection control practices is to reduce the risk of transmission of infectious
microorganisms in all healthcare settings by:
Understanding the concepts of the chain of transmission;
Understanding the concepts and application of Routine Practices (RP);
Knowing why and when to use Additional Precautions (AP); and
Appropriately using, applying and removing personal protective equipment (PPE) when indicated
for the protection of the patient or the healthcare provider.
2.0 DEFINITIONS
Aseptic Technique – refers to practices designed to render the patient’s skin, supplies and surfaces
maximally free from microorganisms. Such practices are required when performing procedures that
expose the patient’s normally sterile sites e.g., intravascular system, spinal canal, subdural space,
and urinary tract, in such a manner to keep them free of microorganisms.
Health Care Associated Infection (HAI) – an infection that is not present or incubating at the time of
admission to a healthcare facility or program but is associated with admission to or a procedure
performed in a the facility or program.
Infection – occurs when microorganisms invade a body site, multiply in tissue and cause clinical
manifestations of local or systemic inflammation (e.g. fever, redness, heat, swelling, pain, etc.)
PPE – personal protective equipment are barriers used by healthcare providers to protect mucous
membranes, airways, skin and clothing from exposure to blood and body fluids.
Infection Prevention and Control
Introduction to Infection Prevention and Control Manual
FIGURE 2 - An infection can be prevented by breaking any link in the chain of infection. Infection
control measures are designed to break the links and thereby prevent an infection from occurring.
Here are the six links in the chain of infection and how these links can be broken so an
infection does not occur:
1. Causative (infectious) agent including bacteria, viruses, fungi, prions and parasites
Break the link by eliminating or inactivating the agent, preventing the agent from exiting the
reservoir, sterilizing surgical instruments, safe food practices, safe drinking water,
vaccinations, treating infectious individuals, practicing good hand hygiene.
2. Reservoir or “home” of the infectious agent including the human body, animals and the
environment (water, food)
Break the link by treating infectious individuals, vaccination, handling and disposing of body
fluids appropriately, safe food practices, monitoring water for contamination.
3. Portal of exit is the path by which an infectious agent leaves the reservoir or “home” including
any break in the skin or any bodily fluid such as secretions, excretions and blood.
Break the link by implementing safe practices such as covering coughs and sneezes,
handling body fluids with gloves, performing appropriate hand hygiene, and containing
draining wounds. Healthcare providers should not work if they have exudative (wet) lesions
or weeping dermatitis.
4. Mode of transmission – how the infectious agent travels from one place to another; the
mechanism for transfer of an infectious agent from a reservoir to a susceptible host. “Vector-
borne” diseases are spread by insects, rodents, birds and animals. Common vehicle
transmission refers to a single contaminated source such as food, multi-dose vials, intravenous
fluid or equipment which serves to transmit infection to multiple hosts. The primary modes of
transmission in healthcare include:
Contact – direct contact which is person to person spread or indirect contact which is
contact with a contaminated surface or inanimate object to person spread.
Droplet – where large particles are produced when an infected person sneezes, talks or
coughs and settle out on horizontal surfaces leading to indirect contact transmission or direct
contact onto another person’s mucous membranes; droplets can travel 1 - 2 metres.
Airborne – where organisms are contained within droplet nuclei (five microns or smaller in
size) or dust particles in the air and the infectious agent is widely dispersed by air currents
and inhaled by a susceptible host (e.g. Tuberculosis).
Break the link by ensuring transmission between objects or people does not occur;
use appropriate barriers, safe practices, spatial separation, engineering controls,
hand hygiene, environmental sanitation, and equipment disinfection/sterilization.
5. Portal of entry into a susceptible host via mucous membrane, GI, respiratory or broken skin. All
portals of entry have natural protective barriers. These barriers are normally effective but may
allow micro organisms to enter if the barriers are damaged or if they have been compromised by
invasive medical devices (e.g. catheters).
Break the link by performing appropriate hand hygiene, using aseptic technique when
required, applying best practice techniques with wound and catheter care, wearing
appropriate PPE, eliminating invasive devices when safe to do so and providing safe food
and water.
6. Susceptible Host occurs when the normal balance between microorganisms and their host may
be disturbed by chronic diseases that cause an altered immune status e.g. diabetes , infancy, old
age, invasive procedures, drug therapy, poor nutrition, radiation, chemotherapy, burns, etc
Break the link by ensuring hosts are not susceptible including measures such as
immunizations, good nutrition, recognition and treatment of high risk patients
Infection Prevention and Control
Introduction to Infection Prevention and Control Manual
BY UNDERSTANDING THE CHAIN OF INFECTION, THE PROCEDURES DESCRIBED IN THIS MANUAL CAN BE
APPLIED TO INTERRUPT MICROBIAL TRANSMISSION BETWEEN PATIENTS/RESIDENTS, VISITORS, AND
HEALTHCARE PROVIDERS.
2.0 REFERENCE
2.1 Routine Practices and Additional Precautions In all Healthcare Settings. Provincial Infectious
Diseases Advisory Committee (PIDAC), Ontario; November 2012.
2.2 Routine Practices and Additional Precautions for Preventing the Transmission of Infection in
Health Care Settings; Public Health Agency of Canada; 2013.
2.3 Infection Prevention and Control Manual. Vancouver Island Health Authority (VIHA);
2009.
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
1.0 PURPOSE
To protect patients, staff and visitors from infectious organisms within the healthcare environment the
Interior Health Infection Prevention & Control (IPAC) Program has three principle goals:
Protect the patient.
Protect the healthcare provider, visitors and others in the healthcare environment.
Accomplish the previous two goals in a cost-effective manner whenever possible.
2.0 DEFINITIONS
Healthcare Associated Infections (HAIs) – infections that are not present or incubating at the time
of admission to the facility or program but are associated with admission to or a procedure performed
in a healthcare facility or program.
3.1 The IPAC Program functions in accordance with international, national and provincial
guidelines and best practices across the continuum of care.
3.2 The IPAC Program influences practice through direct actions including the following:
Manages critical data including surveillance for infections and disseminates data to
appropriate stakeholders.
Develops and recommends policies, procedures and best practices in IPAC including
but not limited to Routine Practices, Additional Precautions, asepsis, equipment
cleaning, disinfection and sterilization, product selection and evaluation, and
construction consultation as it pertains to IPAC.
Intervenes directly to prevent infections and includes liaison and consultation with
community agencies and programs.
Educates and trains healthcare providers, patients and nonmedical caregivers.
3.3 A multidisciplinary IPAC Committee with representation from across the continuum of care
including administration, clinical and ancillary staff acts as an advocate for the prevention and
control of HAIs, to promote patient safety and provide support that empowers the
implementation of best practices both at the local and corporate level of the organization.
3.4 Each multidisciplinary committee requires its own Terms of Reference that identifies its
purpose, responsibilities, membership and reporting expectations to ensure appropriate
dissemination of information and facilitates medical and administrative support for the IPAC
Program.
.
Infection Prevention and Control
Interior Health Infection Prevention and Control Program
Page 2
3.5 The IPAC Program provides an Annual Report which clearly identifies the goals and priority
objectives of the program and the key improvements for monitoring infection prevention &
control practices that have influenced practices aimed at improving safety for patients and
staff and allocating IPAC resources appropriately.
.
Infection Prevention and Control
Section 03F – IF0100 (Routine Practices for All Care Areas)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
Routine Practices are infection prevention and control practices designed to reduce the risk of blood
and body fluid exposures to healthcare workers AND to prevent and control contamination and
transmission of microorganisms in all healthcare settings.
2.0 DEFINITIONS
Routine Practices
3.1 Routine Practices must be incorporated into the culture of each healthcare setting and into
the daily practice of each healthcare provider.
3.2 Routine Practices apply to all BODY FLUIDS, NON-INTACT SKIN, MUCOUS MEMBRANES OR
EQUIPMENT CONTAMINATED WITH BLOOD, BODY FLUIDS OR TISSUES.
3.3 A Point of Care Risk Assessment must be done by healthcare providers before each
interaction with the patient or their environment to determine which interventions are
required to prevent transmission of microorganisms during that interaction.
Choose patient placement or accommodation based on the risk assessment.
Choose personal protective equipment (PPE) based on the risk assessment.
3.4 PPE is used to prevent transmission of infectious agents both from patient-to-patient and
from patient-to-healthcare provider. Healthcare settings must ensure sufficient supplies of,
and quick, easy access to PPE is provided.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F – IF0100 (Routine Practices for All Care Areas)
Page 2
3.5 Preventing transmission of microorganisms to other patients is a patient safety issue, and
preventing transmission to staff is an occupational health and safety issue. Healthcare
providers are accountable to practice safely to protect patients and themselves by following
organizational infection prevention and control guidelines.
Just because it ‘looks’ clean doesn’t mean it isn’t contaminated by bacteria or viruses
4.0 PROCEDURE
4.1 Point of Care Risk Assessment - to be done before each interaction with a patient or
their environment.
4.2 Use avoidance procedures that minimize contact with droplets (e.g., sitting next to, rather
than in front of, a coughing patient when taking a history or conducting an examination).
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F – IF0100 (Routine Practices for All Care Areas)
Page 3
Gloves – non ▪ Wear for contact with blood or body fluids, mucous membranes, draining
sterile, single wounds or non-intact skin (open skin lesions or rash).
use, latex free ▪ Wear for handling items or surfaces potentially contaminated with blood or
body fluids.
▪ Gloves should be put on directly before the task for which gloves are
required.
▪ Gloves must be removed and discarded immediately after the activity for
which they were used.
▪ Hand hygiene must be done immediately prior to putting on gloves and
after removing gloves.
▪ Gloves are not required for routine care when in contact with intact skin (e.g.
bathing, dressing the patient, taking blood pressure).
▪ Gloves are not required to handle food trays and dishes.
▪ Change gloves after touching a contaminated body site and before touching
a clean body site or the environment.
▪ Do not wash or re-use single use gloves.
▪ Sterile gloves are worn to protect the patient during aseptic procedures.
▪ Disposable gloves are worn for tasks other than direct patient care (e.g.
laundry, working with chemicals, cleaners and disinfectants).
I.H. Facilities refer to the GLOVES, HAND HYGIENE AND YOU (NOT AVAILABLE TO
NON IH FACILITIES).
Masks and eye ▪ Wear to protect the mucous membranes of the nose, mouth and eyes during
protection procedures/activities likely to generate splashes of blood, body fluids,
secretions or excretions or within two metres of a coughing patient.
▪ Change mask if it becomes wet.
▪ Do not allow mask to hang or dangle around the neck.
▪ Remove mask by using ties or elastic and discard mask promptly after use.
▪ Remove and discard the eye protection after use if disposable; if re-usable,
clean with a disinfectant after each use.
▪ The outside of the mask and eye protection are considered contaminated.
▪ Clean hands after removing the mask and eye protection.
▪ Do not re-use disposable masks.
▪ Prescription eye glasses are not acceptable as eye protection.
N95 Respirators ▪ Must be fit tested prior to wearing N95 respirator.
▪ Wear when caring for patients on Airborne Precautions.
▪ A single-use N95 mask must only be worn once.
Gowns/aprons – ▪ Wear impermeable long sleeve gown to protect uncovered skin and prevent
single use soiling of clothing during activities likely to generate aerosolization of blood or
body fluids.
▪ The gown/apron should be put on immediately before the task and must be
worn properly, i.e., tied at top and around the waist.
▪ Gowns/aprons are SINGLE USE - remove promptly after use and discard in
appropriate receptacle. The outside of the gown/apron is considered
contaminated so hand hygiene must be done following removal.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F – IF0100 (Routine Practices for All Care Areas)
Page 4
Patient ▪ Options include single patient rooms, two patient rooms and multi-bed
Placement rooms/bays.
▪ Single room with dedicated bathroom and sink preferred when there is a
potential for transmission of an infectious agent (i.e.) patients with
uncontrolled diarrhea
▪ Maintain a spatial separation of at least 2 meters between coughing
patients and others in the room – draw the privacy curtain between beds.
▪ Cohorting a group of patients (with same disease/organism) in the same
area is an option if single rooms are not available.
Patient transport ▪ Patient’s gown/clothing is clean.
▪ Patient has clean hands prior to going to another department.
▪ Wounds are covered with clean, intact dressings.
▪ Incontinence products are in place and intact when required.
▪ Patients who are coughing need to wear a surgical/procedure mask.
Patient care ▪ ALL patient care equipment including transport equipment requires
equipment cleaning and disinfection after each use.
▪ Storage of contaminated equipment is to be in a designated area/container
– usually in a Soiled Utility Room.
▪ Gross soil must be removed before the item can be cleaned and
disinfected.
▪ Once items are cleaned and disinfected, they should be labeled as such,
and moved to a clean storage area.
▪ Dedicate bedpans and commodes for single patient use. Clean and
disinfect before use by another patient.
▪ Single use items are to be discarded, not reused.
▪ Procedures should be established for assigning responsibility for routine
cleaning of all healthcare equipment.
▪ Wear appropriate PPE when handling, cleaning and disinfecting soiled
equipment.
▪ Personal care supplies are single patient use items and are NOT to be
shared (i.e.) soap, lotions and creams.
REFER TO IX0800 PERSONAL CARE SUPPLIES GUIDELINE
▪ When using nursing bags in the Community settings, place soiled
equipment in impervious container and do not return it to the nursing bag.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F – IF0100 (Routine Practices for All Care Areas)
Page 5
Environmental ▪ High touch surfaces in patient care areas are cleaned and disinfected with a
cleaning hospital-grade disinfectant (quaternary ammonium compound or hydrogen
peroxide product) daily and more frequently if the risk of environmental
contamination is higher.
▪ Floors are cleaned with a detergent product.
▪ No “re-dipping” (double dipping) of cleaning cloths in the cleaning solutions.
▪ Gloves should be worn during cleaning and disinfecting procedures.
▪ Containers for liquid soap and ABHR are disposable and should not be
‘topped up’.
▪ When a patient is discharged or transferred the room or bed space must be
cleaned and disinfected thoroughly before the next patient occupies the space.
▪ Do not apply cleaning chemicals by aerosol or trigger sprays.
▪ Tubs should be cleaned and disinfected after each use. Use cold water when
using the disinfectant and ensure contact time of the disinfectant with all
surfaces is for 10 minutes or as recommended by the manufacturer.
▪ Use gloves when handling waste/garbage.
▪ Place biohazardous waste (items saturated, dripping with blood) in appropriate
biomedical waste container in the soiled utility room.
▪ Items that are broken, torn, cracked or malfunctioning need to be replaced.
Dishes ▪ Use commercial dishwashers or wash with hot water and detergent for ALL
dishes, including those used by patients on Additional Precautions.
▪ Disposable dishes are not required.
▪ Gloves are not required when transporting dirty dishes.
▪ If Food Service Workers identify trays that contain bodily fluids or sharps, they
will bring this to the attention of the nursing staff.
Laundry ▪ ALL laundry is handled the same way, including those patients on Additional
Precautions.
▪ Wear appropriate PPE when handling soiled laundry (i.e. gloves and if
necessary disposable gown or apron).
▪ Position hamper/tote/laundry bag in room or as close to the room entrance as
possible.
▪ Ensure that laundry is free of sharps, instruments, and patient‘s personal
belongings.
▪ Excrement should removed manually, not by spraying with water.
▪ Roll laundry carefully into itself. Avoid shaking or fluffing.
▪ Dirty laundry is not to be placed on the bedside tables, floor or in the sink.
▪ Place soiled laundry into leak proof bags.
▪ Laundry bags should be tied securely and not over-filled.
▪ Remove PPE after handling soiled linen and perform hand hygiene before
handling clean laundry.
Sharps ▪ Sharps disposal containers must be readily available in all areas.
▪ Sharps must be discarded immediately after use, directly into a disposal
container at the point of use.
▪ Do not recap needles.
▪ Scalpel blades must be removed using forceps.
▪ Never fill a sharps disposal container more that ¾ full.
▪ Never leave a sharp protruding from the sharps disposal container.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F – IF0100 (Routine Practices for All Care Areas)
Page 6
Healthcare ▪ Ongoing education includes hand hygiene, Point of Care Risk Assessment,
Provider Routine Practices & Additional Precautions, cleaning & disinfection of the
Education environment and equipment and staff safety.
Patient Education ▪ Includes hand hygiene, respiratory hygiene and not sharing personal care
items.
Respiratory ▪ Post signs with instructions to patients and visitors on how to ‘cough/sneeze
Hygiene into your sleeve’, ‘cover your cough’ with a tissue and promptly dispose of
used tissue, or put on a mask if the symptoms are uncontrollable or person
cannot comply with instructions.
▪ Hand hygiene must be done following contact with respiratory secretions
including disposal of used tissues.
▪ Maintain spatial separation, ideally more than 2 meters (6 feet) between
persons with respiratory symptoms in common areas, such as waiting rooms.
▪ Healthcare providers to use and teach patients avoidance measures that
minimize contact with droplets when coughing or sneezing, such as: turning
the head away from others; covering the nose and mouth with tissue.
Visitors ▪ Should not enter the healthcare setting if they are sick or unable to comply
with hand hygiene and other precautions that might be required.
▪ Should be instructed to do hand hygiene when entering and exiting the
patient’s room.
▪ Encourage visitors to have annual influenza vaccine.
▪ Provide visitor with information pamphlets located on the INFECTION
PREVENTION & CONTROL WEBSITE. (NOT AVAILABLE TO NON IH FACILITIES).
Healthy ▪ Staff not to come into work when ill with symptoms that are of an infectious
Workplace origin.
Practices ▪ Provide appropriate immunizations to patients and healthcare providers
including annual influenza vaccine.
Aseptic ▪ Use for handling medications and for procedures such as intravenous
Technique catheterization, urinary catheterization, wound care, etc.
Aerosol- ▪ Only those needed to perform the procedure should be present in room.
Generating ▪ Use Routine Practices including hand hygiene and appropriate PPE based
Medical on the Point of Care Risk Assessment
Procedures
▪ Use Additional Precautions based on the Point of Care Risk Assessment and
potential for infectious disease diagnosis.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F – IF0100 (Routine Practices for All Care Areas)
Page 7
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F – IF0100 (Routine Practices for All Care Areas)
Page 8
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F – IF0100 (Routine Practices for All Care Areas)
Page 9
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F – IF0100 (Routine Practices for All Care Areas)
Page 10
5.0 REFERENCES
5.1. Routine Practices and Additional Precautions for Preventing the Transmission of
Infection in Health Care; Public Health Agency of Canada; Sept 1, 2010 – Final Version.
5.2. Routine Practices and Additional Precautions In all Healthcare Settings. Provincial
Infectious Diseases Advisory Committee (PIDAC), Ontario; July 2011.
5.3. Best Practice for Environmental Cleaning for Prevention and Control of Infections in all
nd
Healthcare Settings. 2 Edition. Provincial Infectious Diseases Advisory Committee
(PIDAC), Ontario; May 2012.
APPENDIX A
Aerosol-generating medical procedures (AGMPS) - procedures that stimulate coughing and promote
generation of aerosols; examples include intubation and related procedures, manual ventilation, open
endotracheal suctioning, CPR, bronchoscopy, sputum induction, surgery, autopsy, and non-invasive
positive pressure ventilation (CPAP, BiPAP), high concentration oxygen therapy (50% or higher). For
diagnostic (but not therapeutic) bronchoscopy or sputum induction, use an N95 respirator, due to risk
from undiagnosed TB.
Cleaning – the physical removal of dirt, dust or foreign material. Cleaning usually involves soap and
water, detergents or enzymatic cleaners. Thorough cleaning is required before disinfection or
sterilization may take place.
Cohorting – the placement and care of patients in the same room, who are infected or colonized with the
same microorganism; or placing those who have been exposed together to limit risk of further
transmission.
Disinfection – removal and destruction of most pathogens (or disease-causing organisms) except
bacterial spores; requires friction (cleaning) and the use of a disinfectant product.
High touch areas/surfaces – are those that have frequent contact with hands and require more frequent
cleaning, particularly during outbreaks. Examples include doorknobs, elevator buttons, telephones, call
bells, bedrails, light switches, monitoring equipment, chair arms, faucet handles, over bed tables, hand
rails, flusher handle, soap and ABHR dispensers, paper towel holder and edges of privacy curtains.
Housekeeping Clean
Terminal/Discharge Clean – refers to the process of cleaning and disinfection which is
undertaken upon discharge of a patient from a room. The patient room, cubicle, or bed space,
bed, bedside equipment, environmental surfaces, hand washing sink and bathroom should be
thoroughly cleaned before another patient is allowed to occupy the space.
Isolation Terminal Clean – refers to the process of cleaning and disinfection which is
undertaken upon discharge of a patient from or discontinuation of any ‘Isolation Precautions’
(Additional Precautions). In addition to the Terminal/Discharge clean, privacy and shower
curtains are changed, toilet paper, paper towel, glove box and toilet brush should all be
discarded and replaced.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F – IF0100 (Routine Practices for All Care Areas)
Page 11
Non-critical Medical Equipment – equipment in the patient care environment that is used between
patients (e.g. imaging equipment, electronic monitoring equipment, commode chairs); items that touch
only intact skin but not mucous membranes.
N95 Respirator – type of mask used to prevent inhalation of small particles that may contain infectious
agents transmitted via the airborne route.
Personal Protective Equipment (PPE) – barriers placed between the infectious source and one’s own
mucous membranes, airways, skin and clothing to prevent exposure to blood and body fluids.
Point of Care Risk Assessment – a dynamic process done before each interaction with a patient or
their environment in order to determine which interventions are required to prevent transmission of
microorganisms during the interaction considering the patient’s status can change.
Respiratory Hygiene – personal practices that help prevent the spread of microorganisms that cause
respiratory infections; applies to any person entering a healthcare facility who has signs of illness,
including cough, congestion, runny nose or increased production of respiratory secretions.
Routine Practices – based on the assumption that all blood and body fluids contain potentially infectious
organisms, the same safe standards of practice should be used routinely with all patients to prevent
exposure to blood, body fluids, secretions, excretions, mucous membranes, non-intact skin or soiled
items and to prevent the spread of microorganisms.
Sharps – are devices that can cause occupational injury to healthcare providers (e.g. laceration or
puncture the skin). Some examples of sharps include needles, lancets, blades and clinical glass.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F - IF0200 (Hand Hygiene Guidelines)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
1.0 PURPOSE
Hand hygiene (hand cleaning) is the single most important procedure for preventing the spread of
healthcare associated infections.
2.0 DEFINITIONS
3.1 Hand hygiene is known to reduce patient morbidity and mortality from healthcare associated
infections. It causes a significant decrease in the carriage of potential pathogens on the
hands.
3.2 Hand sanitizing with an alcohol-based hand rub (ABHR) is the preferred method (when
hands are not visibly soiled) for cleaning hands.
3.3 There is standardized ABHR product placement in acute, residential and community areas
throughout IH :
At entrances to facilities
In waiting rooms
At entrances to units
In dining rooms
At entrance to each patient room
At entrance to soiled utility rooms, medication rooms, clean supply rooms
At point-of-care, within 3 feet of the patient bed, unless there are safety concerns (e.g.
psychiatry, residential)
Affixed to the mobile work carts such as vital sign carts, med carts, dressing carts, clean
linen carts, housekeeping carts, and others
ABHR that is attached to the wall must not be installed directly over a source of ignition
(i.e. electrical outlets). The risk of fire related to the use of ABHR is very small
Entrance to clean and soiled service rooms
In any location where personal protective equipment is donned or doffed
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F - IF0200 (Hand Hygiene Guidelines)
Page 2
3.5 The use of gloves is not a substitute for performing hand hygiene. Hand hygiene must be
performed before putting on gloves and after removing gloves.
3.7 The fingernails are the area of greatest contamination. Short nails are easier to clean and are
less likely to tear gloves. Artificial nails and nail enhancements have been implicated in the
transfer of microorganisms.
The areas of the hands that are often missed when performing hand hygiene are the
wrist creases, thumbs, fingertips, under the fingernails and under jewelry.
Dry or damaged skin conditions of the hands show a higher bacterial load, which is
more difficult to remove than with healthy, intact skin.
3.8 Compatibility between lotions and hand hygiene products, and lotion‘s potential effect on
glove integrity should be considered (i.e. lotions should not be petroleum based).
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F - IF0200 (Hand Hygiene Guidelines)
Page 3
4.0 PROCEDURE
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F - IF0200 (Hand Hygiene Guidelines)
Page 4
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F - IF0200 (Hand Hygiene Guidelines)
Page 5
4.10 Education
IH will provide staff hand hygiene education, training, and competency assessment and
inform all healthcare providers of the hand hygiene policy at the time of hiring and
during orientation (AH0700 Hand Hygiene Administrative Policy).
The requirements to complete education/training are as follows:
Physicians – Yearly at the time of credentialing, physicians will complete the I-Learn
education module (course ID: module: 855, quiz: 856).
1. Direct Patient Care Staff – Education will be linked to performance rates of the
unit. Staff working on units with hand hygiene compliance less than 69% over a
one year period will be required to complete the I-Learn education module
(course ID: module:853, quiz: 854)
2. New Hires – At the time of their orientation.
3. Students – At the time of their orientation.
Provide education for patients, families and visitors including instructions regarding
when and how to perform hand hygiene – use information brochures, posters.
The hand hygiene pamphlet for patients, visitors, and families shall be at the bedside for
each new admission.
Routinely monitor healthcare provider hand hygiene compliance and provide timely
feedback for each quarter that a unit has less than 69% compliance using an action
plan with the goal of improving patient safety by increasing hand hygiene compliance
rates.
5.0 REFERENCES
5.2 Best Practices for Hand Hygiene In All Healthcare Settings and Programs. British
Columbia Ministry of Health; July 2012.
th
5.3 Best Practices for Hand Hygiene In all Healthcare Settings – 4 Edition. Provincial
Infectious Diseases Advisory Committee (PIDAC), Ontario;(2010).
http://www.publichealthontario.ca/en/eRepository/2010-12%20BP%20Hand%20Hygiene.pdf
5.5 World Health Organization (WHO) World Alliance for Patient Safety. WHO Guidelines on
Hand Hygiene in Health Care
http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf
5.6 Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update
Source: Infection Control and Hospital Epidemiology, Vol. 35, No. 6 (June 2014), pp. 628-645
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F - IF0200 (Hand Hygiene Guidelines)
Page 6
APPENDIX A
Glossary
Alcohol-based Hand Rub (ABHR) – can be a liquid, gel, or foam formulation. ABHR’s are the preferred
method to routinely decontaminate hands in clinical situations when hands are not visibly soiled as they
provide for a rapid kill of most transient microorganisms, are less time-consuming than washing with soap and
water and are easier on skin. ABHR must contain between 70 - 90% alcohol. Can be used as a surgical
scrub.
Contamination: The presence of an infectious agent on hands or on a surface, such as clothing, gowns,
gloves, bedding, toys, surgical instruments, patient care equipment, dressings or other inanimate objects.
Direct Care: Provision of hands-on care (e.g. bathing, washing, turning patient, changing clothes, continence
care, dressing changes, care of open wounds/lesions, toileting).
Environment of the Patient: The immediate space around a patient that may be touched by the patient and
may also be touched by the healthcare provider when providing care. For example:
In a single room, the patient environment is the room
In a multi-bed room, the patient environment is the area inside the individual’s curtain and including
the curtain
In an ambulatory setting, the patient environment is the area that may come into contact with the
patient within their cubicle
In a nursery/neonatal setting, the patient environment includes the inside of the bassinette or isolette,
as well as the equipment outside the bassinette or isolette used for that infant (e.g. ventilator,
monitor)
Hand Care: Actions and products that reduce the risk of skin irritation. A hand care program for staff is a key
component of hand hygiene and includes hand care assessment, staff education and an occupational health
assessment.
Hand Hygiene: A general term referring to any action of hand cleaning. Hand hygiene relates to the removal
of visible soil and removal or killing of transient microorganisms from the hands. Hand hygiene for patient
care may be accomplished using an alcohol-based hand rub or soap and running water. Hand hygiene
includes surgical hand preparation.
Hand Hygiene Moment - points to a patient care activity during which hand hygiene is essential because the
risk of transmission of microorganisms is greatest. There may be several hand hygiene moments in a single
care sequence or activity.
Hand Washing: The physical removal of microorganisms from the hands using soap and running water.
Healthcare Provider (HCP): Any person working in the healthcare system. This includes, but is not limited
to, the following: emergency service workers, physicians, dentists, nurses, respiratory therapists and other
health professionals, personal support workers, clinical instructors, students, environmental and food
services, facility maintenance, contracted providers and home healthcare workers. In some settings,
volunteers might provide care and would be included as a healthcare provider.
Nail Enhancement: Nail enhancements refer to artificial nails, resin wraps, tips, acrylics, gems, sticker,
piercings or gels.
Occupational Health and Safety (OHS)/Workplace Health: Preventive and therapeutic health services in
the workplace provided by trained occupational health professionals, e.g. nurses, hygienists, and physicians.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F - IF0200 (Hand Hygiene Guidelines)
Page 7
Patient: The term ‘patient’ in this document refers to any patient, clients and residents receiving care within a
healthcare setting.
Plain Soap: Detergents that do not contain antimicrobial agents or that contain very low concentrations of
antimicrobial agents that are present only as preservatives.
Point-of-Care: The place where three elements occur together: the patient, the healthcare provider and care
or treatment involving patient contact. Point-of-care products should be accessible to the healthcare provider,
within arm’s reach, without the provider leaving the zone of care.
Surgical hand preparation: The preparation of hands for surgery, using either antimicrobial soap and water
or an alcohol-based hand rub, preferably one with sustained antimicrobial activity.
Visibly Soiled Hands: hands on which dirt or body fluids can be seen.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F - IF0300 (Waste Management)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
To prevent the spread of infection, reduce the risk associated with waste disposal and ensure the safety
of the general public, patients and healthcare providers in regards to waste disposal processes.
2.0 DEFINITION
3.1. Written procedures for the management of biomedical waste from healthcare settings should be
developed based on provincial and municipal regulations and legislation.
3.2. All staff handling waste or garbage will wear personal protective equipment
including protective gloves.
3.3. Waste should be segregated according to the categories listed in the table below. Waste
from several different categories should not be mixed in one bag. NOTE: Placing
regular waste that does not require special disposal will result in increased cost and may
incur penalties from collection agencies.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F - IF0300 (Waste Management)
Page 2
3.4. Plastic waste holding bags are color coded and sturdy enough to resist puncture under conditions of
use and to the point of disposal. Use the Soiled Utility Room to gather together disposable
biomedical waste.
Educate staff about the risks associated with sharps, including safe disposal of sharps in
puncture-resistant containers if found in the environment (e.g. sharps in laundry, waste,
bedside, floor).
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F - IF0300 (Waste Management)
Page 3
4.0 PROCEDURE
4.1. Use appropriate PPE when handling waste/garbage including puncture resistant
gloves.
4.2. Ensure bags are not torn, are securely closed and no sharp objects are protruding
through.
4.3. It is not necessary to double bag garbage unless the first bag is leaking.
4.4. Human blood & body fluid waste can be disposed of from drainable devices into a sanitary sewer
and does not require special treatment before disposal. When handling these fluids care must
be taken to eliminate spills and the formation of aerosols.
4.5. Place all general waste into the regular garbage containers.
4.7. SHARPS
Choose the correct size/shape of sharps container for the situation
(e.g.) small closable container for Home/Community care.
Staff responsible for collecting and replacing sharps containers should
be trained in proper handling methods.
All SHARPS containers must have an approved biohazard waste
label.
Place all sharp items in an approved sharps container.
DO NOT over fill sharps containers.
Wear appropriate personal protective equipment to clean up spills (e.g.) gloves, gown and
face shield if there is a danger of splashing.
Clean the area - gross soil must be removed prior to cleaning and disinfecting
o Use paper towels for small spills, mop for large spills.
o Used paper towels should be placed in biohazardous waste container.
o Mop heads should be placed in laundry bags.
Disinfect area with approved hospital disinfectant.
Cleaning equipment/reusable gloves are to be cleaned/discarded appropriately.
Hands must be washed at the end of the procedure.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 03F - IF0300 (Waste Management)
Page 4
APPENDIX A
Glossary
Anatomical Waste – placentas, human tissues, organs and body parts; does not include teeth, hair and
nails.
Biomedical waste – waste that requires additional precautions due to potential infectious nature;
includes anatomical waste, fluid waste, sharps, microbiology laboratory waste and sharps as defined in
APPENDIX A.
Drainable devices – any device that can have its liquid contents evacuated or drained out.
Fluid Waste – human fluid blood and blood products, items saturated or dripping with blood, body fluids
contaminated with blood and body fluids removed for diagnosis during surgery, treatment or autopsy;
does not include urine or feces.
General Waste – includes items such as dressings, sponges, diapers, incontinent pads, PPE,
disposable drapes, dialysis tubing and filters, empty IV bags and tubing, catheters, empty specimen
containers, disposable lab coats and aprons and pads that will not release liquid or semi-liquid blood if
compressed.
Includes waste from Contact, Droplet and Airborne Precautions rooms.
Includes waste from offices, kitchens, washrooms, public areas.
Non drainable and/or Single Use devices – any device that is not able to have its liquid contents
drained out or are meant to be used once and then the device discarded.
Personal Protective Equipment (PPE) – barriers used by healthcare providers to protect mucous
membranes, airways, skin, and clothing from exposure to blood and body fluids. Can include gloves,
mask, eye protection or gown, as needed.
Sharps – items capable of cutting or puncturing the skin and that have come into contact with blood,
body fluids or microorganisms – items include all needles and devices containing needles or spikes,
broken medical glassware, contaminated scalpel blades, scissors, razors, lancets.
5.0 REFERENCES
5.1 Canadian Council of Ministers of the Environment (CCME) Guidelines for the Management of
Biomedical Waste in Canada. CCME-EPC-WM-42E. February 1992.
5.2 Best Practices for Environmental Cleaning for Prevention and Control of Infections In
All Health Care Settings - 2nd edition. Provincial Infectious Diseases Advisory Committee
(PIDAC), Ontario; May 2012.
5.3 City of Kelowna. (2012). Solid Waste Management Regulation Bylaw Number 10106.
February 13, 2012.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0100 (Additional Precaution for All Care Areas-Transmission Tables)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
1.0 PURPOSE
Routine practices properly and consistently applied should prevent transmission by the contact and
droplet routes.
For certain situations that may result in extensive contamination of the environment or for
microorganisms with a very low infectious dose, additional precautions may be indicated. These
include contact, droplet and airborne precautions.
Table 9 identifies the additional precautions that should be used for conditions and/or clinical
presentations of patients.
Table 10 identifies the additional precautions that should be used for specific etiologies identified –
that is the causative microorganism has been identified.
Note: in this document the term “patient” is inclusive of patient, resident or client.
2 | ROUTINE PRACTICES AND ADDITIONAL PRECAUTIONS FOR PREVENTING THE TRANSMISSION OF INFECTION IN HEALTHCARE
SETTINGS
Bronchiolitis RSV, human metapneumovirus Droplet and contact Respiratory secretions Large droplet and Duration of symptoms Patient should not share
parainfluenza virus, influenza, direct and indirect room with high-risk
adenovirus contact roommates
Burns, infected
See draining wound
Cellulitis H. influenzae type B in non- Droplet if Respiratory secretions Large droplet, direct Until 24 hours of
Draining: See draining immune child <2 years of age; H. influenzae type B contact appropriate
wound Streptococcus pneumoniae, is possible cause, antimicrobial therapy
Periorbital in child Group A Streptococcus, otherwise routine received or if
<5 years old without S. aureus, other bacteria practices H. influenzae type B
portal of entry ruled out
Cold Rhinovirus, RSV, human Droplet and contact Respiratory secretions Large droplet and Duration of symptoms Patient should not share
metapneumovirus, direct and indirect room with high-risk
parainfluenza, adenovirus, contact roommates
coronavirus
Conjunctivitis Adenovirus, enterovirus, Contacta Eye discharge Direct and indirect Until viral etiology ruled aRoutine if non-viral
chlamydia, Neisseria contact out; duration of
gonorrhea, other microbial symptoms, up to 14
agents days if viral
Cough, fever, acute Rhinovirus, RSV, human Droplet and contact Respiratory secretions Large droplet, direct Duration of symptoms Consider fever and
upper respiratory tract metapneumovirus and indirect contact or until infectious asthma in child <2 years
infection parainfluenza, influenza, etiology ruled out old as viral infection
adenovirus, coronavirus, Patient should not share
pertussis room with high-risk
roommates
3 | ROUTINE PRACTICES AND ADDITIONAL PRECAUTIONS FOR PREVENTING THE TRANSMISSION OF INFECTION IN HEALTHCARE
SETTINGS
Gas gangrene, Routine Variable Not person to Found in normal gut flora, soil;
abscesses, person infection related to devitalized tissue
myonecrosis
Coccidioido- Pneumonia, Routine 1–4 weeks Not person to Acquired from spores in soil, dust in
mycosis draining lesions person endemic areas
(Coccidioides
immitis)
Colorado tick fever Fever Routine Tick-borne 3–6 days Not person to
See Dengue Fever person
(Arbovirus)
Congenital rubella
See Rubella
Coronavirus (CoV) Common cold Droplet and Respiratory Direct and 2–4 days Until symptoms Duration of May cohort if infected with same virus
(other than SARS- contact secretions indirect contact cease symptoms Patient should not share room with
CoV) Possible large high-risk roommates
For SARS CoV, see droplet
Severe acute
respiratory
syndrome
15 | ROUTINE PRACTICES AND ADDITIONAL PRECAUTIONS FOR PREVENTING THE TRANSMISSION OF INFECTION IN HEALTHCARE
SETTINGS
Sporotrichosis Skin lesions, Routine Variable Rare person to Acquired from spores in soil, on
(Sporothrix disseminated person vegetation
schenckii)
z
Staphylococcus Skin (furuncles, MINOR: Drainage, pus Direct and Variable As long as Until drainage MAJOR: drainage not contained by
aureus impetigo) wound Routine indirect contact organism is in resolved or dressings
(if methicillin- or burn infection; MAJOR: the exudates or contained by
resistant, see also abscess; Contactz drainage dressings
ARO) scalded skin
syndrome,
osteomyelitis
Endometritis Routine
Food poisoning Routine Foodborne
Pneumonia ADULT: Respiratory Large droplets, Variable Until 24 hours
Routine secretions direct contact of appropriate
PAEDIATRIC: antimicrobial
Droplet therapy
received
Toxic shock Routine
syndrome
Streptobacillus
moniliformis
disease
See Rat-bite fever
Streptococcus Pneumonia, Routine Variable Normal flora
pneumoniae meningitis and
other
32 | ROUTINE PRACTICES AND ADDITIONAL PRECAUTIONS FOR PREVENTING THE TRANSMISSION OF INFECTION IN HEALTHCARE
SETTINGS
Vancomycin- Infection or Contact Infected or Direct and Variable Duration of As directed by Enterococci persist in the
resistant colonization of colonized indirect contact colonization ICP environment; pay special attention to
enterococci (VRE) any body site secretions, cleaning
excretions See Appendix VI, 2. ARO
Vancomycin- Infection or Contact Infected or Direct and Variable Duration of As directed by Local public health authorities should
resistant S. aureus colonization of colonized indirect contact colonization ICP be notified immediately
(VRSA) any body site secretions, See Appendix VI, 2. ARO.
Theoretical; to excretions
date, not reported
Varicella zoster Fever with Airborne and Skin lesion Airborne, direct 10–21 days 1–2 days before Until all HCWs, roommates and caregivers
virus vesicular rash contact drainage, and indirect rash and until lesions have should be immune to chickenpox
Varicella respiratory contact skin lesions have crusted and No additional precautions for
(chickenpox) secretions crusted dried pregnant HCWs
May be Respirators for non-immune persons
prolonged in that must enter
immuno- Susceptible high-risk contacts should
compromised receive varicella zoster
patients immunoglobulin as soon as possible,
latest within 96 hours of exposure
Varicella zoster immunoglobulin may
extend the incubation period to 28
days
Refer to Canadian Immunization for
specific information, available at:
http://www.phac-
aspc.gc.ca/publicat/cig-gci/index-
eng.php
36 | ROUTINE PRACTICES AND ADDITIONAL PRECAUTIONS FOR PREVENTING THE TRANSMISSION OF INFECTION IN HEALTHCARE
SETTINGS
.
Infection Prevention and Control
Section 04H-1H0200 (Airborne Precautions)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
Airborne Precautions refer to infection prevention and control interventions to be used in addition
to Routine Practices to prevent transmission of airborne particles that remain suspended in the air,
travel on air currents and are then inhaled by others who are nearby or who may be some distance
away from the source patient, in a different room or ward (depending on air currents) or in the same
room that a patient has left, if there have been insufficient air exchanges. Common microorganisms
transmitted by the airborne route are Mycobacterium tuberculosis (TB), varicella virus (chickenpox
virus) and measles virus.
2.0 DEFINITIONS
Airborne Precautions – measures used for diseases that are spread by airborne transmission. This
primarily occurs through dissemination of microorganisms by aerosolization. Organisms are
contained in droplet nuclei which are small airborne particles, less than 5 microns in size that result
from evaporation of large droplets. Organisms can also be contained in debris in dust particles that
remain suspended in the air for long periods of time. These microorganisms are then widely
dispersed by air currents and can be inhaled by susceptible hosts who may be some distance away
from the source patient. Control of airborne transmission is the most difficult, as it requires control of
air flow through special ventilation systems and use of respirators.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H-1H0200 (Airborne Precautions)
Page 2
Aerosol-generating medical procedures (AGMPs) - are medical procedures that can generate
aerosols as a result of artificial manipulation of a patient’s airway. Examples include intubation,
manual ventilation, open endotracheal suctioning, CPR, bronchoscopy, sputum induction, nebulized
therapy, surgery, autopsy, and non-invasive positive pressure ventilation (CPAP, BiPAP)
Airborne Isolation Room – a single patient room that is equipped with special air handling (negative
pressure) and ventilation capacity.
Anteroom – is considered a clean area and is used to transition people in and out of the airborne
isolation room when it is under negative pressure. An anteroom is used as a transitional space
between the hallway and the airborne isolation room. This transition area is where the Healthcare
Worker puts on their PPE when entering the Airborne isolation room. The HCW also will store all
clean PPE in this area.
See Anteroom Protocol
Negative Pressure Room – also known as an Airborne Isolation Room; a negative pressure room
that is a single-occupancy patient-care room used to isolate persons with a suspected or confirmed
airborne infectious disease.
N95 Respirators – specific masks that filter particles one micron in size, have a 95% filter efficiency
and provide a tight facial seal with less than a 10% leak.
3.1. Maintain a high degree of suspicion for those patients who present with compatible symptoms of
an airborne infection, prompt implementation of airborne precautions and rapid diagnosis.
3.2. For the purpose of this guideline, the term Airborne Isolation Room will be used to
refer to a “negative pressure room”. An Airborne Isolation Room must have:
Ventilation creating inward directional airflow from adjacent spaces to the room (‘negative
pressure’) that is regularly monitored.
Direct exhaust of air from the room to the outside of the building or recirculation of air
through a HEPA filter before returning to circulation.
Twelve (12) air changes per hour.
The door into the room kept closed to maintain negative pressure, even if the patient is
not in the room.
Windows closed at all times; opening the window may cause reversal of air flow, an
effect that can vary according to wind direction and indoor/outdoor temperature differentials.
All healthcare providers in high risk areas must be fit tested for an N95 respirator.
REFER TO AV 1900 RESPIRATORY PROTECTION PROGRAM POLICY (NOT AVAILABLE
TO NON IH FACILITIES)
3.3. Only immune healthcare providers should enter a room where airborne precautions are in place for
measles or varicella; an N95 respirator is not required.
3.4. An N95 respirator must be worn if non-immune health care providers are required to enter the room
of a patient with measles or varicella when there are no qualified immune health care providers
available and patient safety would be compromised if they did not provide care.
A point of care risk assessment for every patient interaction needs to be done to determine
additional precautions, room placement and PPE:
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H-1H0200 (Airborne Precautions)
Page 3
Clinical Syndromes Requiring the Use of Controls (Including PPE) Pending Diagnosis
4.0 PROCEDURE
As well as Routine Practice, Airborne Precautions includes the following:
b) The following strategies should be applied to reduce the level of aerosol generation when
performing aerosol-generating medical procedures (AGMPs) for patients with
suspected airborne disease.
AGMPs should be limited to those that are medically necessary.
The number of personnel in the room should be limited to those required.
Consider appropriate patient sedation.
AGMPs should be performed in an airborne isolation room.
Single rooms (with the door closed and away from high-risk patients), should be used
in settings where airborne isolation rooms are unavailable.
N 95 respirators should be worn by all personnel in the room during the procedure.
Closed endotracheal suction systems should be used wherever possible.
In an emergency situation when an airborne isolation room is not available; at a
minimum pull the privacy curtains and all personnel to wear N95 respirator. Remove
visitors and other patients from the room/area.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H-1H0200 (Airborne Precautions)
Page 4
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H-1H0200 (Airborne Precautions)
Page 5
Upon discharge or discontinuation of airborne precautions door must remain closed and
negative air flow maintained until all air in the room has been replaced. Requires 45
minutes.
5.0 REFERENCES
5.1 Routine Practices and Additional Precautions In all Healthcare Settings. Provincial Infectious
Diseases Advisory Committee (PIDAC), Ontario; November 2012.
5.2 Routine Practices and Additional Precautions for Preventing the Transmission of Infection in
Health Care Settings; Public Health Agency of Canada; 2013.
5.3 Routine Practices and Additional Precautions Assessment and Educational Tools. Public
Health Agency of Canada; 2013.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H-1H0200 (Airborne Precautions)
Page 6
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H-1H0200 (Airborne Precautions)
Page 7
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H-1H0200 (Airborne Precautions)
Page 8
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H-1H0200 (Airborne Precautions)
Page 9
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H-1H0200 (Airborne Precautions)
Page 10
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H-1H0200 (Airborne Precautions)
Page 11
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H-1H0200 (Airborne Precautions)
Page 12
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H-1H0200 (Airborne Precautions)
Page 13
REVISED DATE:
1.0 PURPOSE
An anteroom is used as a transitional space between the hallway and the airborne isolation room.
This transition area is where the Health Care Worker puts on their PPE when entering the Airborne
isolation room. The HCW also will store all clean PPE in this area.
2.0 DEFINITIONS
Anteroom - anteroom is considered a clean area and is used to transition people in and out of the
airborne isolation room when it is under negative pressure.
The anteroom is to be used for anyone entering or exiting the patient room when the
room is used for airborne precautions.
The laundry hamper shall be situated just inside the patient room when additional
precautions are in place.
The only items that should be stored in this room include:
o PPE ( N95 respirators, procedure masks, gowns, eye protection, gloves).
o Garbage container.
o Alcohol based hand rub (ABHR) in a holder.
o Disinfectant wipes in a holder.
o Precaution signs.
o Hand soap in a holder.
o Paper towels in a holder.
Posters could include – hand hygiene, donning and doffing, instructions for families.
4.0 PROCEDURE
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0300 (Droplet Precautions)
Page 1
REVIEWED DATE:
1.0 PURPOSE
2.0 DEFINITIONS
Droplet Precautions – measures used for diseases that are spread by direct contact through
droplet transmission. Droplet transmission refers to large droplets, greater than 5 microns in
diameter, generated from the respiratory tract of the source patient during coughing or sneezing,
or during procedures such as suctioning or bronchoscopy. These droplets are propelled a short
distance of less than two metres (6 feet) through the air and deposited on the nasal, oral or
conjunctival mucosa of the new host or fall onto surfaces. Large droplets do not remain
suspended in the air. Special ventilation is not required since true aerosolization does not occur.
A point of care risk assessment for every patient interaction needs to be done to determine
additional precautions, room placement and PPE:
Clinical Syndromes Requiring the Use of Controls (Including PPE) Pending Diagnosis
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0300 (Droplet Precautions)
Page 2
3.0 PROCEDURE
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0300 (Droplet Precautions)
Page 3
Patients should not use common areas of hospital such as lounge or go into other
patient rooms.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0300 (Droplet Precautions)
Page 4
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0300 (Droplet Precautions)
Page 5
4.0 REFERENCES
4.1 Routine Practices and Additional Precautions In all Healthcare Settings. Provincial
Infectious Diseases Advisory Committee (PIDAC), Ontario; November 2012.
4.2 Routine Practices and Additional Precautions for Preventing the Transmission of
Infection in Health Care Settings; Public Health Agency of Canada; 2013.
4.3 Routine Practices and Additional Precautions Assessment and Educational Tools.
Public Health Agency of Canada; 2013.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0300 (Droplet Precautions)
Page 6
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0300 (Droplet Precautions)
Page 7
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0300 (Droplet Precautions)
Page 8
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0400 (Contact Precautions)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
4.0 DEFINITIONS
A point of care risk assessment for every patient interaction needs to be done to
determine additional precautions, room placement and PPE:
Clinical Syndromes Requiring the Use of Controls (Including PPE) Pending Diagnosis
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0400 (Contact Precautions)
Page 1
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0400 (Contact Precautions)
Page 2
5.0 PROCEDURE
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0400 (Contact Precautions)
Page 3
Patients do not need to wear gloves and isolation gown when outside the room
Patients should not use common areas of hospital such as lounge or go into other patient
rooms.
For Clostridium difficile Infections (CDI) please refer to the CDI cleaning poster
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0400 (Contact Precautions)
Page 4
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0400 (Contact Precautions)
Page 5
6.0 REFERENCES
6.1 Routine Practices and Additional Precautions In all Healthcare Settings. Provincial
Infectious Diseases Advisory Committee (PIDAC), Ontario; November 2012.
6.2 Routine Practices and Additional Precautions for Preventing the Transmission of
Infection in Health Care Settings; Public Health Agency of Canada; 2013.
6.3 Routine Practices and Additional Precautions Assessment and Educational Tools.
Public Health Agency of Canada; 2013.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0400 (Contact Precautions)
Page 6
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0400 (Contact Precautions)
Page 7
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0400 (Contact Precautions)
Page 8
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0100 (Reportable Communicable Diseases)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
To reduce the risk of transmission of communicable diseases within healthcare facilities and to programs.
2.2. THE Communicable Disease Regulation states in Section 1.2.1 that any person knowing or
suspecting that another person is suffering from a communicable disease shall without delay
make a report to the medical health officer.
3.0 PROCEDURE
Contact the Infection Control Practitioner (ICP) as soon as possible when a patient who is known or a
suspect case of a Reportable Communicable Disease included in SCHEDULE A is admitted to the
facility/program. The ICP will advise regarding reporting process.
If the ICP is unavailable, contact the Communicable Disease (CD) Unit as soon as
possible at 1-866-778-7736.
The laboratory is responsible for reporting Schedule B diseases listed in the REPORTABLE
COMMUNICABLE DISEASES IN BC (JULY 2009) LIST.
Note: In this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 04H – IH0400 (Contact Precautions)
Page 2
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0200 (Clostridium difficile)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
To prevent the transmission of Clostridium difficile infection (CDI) in healthcare facilities including
hospitals, residential care homes and community settings and to minimize the risk of complications
associated with CDI.
2.0 DEFINITIONS
Clostridium difficile (C. difficile) is a bacterium that causes mild to severe diarrhea and intestinal
conditions like pseudomembranous colitis (inflammation of the colon). C. difficile is the most frequent
cause of healthcare associated infectious diarrhea in hospitals and residential care facilities and is
becoming more prevalent in the community.
Most cases of C. difficile occur in persons who are taking certain antibiotics which can destroy the
person’s normal bacteria found in the gut, causing C. difficile bacteria to grow. When this occurs, the
C. difficile bacteria produce toxins which can damage the bowel and cause diarrhea. Some people
can have C. difficile bacteria present in their bowel and not show symptoms. There are many
different strains of C. difficile and one strain known as NAP1 (North American Pulsed Filed type 1)
can cause serious illness.
C. difficile bacteria are found in feces and produce spores that are resistant many common types of
environmental disinfectants. These spores can live in the environment for long periods of time,
contaminating toilet areas and commodes. People can get infected if they touch surfaces
contaminated with the spores, and then touch their mouth. Healthcare workers can spread the
bacteria to their patients if their hands are contaminated.
C. difficile poses a particular risk to the elderly, pediatric and oncology patients and pregnant women.
Additional risk factors include antibiotic usage, proton pump inhibitor usage, bowel disease and bowel
surgery, prolonged hospitalization, and immunosuppressive therapy post-transplant.
Symptoms include watery diarrhea, fever, loss of appetite, nausea and abdominal pain/tenderness.
Persons are infectious while diarrhea is present.
Additional Precautions Twice Daily Clean with a Sporicidal Disinfectant – the type of clean
housekeeping uses for cleaning and disinfecting rooms/cubicles where a patient is on additional
precautions for C. difficile. Cleaning occurs twice daily, the second cleaning and disinfection is 6-8
hours after the first cleaning and disinfection and focuses on the high touch areas in the patient
room/area/space and bathroom (IH Housekeeping for Healthcare manual pg.87).
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0200 (Clostridium difficile)
Page 2
Additional Precautions Discharge Clean – refers to the cleaning and disinfection process of a
patient room when additional precautions is discontinued or the patient is discharged and includes
changing the privacy curtains (IH Housekeeping for Healthcare manual pg.109).
Best Practice Checklist for Management of CDI – is a tool used to monitor infection control
processes during usual CDI activity on a nursing unit and is NOT part of the patient chart. It can be
completed by either a nurse leader/educator or Infection Control Practitioners (ICPs).
Internal Alert – when the number of CDI cases in a unit or facility is above the pre-determined
threshold (trigger point) or there is suspected transmission. Internal alerts bring increased staff
awareness of CDI cases in the unit/facility so actions can be taken to prevent an outbreak. The
Infection Prevention and Control epidemiologist monitors the internal alert and informs the ICP when
the internal alert level is triggered at their site.
Outbreak Definition – CDI cases are classified as an outbreak when the number of new, time-
related, healthcare associated CDI cases in a unit or facility is above the expected threshold for that
unit or facility and where there is evidence of ongoing transmission despite appropriate interventions.
Declaring an outbreak must be done in conjunction with the facility Outbreak Management Team.
Outbreak Management Team – at a minimum, includes the site Infection Control Practitioner,
Infection Prevention and Control (IPAC) director, Medical Microbiologist and epidemiologist, site
administrator and medical director, nursing unit manager and housekeeping supervisor.
3.0 PROCEDURE
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0200 (Clostridium difficile)
Page 3
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0200 (Clostridium difficile)
Page 4
3.11 Treatment
Use physician pre-printed orders for Clostridium difficile Treatment.
http://inet.interiorhealth.ca/infoResources/forms/Documents/829517.pdf
3.12 Surveillance
Surveillance for healthcare associated CDI is carried out as per guidelines under 4.2 of ,
IV0200 DEFINITIONS FOR HEALTHCARE ASSOCIATED INFECTIONS (HAI)
Best Practice Checklist for Management of CDI available to use when increasing
rates of CDI identified in specific units/facilities
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0200 (Clostridium difficile)
Page 5
4.0 REFERENCES
4.1 ANNEX C Testing, Surveillance and Management to Clostridium difficile In All Health
Care Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; 2013.
4.2 Best Practice for Environmental Cleaning for Prevention and Control of Infections in
nd
all Healthcare Settings. 2 Edition. Provincial Infectious Diseases Advisory Committee
(PIDAC), Ontario; May 2012.
4.3 Clostridium difficile Infection (CDI) Toolkit. Provincial Infection Control Network of BC;
2013.
4.4 Fact Sheet Clostridium difficile. Public Health Agency of Canada; 2014.
4.5 A Review of C. difficile Control Measures….. Dr. Michael Gardam, Director of Infection
Prevention & Control, University Health Network and Women’s College Hospital, Toronto,
Ontario; February 2012.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0200 (Clostridium difficile)
Page 6
Note: in this document the term “patient” is inclusive of patient, resident or client.
Residential Care Plan for Clostridium difficile Infection
Mobility: If the resident has uncontrolled diarrhea, keep them in their room until the
symptoms are resolved or can be easily contained with personal hygiene products.
Contact Precautions can be discontinued when resident has no diarrhea for 72 hours.
Ensure Signage regarding C-difficile infection may be required. Contact Plus Precautions sign
Resident 1. Housekeeping needs to be informed to ensure twice daily cleaning is performed.
Confidentiality 2. Upon transfer, notify receiving sites that Contact Precautions are required.
Environmental Reduce 1. Use a sporicidal product (accelerated hydrogen peroxide 4.5%) for cleaning and
Cleaning transmission of disinfection of resident room.
C-difficile
Clean occurs twice daily, the second cleaning and disinfection is 6-8 hours after the first
cleaning and disinfection and focuses on the high touch areas in the resident
room/area/space and bathroom.
Housekeeping will do additional precautions discharge clean of the room when Contact
Precautions are discontinued.
Persistent or Prevent Clostridium difficile preprinted orders available for physician use.
recurrent recurring 1. Observe and report progression or recurrence of symptoms.
diarrhea infection 2. Use Bristol Stool chart - Form #809505 to monitor diarrhea.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0200 (Clostridium difficile)
Page 8
Patient
GOAL INTERVENTION COMMENTS
CONCERN
C-difficile Control spread 1. In addition to Routine Practice, use Contact Plus Precautions
associated of C-difficile o private room with dedicated toilet/commode
infection o empty contents of commode in Dirty Service Room in waste disposal
unit
2. Mobility: The patient should remain in his/her own room unless going to the operating
room, attending a medical treatment session, or requiring diagnostic tests.
Contact Plus Precautions can be discontinued when patient has no diarrhea for 72 hours.
Ensure Patient 1. Post the Contact Plus Precautions sign on outside the patient’s door.
Confidentiality 2. When patient goes to another department, or is transferred to another facility, the
receiving department or facility MUST be notified of need for Contact Precautions.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0200 (Clostridium difficile)
Page 9
Environmental Reduce Use a sporicidal product (accelerated hydrogen peroxide 4.5%) for cleaning and
Cleaning transmission of disinfection of resident room.
C-difficile
Clean occurs twice daily, the second cleaning and disinfection is 6-8 hours after the first
cleaning and disinfection and focuses on the high touch areas in the patient
room/area/space and bathroom.
Housekeeping will do additional precautions discharge clean of the room when Contact
Precautions are discontinued.
Persistent or Prevent 1. Clostridium difficile pre-printed orders available for physician use.
recurrent recurring 2. Observe and report progression or recurrence of symptoms.
diarrhea infection Use Bristol Stool chart - Form #809505 to monitor diarrhea.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0300 (Antibiotic Resistant Organisms)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1. PURPOSE
2. DEFINITION
Antibiotic Resistant Organism (ARO) – microorganisms that have developed resistance to the
action of several antimicrobial agents and that is of special clinical or epidemiological significance.
This guideline will refer primarily to MRSA, VRE, ESBLs and CPOs.
Cohorting – the practice of grouping patients (infected or colonized) with the same ARO together, to
confine their care to one area.
Colonization – the presence of microorganisms in or on a host with growth and multiplication but
without tissue invasion or cellular injury. With most microorganisms, colonization is far more frequent
than clinical disease. The patient will be asymptomatic. MRSA colonization may occur in the nose,
perineum, decubitus ulcers, sputum, urine and at sites of invasive devices such as feeding tubes and
tracheostomies. VRE colonization occurs primarily in the feces.
Contact – an individual who is exposed to a person, colonized or infected, with an ARO in a manner
that allows potential transmission to occur, i.e. roommate.
Decolonization – the use of topical and systemic antimicrobials to eradicate colonization of resistant
bacteria. Current evidence does not recommend MRSA decolonization therapy as this may promote
antibiotic resistance, long-term efficacy is poor and systematic therapy may lead to adverse events.
Enterococci – bacteria normally found in the gastrointestinal tract of 95% of healthy people.
Enterococci may contaminate open wounds and, occasionally, are capable of causing invasive
disease, particularly in severely immunocompromised people.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0300 (Antibiotic Resistant Organisms)
Page 2
Infection – when sufficient cellular and tissue changes occur to produce overt signs and symptoms,
the individual has clinical disease. Depending on the microorganism and health status of the host,
this disease may range from mild to severe. Clinical manifestations of local or systemic infection can
include fever, increased white blood cell count, purulence, inflammation, redness, heat, swelling,
and/or pain.
MRSA - Methicillin Resistant Staphylococcus aureus – strains of Staphylococus aureus that are
resistant to oxacillin (cloxacillin). Most people with MRSA are colonized. High risk groups in the
community include injection drug users, homeless persons, chronically ill persons, individuals taking
frequent or prolonged courses of antibiotics and individuals who are in hospital for longer than 48
hours.
Outbreak Management Team – multidisciplinary team including Infection Prevention & Control,
Occupational Health, Administration, Nursing, Medical Staff, Support Services; may include Medical
Health Officer (MHO).
Point prevalence screening – the collection of specimens on all patients at a single point in time, to
determine the total number of cases and evidence of ongoing transmission of a particular
microorganism.
Screening – a process to identify patients at risk for being colonized with MRSA and/or CPO and
subsequently, obtaining appropriate specimens and ensuring Additional Precautions are
implemented.
Staphylococcus aureus (S. aureus) – a bacteria normally found in the nose and on the skin of 25 -
35% of healthy people. It can cause infections such as impetigo, boils, abscesses, wound infections
or invasive disease such as pneumonia.
3. GUIDING PRINCIPLES
3.1 Due to the limited number of single rooms available in acute care use the Algorithm for
IPAC Private Room Allocation in Acute Care Facilities to determine priority for the single
room assignments. (NOT AVAILABLE TO NON IH FACILITIES)
Note
The single most common mode of transmission for AROs in a health care
setting is on the hands of health care workers who acquire it from contact with
colonized or infected patients, OR after handling contaminated surfaces or
equipment.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0300 (Antibiotic Resistant Organisms)
Page 3
3.3 An ARO Alert is entered into the patient’s electronic record by the Infection Control
Practitioner when required. Alerts must protect the confidentiality of the patient.
3.4 The ARO status of a patient should not affect the decision about accepting the individual in
transfer from another healthcare setting or department and a negative specimen is not
required to transfer a patient.
3.5 In high risk areas of acute care such as ICUs, burn units, transplantation units or
cardiothoracic units any patients potentially exposed to a known MRSA or CPO positive
patient should have screening cultures performed. However, in other situations screening of
contacts may not be practicable as there are limited possibilities to intervene based upon
results.
3.6 An outbreak of an ARO occurs when there is an increase in the rate of healthcare associated
cases (infected and colonized) over the baseline rate, or a clustering of healthcare
associated cases due to the transmission of a specific microbial strain(s) in a healthcare
setting. Infection Control would call together a multidisciplinary Outbreak Management Team
to review the situation and provide guidance and support in regards to appropriate control
measures to implement.
4.0 PROCEDURE
4.2 A PCRA (point of care risk assessment) for every patient interaction needs to be done to
help determine room placement and necessary personal protective equipment.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0300 (Antibiotic Resistant Organisms)
Page 4
Cohort
o Cohort patients who are infected or colonized with the same microorganism and
are suitable roommates
o Contact your ICP regarding appropriateness of cohorting
Shared Room
o Maintain spatial separation of at least 2 metres between patients
o Roommates should be selected based on their ability to comply with precautions
o Roommates should not be at high risk for serious disease if transmission occurs
o A patient with diarrhea should not share a toilet with another patient
4 C’s
Clean Hands: do hand hygiene.
Clean Clothes: wear a clean gown or clothes.
Contained wounds/body fluids: wounds covered with clean
dressing. Urine/feces and other body fluids contained.
Co-operative: able to follow instructions.
Patients are not to wear gloves and/or an isolation gown when outside the room.
Patients should not use common areas of the hospital such as the
cafeteria or lounge and should not enter other patient rooms
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0300 (Antibiotic Resistant Organisms)
Page 5
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0300 (Antibiotic Resistant Organisms)
Page 6
Hand hygiene and cleaning and disinfection of shared equipment are the most
important ways to reduce risk of transmission of any AROs
ARO positive persons should not be denied admission to Community Care programs.
In addition to Routine Practice:
Symptomatic clients in the home should be advised to:
o Stay away from others, in a separate room, if available
o Use a designated bathroom, whenever possible
o Clean the bathroom frequently, especially frequently touched surfaces
o Not share towels or other personal items
o Stay home until symptoms resolved
o If medical appointment necessary – advise of symptoms
o See the COMMUNITY ARO CARE PLAN
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0300 (Antibiotic Resistant Organisms)
Page 7
5.0 REFERENCES
5.1 Routine Practices and Additional Precautions for Preventing the Transmission of
Infection in Health Care Settings; Public Health Agency of Canada; 2013.
5.2 Best Practices for Infection Prevention and Control in Perinatology In All Health Care
Settings that Provide Obstetrical and Newborn Care; Provincial Infectious Diseases
Advisory Committee (PIDAC), Ontario; April, 2012.
5.3 Annex A: Screening, Testing and Surveillance for Antibiotic Resistant Organisms
(AROs) in All Health Care Settings. Provincial Infectious Diseases Advisory Committee
(PIDAC), Ontario; February, 2013.
5.4 Antibiotic Resistant Organisms Prevention and Control Guidelines For Healthcare
Facilities. Provincial Infection Control Network (PICNet) BC; March 2013.
5.5 Routine Practices and Additional Precautions Assessment and Educational Tools.
Public Health Agency of Canada; 2013.
Note: in this document the term “patient” is inclusive of patient, resident or client.
ACUTE CARE PLAN FOR AROs (Antibiotic Resistant Organisms)
COMMENTS – Date
PATIENT CONCERN GOAL INTERVENTION
& Signature
Colonization: Control spread of 1. In addition to Routine Practice, initiate Contact Precautions
ARO 2. Always do a Point of Care Risk Assessment for every patient interaction to determine
any additional precautions that need to be taken
MRSA 3. 4 C’s should be adhered to if patient is leaving room:
ESBL Clean Hands: Wash hands for at least 15 seconds with soap and water or alcohol
Other based hand rub (ABHR).
Clean Clothes: wear clean patient gown or clean clothes.
Contain wounds/body fluids: wounds covered with clean, dry dressing. Urine/feces
and other body fluids contained.
Co-operative: able to follow instructions.
4. Patient and Visitor Teaching: use ARO Information pamphlets
Ensure compliance with proper hand hygiene.
Teach visitors re: hand washing as above and use of appropriate PPE.
Visitors are not required to wear PPE unless participating in direct patient care.
Visitors and patients who leave the patient’s room are asked to not use the kitchen,
lounges or other facilities in the hospital.
5. Safety: Compliance with hand hygiene requires continuous reinforcement!
Equipment that is not dedicated to resident use must be cleaned and disinfected
between uses.
6. Documentation: Each shift, check off on the patient record that the appropriate care
plan has been followed and Infection Control Recommendations remain in place.
Ensure Patient 1. Signage regarding Contact Precautions is required outside patient’s room.
Confidentiality 2. Information about the patient’s ARO status is to remain confidential among direct care
providers (i.e. housekeeping and dietary staff only need to know type of precautions,
not patient condition).
3. When patient goes to another department, or is transferred to another facility, the
receiving department or facility MUST be notified of ARO status.
Effective Date: September 2006 Revised Date: Feb 2011 / Feb 2015
Note: in this document the term “patient” is inclusive of patient, resident or client.
RESIDENTIAL CARE PLAN FOR AROs (Antibiotic Resistant Organisms)
EFFECTIVE DATE: September 2006 REVISED DATE: Feb 2011 / Feb 2015
COMMUNITY CARE PLAN FOR AROs (Antibiotic Resistant Organisms)
Note: in this document the term “patient” is inclusive of patient, resident or client.
CLIENT CONCERN GOAL INTERVENTION COMMENTS
Infection: Control spread of 1. In addition to Routine Practices, use Contact Precautions Add pertinent interventions to
ARO Always do a Point of Care Risk Assessment for every client interaction to CHW care plan; i.e. decisions
determine any additional precautions that need to be taken. regarding a designated toilet
MRSA WOUND: Cover open wounds with dressing or clothing. and clothing over open wounds
ESBL URINE or STOOL: If possible, client should have separate toilet. Empty urinary will need to be included in the
Other catheter contents in designated toilet. When separate toilet not available, the CHW care plan
shared toilet requires routine cleaning with a household disinfectant.
Site: SPUTUM: If possible, clients with symptoms of respiratory infection should be
Wound requested to stay at home until symptoms resolve.
Stool 2. Mobility: The client is not restricted in home or public unless there is an uncontained
Urine draining wound – public pools and contact sports or other skin to skin contact should
be avoided until the wound is healed. Client should notify any medical personnel of
Sputum MRSA status prior to appointments. Teach client to follow the 4 C’s:
Clean Hands: Wash hands for 15 s with soap and water or alcohol based hand rub
(ABHR) often while at home and in the community.
Clean Clothes: wear clean clothes every day and practice good personal hygiene.
Contain wounds/body fluids: wounds covered with clean, dry dressing or clothing;
urine/feces and other body fluids container.
Co-operative: able to follow instructions.
3. Client & Family Teaching: use ARO Information pamphlets
1. Assist with hand washing with plain soap – to be done prior to leaving their home,
after using the toilet, prior to eating/handling food and when are visibly soiled.
Remind visitors to practice good hand hygiene.
4. Safety: Compliance with hand hygiene requires continuous reinforcement!
Ensure Client 1. Signage regarding ARO status is NOT required. To ensure client confidentiality,
Confidentiality 2. Information about the client’s ARO status is to remain confidential among direct care DO NOT write the ARO status
providers. on the CHW care plan.
3. Notify acute or residential site of ARO status upon transfers – teach client and visitors
regarding additional precautions taken at acute care sites (Contact Precautions, single
room, etc.).
EFFECTIVE DATE: September 2006 REVISED DATE: Nov 2010 / Feb 2015
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0300S (Carbapenemase Producing Organisms (CPOs)
Page 11
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0300A (Carbapenemase Producing Organisms (CPOs)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
1.0 PURPOSE
2.0 DEFINITIONS
Many people with a CPO harbor the bacteria without causing symptoms (colonization). Others may
have an infection in their bloodstream, urinary tract or surgical site, with very limited antibiotic
treatment options and poor clinical outcomes. In Canada, most CPO cases have been identified in
persons who have been hospitalized and/or had a medical procedure done in countries outside of
Canada.
CPOs are usually spread person-to-person through contact with infected or colonized people, or
contaminated surfaces or medical equipment. Good hand hygiene by healthcare workers, patients,
and visitors and careful cleaning and disinfection of rooms and equipment, can help prevent the
spread of CPOs.
Contact – an individual who is exposed to a person, colonized or infected, with a CPO in a manner
that allows potential transmission to occur (i.e.) roommate.
Infection – when sufficient cellular and tissue changes occur to produce overt signs and symptoms,
an individual has clinical disease. Depending on the microorganism and health status of the host this
disease may range from mild to severe. Clinical manifestations of local or systemic infection can
include fever, increased white blood cell count, purulence, inflammation, redness, heat, swelling,
and/or pain.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0300A (Carbapenemase Producing Organisms (CPOs)
Page 2
Internal Alert – when the number of CPO cases in a unit or facility is above the pre-determined
threshold (trigger point) or there is suspected transmission. Internal alerts bring increased staff
awareness of CPO cases in the unit/facility so actions can be taken to prevent an outbreak.
Outbreak Definition – CPO cases are classified as an outbreak when the number of new, time-
related, healthcare associated CPO cases in a unit or facility is above the expected threshold for that
unit or facility and where there is evidence of ongoing transmission despite appropriate interventions.
Molecular confirmation of CPO genes in patient’s isolates is required to determine ongoing
transmission. Declaring an outbreak must be done in conjunction with the facility Outbreak
Management Team.
Outbreak Management Team – at a minimum, includes the site Infection Control Practitioner,
Infection Prevention and Control (IPAC) director, Medical Microbiologist, epidemiologist, site
administrator, site medical director, nursing unit manager and housekeeping supervisor.
Screening – a process to identify patients at risk for being colonized with CPO, obtaining specimens
for CPO identification and ensuring Additional Precautions are implemented.
3.1 Anyone being screened for CPO must be placed on Contact Precautions in a single room
while awaiting screening results. If the PCRA (point of care risk assessment) identifies
respiratory symptoms, use Droplet Contact Precautions.
Note
3.3 An ARO Alert is entered into the patient’s electronic record by the Infection Control
Practitioner.
3.4 Any patients potentially exposed to a known CPO positive patient should have a screening
test (rectal swab; stool if rectal swab not available) performed.
3.5 The CPO status of a patient should not prevent transfer of the individual within a facility or to
another facility.
4.0 PROCEDURE
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0300A (Carbapenemase Producing Organisms (CPOs)
Page 3
Screening for MRSA and CPO tool for pre-surgical screening, for surgical patients with an
unplanned admission and for patient transfers between acute care facilities.
Patients require a rectal swab (stool if rectal swab not available) for CPO screening if they
answer ‘yes’ to any of the following:
Has the patient ever had a CPO?
Has the patient been outside of Canada and had an overnight stay in a hospital or
undergone a medical/surgical procedure within the past 12 months?
Has the patient had dialysis outside Canada within the past 12 months?
Has the patient had close contact with a known CPO patient within the past 12
months? (close contact defined as household member or roommate in hospital)
Has the patient been transferred from a facility with known, active CPO
transmission?
There are different types of CPOs, so patients who are known to be CPO positive
must be retested for each hospital admission.
Please Note: For negative screening results, there will be a comment on the lab
result that states ‘Continue Contact Precautions as patient has had a previous
positive CPO result’.
Any patient requiring CPO screening swabs must be placed on Contact Precautions in
a single room. Precautions may be discontinued if the screening swab is negative and the
patient was not previously CPO positive.
4.2 Patients who have a CPO identified in a clinical specimen must be placed on Contact
Precautions for the duration of their hospitalization. Use Droplet Contact Precautions if a
CPO is identified in a sputum culture.
4.11 Surveillance
For patients confirmed to be positive for a CPO, Infection Prevention and Control (IPAC)
will collaborate with unit staff and the BC Public Health Microbiology & Reference
Laboratory (BCPHMRL) to collect data required for surveillance purposes
For positive CPO isolates, BCPHMRL will assign a unique identifier which will be
included in the laboratory report and will notify the submitting laboratory
The submitting laboratory will work with the site ICP to ensure completion of the
surveillance form for CPO https://www.picnet.ca/wp-content/uploads/CPO-Surveillance-
Form.pdf: Complete Appendix C for CPO colonization cases. Complete Appendix C and
Appendix D for CPO infected cases.
Submit completed forms to the Provincial Infection Control Network (PICNet) and IPAC
epidemiologist
The IPAC epidemiologist will submit denominator data to PICNet on a quarterly basis
including:
Total number of hospital admissions per quarter
Total number of inpatient days per quarter
Total number of CPO cases per quarter
PICNet and BCPHMRL will summarize the CPO data and report back to the health
authorities, the Ministry of Health and the BC Association of Medical Microbiologists
(BCAMM) quarterly.
5.0 REFERENCES
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0300A (Carbapenemase Producing Organisms (CPOs)
Page 6
Appendix 1
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0400 (Scabies/Lice)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
1.0 PURPOSE
2.0 DEFINITIONS
Scabies
Scabies is a contagious parasitic infestation caused by a mite, Sarcoptes scabiei.
Scabies infestations are identified by the following characteristics:
o Skin penetration is visible as papules or vesicles.
o Linear burrows formed by the mite under the skin.
o Severe pruritus.
These lesions commonly appear in interdigital spaces, anterior surfaces of wrists and ankles, axillae,
skin folds, genitalia, belt-line and abdomen. Itching may be intense, especially at night and lesions
may become secondarily infected due to scratching.
Crusted (Norwegian ) scabies presents as a crusty, scaly dermatitis usually on hands and feet,
including dystrophic nails. Some affected individuals may have a generalized erythematous eruption.
Norwegian scabies is highly infectious owing to the large numbers of mites present.
Lice
Lice (pediculosis) are called ectoparasites because they live outside the host’s body. There are three
types of human lice which are usually, but not always, confined to a certain part of the body. They
are named according to the region of the body that they infest or their general appearance: head
louse, body louse, and pubic or crab louse. These creatures cannot fly or jump, but head and body
lice move quickly, passing rapidly from host to host.
Head Lice
Head lice generally prefer the fine hairs of the head especially around the ears and the nape of the
neck or eyebrows and eyelashes. Adult larvae and nits are visible to the naked eye:
Adult lice are reddish-brown.
Unhatched eggs are pearly white.
Hatched eggs are translucent.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0400 (Scabies/Lice)
Page 2
Infectious Period
Scabies and lice can be transmitted up until the time they are eradicated by treatment with 5%
permethrin cream.
The incubation period for primary infestation occurs as early as 10 days, but it is typically 4 – 6
weeks.
Transmission
Scabies and lice are transmitted through direct or indirect contact.
Although blood and body fluids are not affected by these infestations, the patient’s clothing, bed
linen, and mattress are contaminated by direct contact with the infected patient.
Head lice are transmitted through contact with infested hair or with articles such as brushes,
combs, headgear, or clothing of the infested person.
Transmission of pubic lice is usually by sexual contact.
3.0 PROCEDURE
In persons with crusted scabies, the length of additional precautions may be longer.
Staff to wear a gown and gloves for all patient contact until the treatment has been
completed and Contact Precautions discontinued.
3.2 Treatment
Ordered by the attending physician.
5% permethrin cream applied as directed. Milder doses may be required for children and
pregnant or lactating women.
Itching may persist for days to weeks following treatment. This is not to be
mistaken for treatment failure.
Carefully examine the patient for new burrows in seven days. If there is evidence of
continued infestation, treatment may be repeated if considered necessary - ordered by
the attending physician.
3.3 Staff
Contact Workplace Health and Safety if symptomatic.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0400 (Scabies/Lice)
Page 3
3.5 Housekeeping
Perform routine cleaning.
REFER TO IF0100- ROUTINE PRACTICES FOR ALL CARE AREAS GUIDELINE
4.0 REFERENCES
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0500A (Tuberculosis)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
The goal of the Tuberculosis (TB) Management Program is to prevent transmission of TB to staff
and patients.
2.0 DEFINITIONS
The most common site of TB infection is in the upper regions of the lungs. Mycobacterium
tuberculosis is spread by the airborne route when patients expectorating viable tubercle bacilli
contaminate the surrounding airspace. Aerosolized tubercule bacilli can be inhaled by
susceptible patients and staff and can lead to primary tuberculosis infection. The incubation
period for TB is between two and twelve weeks.
Pulmonary and laryngeal TB are the only types of TB that are spread via the airborne route.
In Canada, TB occurs in well-defined populations including Aboriginal Canadians, the urban poor
or immigrants from high-incidence countries in Asia, Eastern Europe, Africa and Latin America.
Immunocompromised persons such as those with HIV and diabetes are also at an increased risk
of developing active TB. Other groups at risk include people who live or work in residential care
facilities (e.g. jail, nursing homes, drug treatment centers), alcoholics, indigent persons and IV
drug users. Persons who live in the same household with a high risk individual are also at risk.
Because healthcare providers have frequent contact with persons in these groups, the risk of
transmission of TB remains an important potential occupational hazard.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0500A (Tuberculosis)
Page 2
The risk of transmission increases with the increasing amount of time spent with
an infectious patient without wearing appropriate personal protective equipment
(PPE).
In buildings with sealed windows and mechanical ventilation systems,
recirculation of air can contribute to transmission in healthcare facilities.
Recommend that all facilities make available to their healthcare workers annual
summary information on the clinical, epidemiologic and microbiologic features of
patients whose TB is diagnosed within the hospital – will help to increase awareness
of TB in the patient population served by the hospital.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0500A (Tuberculosis)
Page 3
4.0 PROCEDURE
If an Airborne Isolation Room is not available then arrange to have the patient
transferred to a facility with the necessary room requirements as quickly as possible.
Staff entering the room must wear approved respiratory protection (will be referred to
as N95 respirators for remainder of document), ensuring the seal checks are done
when the N95 respirator is put on.
REFER TO IH0200 – AIRBORNE PRECAUTIONS GUIDELINE
Visitors entering the room should be offered an N95 respirator, staff to teach the seal
check and how to put the N95 respirator on. Visits by children should be discouraged
because of their increased susceptibility.
Patient is to leave the room for essential procedures only and is to wear a
surgical/procedure mask when outside their isolation room.
Exceptions due to extenuating circumstances must be reviewed and approved by the
attending physician & Infection Control – a written order is required.
Notify receiving departments of Airborne Precautions requirements – staff will need to
wear an N95 respirator when the patient is unable to wear a surgical/procedure mask.
If transport between facilities is required, patient should be transported in well-
ventilated vehicles (i.e. with the window open) and attendants should wear an
approved respirator mask – DO NOT use public transportation.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0500A (Tuberculosis)
Page 4
Surgery
o Surgery should be postponed or scheduled at the end of the day.
o If intubation and mechanical ventilation is required, an appropriate
bacterial filter should be placed on the endotracheal tube to prevent
contamination of the ventilator and the ambient air.
o Use Airborne Isolation Room (if available) for procedure.
o Staff must wear N95 respirator.
o Door to room patient is in must remain closed.
Note:
A single negative AFB smear from bronchoalveolar lavage (BAL) does
NOT definitively exclude active TB and three induced sputum
specimens have superior yield for the diagnosis of active TB than a
single bronchoscopy.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0500A (Tuberculosis)
Page 5
4.2.1 Ventilation
Newly constructed Airborne Isolation Rooms should have 12 air changes per
hour; pre-existing rooms should have at least 6 air changes per hour or as
per current CSA Standards.
The direction of air flow should be from the hall and into the room and then
exhausted outdoors.
Direction of air flow should be tested with smoke tubes at all four corners of
the door daily when the room is occupied, unless the room is equipped with
automatic pressure monitoring.
Windows and doors should be kept closed at all times.
The air changes and direction of air flow should be verified at least every 6
months AND if any changes occur such as HVAC equipment failure or alarm
failure.
Time needed to remove airborne contaminants after generation of infectious
droplet nuclei has ceased is 45 minutes.
Current recommendations call for particulate respirator masks that filter 95% of particles
of 1 micron or larger and have less than 10% leak to protect workers against airborne
TB.
Most common product used are NIOSH-designated N95 respirators.
Healthcare providers require education regarding the occupational risk of TB, the role of
respiratory protection to reduce that risk, the importance of wearing the N95 respirator
properly, doing a seal check each time the N95 respirator is put on so that there is a tight
facial seal and ensuring the N95 respirator is put on correctly before entering the
patient’s room.
N95 respirators must be available for staff whenever a patient is identified who is
suspected of or confirmed to have active TB.
N95 respirators should be worn by workers involved in the transport of patients
suspected of or confirmed as having active TB, e.g. ambulance workers, particularly
when patient cannot wear a surgical/procedure mask.
N95 respirators should be available for caregivers, e.g. community healthcare workers
who may have to provide care while waiting for patient transfer to a facility with
appropriate environmental controls.
TB patients can wear surgical/procedure mask when they leave their rooms as these
mask are effective in trapping the large infectious particles expelled by TB patients.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0500A (Tuberculosis)
Page 6
Visitors should be offered an N95 respirator, staff to teach the seal check and how to put
the mask on.
4.4.3 Periodic TST for Workers in Medium Risk Hospitals and Programs OR
Those Performing High Risk Activities in All Hospitals
Annual TST is recommended for healthcare workers with negative baseline
TST who are involved in moderate-risk activities in medium-risk hospitals
AND for workers involved in high-risk activities in all hospitals.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0500A (Tuberculosis)
Page 7
ICP to work collaboratively with the Communicable Disease (CD) Unit, WH&S and
medical staff to ensure appropriate contact investigation and follow up is implemented
promptly.
Patients are considered a contact if they have shared a room with another patient
confirmed with TB – they have had regular, prolonged contact with the source case and
share breathing space daily.
Patient contacts are NOT infectious and DO NOT require Airborne Precautions, however,
they do require follow up evaluation by their family physician.
ICP notifies CD Unit of positive active TB case and potential contacts in hospital – Public
Health will assist in follow up of discharged patients, visitors and volunteers.
ICP notifies WH&S regarding the contact investigation of an active case of TB – WH&S
will carryout follow up for staff exposures (Section 5.2 above).
ICP notifies the ‘contact’ patient’s attending physician regarding the potential exposure of
their patient to an active TB case and advises that follow up is necessary - if patient still
in hospital, a baseline TST can be done by the institution.
ICP notifies the Patient Transport Office (PTO) of potential external contacts such as
ambulance personnel, first responders and other transport services and advises that
follow up is necessary – PTO will ensure contact is made with the necessary providers in
this regard.
4.7 Process/Protocol
As soon as possible after an in-patient is confirmed as having active pulmonary
tuberculosis, the CD Unit will coordinate a case teleconference – this is a collaborative
process for the purpose of information sharing, identification of case contacts, early
recognition of discharge planning needs and coordination of key stakeholders, including:
o CD Unit.
o Hospital Transition Nurse/Discharge Planner (specific to unit where patient is
located).
o Patient Care Coordinator [PCC] (specific to unit where patient is located).
o Hospital Infectious Disease Pharmacist [or designate].
o Urban Outreach Social Worker (if case in Kelowna).
o Urban Outreach Case Manager (if case in Kelowna).
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0500A (Tuberculosis)
Page 8
5.0 REFERENCES:
5.1 Canadian Tuberculosis Standards 6th Edition by The Public Health Agency of Canada
and The Lung Association, 2007; Chapter 16.
5.2 APIC Text of Infection Control and Epidemiology 3rd Edition 2009; Chapter 91.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0500A (Tuberculosis)
Page 9
Place appropriate Airborne Precautions sign on door and ensure that the negative pressure is
turned on and working. Room pressure must be checked each shift.
Collect 3 sputum specimens 8 – 24 hours apart with at least one being an early morning specimen
Discontinue Airborne Precautions only on approval from ICP, Infectious Disease physician,
Respirologist, or Medical Director for IP&C
When Airborne Precautions are discontinued and room is cleaned, 45 minutes is required to
remove airborne contaminants
Discharge planning done collaboratively with Public Health and others – requires minimum of 3
working days to ensure necessary services are organized and available
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0500A (Tuberculosis)
Page 10
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0500A (Tuberculosis)
Page 11
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0500B (Tuberculosis Risk Screening-Adult Residential
Care Facilities, Group Homes, Mental Health Care Facilities)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located
on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
To ensure persons with active respiratory tuberculosis are excluded from admission to an Adult
Residential Care Facility (including Group Homes and Mental Health Care Facilities) until they have
been appropriately treated and are no longer infectious.
The Medical Health Officer may make alternative policy decisions based on local disease incidence
and prevalence.
2.0 DEFINITIONS
Systemic Signs and Symptoms of Active TB Signs and Symptoms of Respiratory TB Disease
Disease
Fever* Cough (dry or productive) for two to three
Night sweats* weeks or longer with or without fever or
Loss of appetite (anorexia) phlegm
Unexplained weight loss Bloody sputum (hemoptysis)
Fatigue Chest pain
Shortness of breath
Abnormalities on chest x-ray**
* May be absent in the very young and elderly
** Radiographic presentation can be atypical in clients who are immune compromised
Immune compromised defined as persons with HIV infection; transplant recipient on immune
suppressing treatment; chronic renal failure and/or dialysis and/or other conditions per clinical
judgment/consultation with TB Services; taking (or about to begin) treatment with immune suppressing
therapies such as TNF alpha inhibitors, chemotherapy, or systemic corticosteroids (equivalent of ≥ 15
mg/day of prednisone for 2 weeks or longer)
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0500B (Tuberculosis Risk Screening-Adult Residential
Care Facilities, Group Homes, Mental Health Care Facilities)
Page 2
All persons being admitted to a licensed Adult Residential Care Facility need to be screened for signs
and symptoms associated with active TB disease. This process needs to be completed prior to the
person being admitted to the care facility, may occur while the person is still living at home or while
the person is in the hospital and can be done within one month prior to admission if not symptomatic.
This information will be recorded on the person’s chart.
As per the Medical Health Officer 2016, this excludes client stays of less than 30 days and
Community Hospice Bed admissions (palliative care clients).
If a client remains in convalescent or respite care for greater than 30 days, they do require TB
screening.
4.0 PROCEDURE
4.2 For all persons who are less than 60 years old:
A tuberculin skin test (TST) must be done, unless contraindicated
o If client is in the community, refer client to Public Health Nursing for TST
o If client is admitted to hospital, nursing staff will perform the TST
In addition, for those persons who have symptoms of respiratory TB disease a
chest x-ray is required – see 4.4 below
If the person has a positive TST, a chest x-ray is required – see 4.4 below
If the person has a TST contraindication, or is immune compromised, a chest x-
ray is required – see 4.4 below
Contraindications for a TST include prior allergic response or severe reaction to a
TST, previous positive TST reaction, previous reactive IGRA (interferon gamma
release assay), previous active TB disease and burns or eczema at test site
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0500B (Tuberculosis Risk Screening-Adult Residential
Care Facilities, Group Homes, Mental Health Care Facilities)
Page 3
Ensure that the name of the person who needs to receive recommendations back is
listed in the “Additional Comments” section (i.e. ‘Please send recommendations to
Jane Smith, Home Health Nurse’; include mailing address)
Send the last page of the BCCDC TB Screening Form with the client to the
radiology provider (this page automatically populates when information is entered
electronically into Part 1 and Part 2 of the form)
Send the first page of the BCCDC TB Screening Form to BCCDC TB Services
Recommendations from BCCDC TB Services are communicated back to providers
via the BCCDC TB Screening Form and/or physician narratives
If a chest x-ray is required, refer person to MRP (most responsible physician) for
follow up; (MRP to order sputum for AFB/TB culture if person has productive cough)
Person cannot be admitted to a residential care facility until assessment by MRP and
BCCDC TB Services has ruled out presence of active respiratory TB disease
4.5 Documentation
Place the completed IH Tuberculosis Risk Screening form #811217 on the
person’s file
When the person is admitted to an Adult Residential Care facility, Group Home or
Mental Health Care facility, send a copy of the completed IH Tuberculosis Risk
Screening form #811217 to the admitting facility; this meets the licensing
requirements by having the completed form on file
If person was sent for chest x-ray and referral to BCCDC TB Services, include
recommendations from TB Services
5.0 REFERENCES
5.1 British Columbia Centre for Disease Control: Tuberculosis Manual. (November 2015)
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0500B (Tuberculosis Risk Screening-Adult Residential
Care Facilities, Group Homes, Mental Health Care Facilities)
Page 4
Tuberculosis Risk Screening for Residential Care EFFECTIVE DATE: July 2007
Facilities - Form #811217 REVISED DATE: June 2016
REVIEWED DATE: November 2010
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0600 (Chickenpox (Varicella-Zoster) and Herpes Zoster (Shingles)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
To prevent the spread of Varicella-zoster and herpes zoster to patients and staff.
2.0 DEFINITIONS
Immunocompromised patients – those with cancer, especially leukemia and lymphoma; those with
HIV; those who have undergone bone marrow or solid organ transplantation; those who are taking
immunosuppressive medications, including steroids, chemotherapy, or transplant – related
immunosuppressive medications; patient status determined by the physician.
Healthcare Worker Exposure Contact – non immune staff that have had contact with a patient
with varicella who is not on Airborne/Contact Precautions.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0600 (Chickenpox (Varicella-Zoster) and Herpes Zoster (Shingles)
Page 2
NOTE: Immune staff does NOT need to wear N95 respirator in patient room.
3.0 PROCEDURE
2. Shingles
(Herpes Zoster)
2a. Immunocompetent Routine Practice Drainage from
patient with: lesions
Localized lesions
AND
Lesions can be
covered with clothing
or dressing
2c. Immuno- Airborne Drainage from Until 72 hours of HCWs must be immune
compromised Contact lesions and effective antiviral Non-immune HCW that
patient with localized possibly treatment must enter room must
shingles respiratory OR wear N95 respirator
secretions If untreated until
all lesions are
crusted & dry
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0600 (Chickenpox (Varicella-Zoster) and Herpes Zoster (Shingles)
Page 3
2d. Patient with Airborne Drainage from Discontinue HCWs must be immune
disseminated Contact lesions and precautions: Non-immune HCW that
shingles possibly must enter room must
respiratory 72 hours after wear N95 respirator
secretions start of effective
antiviral therapy
AND
No new lesions
appear
AND
Existing lesions
are crusted and
dried
OR
If untreated until
all lesions are
crusted and dry
5.0 REFERENCES
4.1. B.C. Centre for Disease Control (BCCDC) Communicable Disease Manual – Varicella
Zoster; July 2004.
4.2. Alberta Health Services Infection Prevention and Control Manual 2012.
4.3. CDC Center for Disease Control and Prevention – Shingles (Herpes Zoster); 2012.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0700 (Invasive Group A Streptococcal Infections (IGAS)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
2.0 DEFINITION
When fetal demise occurs in association with a puerperal infection, isolation of group A
streptococcus from the placenta, amniotic fluid and/or endometrium is also considered
confirmatory for both the mother and the fetus.
3.0 PROCEDURE
3.3 Reporting
Report case to Infection Control who will complete the Communicable Disease
Notification Tool (only available to Infection Control Practitioners)
If Infection Control is not available then report case to the CD Unit (1-877-778-7736)
Monday to Friday 0830-1630 or the Medical Health Officer On-Call (1-866-457-5648)
after hours.
4.0 REFERENCE
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0700 (Invasive Group A Streptococcal Infections (IGAS)
Page 3
BC Centre for Disease Control Communicable Disease Control Manual. Invasive Group A
Streptococcal Disease. April 2014.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0800 (Meningococcal Infection)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
To provide guidance to staff on how to report a case of Meningococcal disease to Public Health.
2.0 DEFINITION
Meningococcal disease
Meningococcal disease is caused by the bacteria Neisseria meningitides (N. meningitides). The
bacteria can be found naturally in the throat or nose of 5-10% of the population, only rarely giving rise
to illness. However, when illness does occur, the infection can progress rapidly and is fatal in about 1
in 10 cases, striking young children and young adults most frequently.
The two most common presentations of invasive meningococcal disease are meningitis and
septicaemia.
The symptoms of meningococcal meningitis are identical to those of other forms of acute
bacterial meningitis. Signs of meningitis include sudden onset of fever, headache, and stiff neck.
Other symptoms frequently seen are nausea, vomiting, light sensitivity and altered mental status.
A petechial rash with pink macules may occasionally be observed.
Meningococcal septicaemia can occur with or without meningitis and may progress rapidly to
purpura fulminans (hypotension, fever and disseminated intravascular coagulation), shock and
death.
Infectious Period
The incubation period is most commonly 3-4 days but can range from 2 to 10 days.
Persons are communicable for 7 days prior to onset of symptoms until 24 hours after
initiation of appropriate antibiotic therapy.
Transmission
Person to person spread occurs through direct contact with respiratory droplets from the
nose and throat of infected people.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0800 (Meningococcal Infection)
Page 2
3.0 PROCEDURE
3.3 Reporting
Report case to Infection Control who will report case to Public Health.
If Infection Control is not available then report case to Public Health via the CD Unit (1-866-
778-7736) Monday to Friday 0830-1630 or the Medical Health Officer On-Call (1-866-457-
5648) after hours.
Contacts will be identified, notified of recommendations and provided direction regarding
medication distribution by Public Health.
Chemoprophylaxis may be considered and is provided free of charge for close contacts of
invasive meningococcal disease and primary meningococcal conjunctivitis cases under
authorization of the Medical Health Officer.
Chemoprophylaxis is only recommended for healthcare workers who have had intensive
unprotected contact (without wearing a mask or eye protection) with infected patients (i.e.
intubating, resuscitating, or closely examining the oropharynx) or unprotected contact with
the purulent discharge from the eye of a case of primary meningococcal conjunctivitis.
Infection Control will ask Unit Managers to identify healthcare workers who meet the above
close contact definition with the patient since admission to 24 hours post treatment and
report these names to the Occupation Health Nurse Specialist for follow-up.
4.0 REFERENCES
4.1 Control of Communicable Disease Manual (19th edition). Heymann, D. (Ed). American
Public Health Association (2008).
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0900 (Creutzfeldt-Jakob Disease)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
2.0 DEFINITION
Creutzfeldt-Jakob Disease (CJD) is an infection which causes progressive mental deterioration and
muscle weakness. It is often difficult to differentiate CJD from other forms of dementia. CJD is caused
by a small agent called a prion. Diagnosis is based on clinical signs, periodic EEG and brain material
histopathology. Confirmation of CJD does not usually occur until autopsy.
2.2. Transmission
CJD is not known to be spread person to person through routine direct or indirect contact.
Transmission has been documented via corneal transplantation, contaminated neurological
electrodes, dura mater grafts and injections of growth hormone or human pituitary gland
origin.
Risk is higher in the Operating Room, Laboratory, CSSD and Autopsy Suite.
3.0 PROCEDURE
3.1. When a patient is suspected of having CJD, notification shall be given to Infection Control
who will report case to Public Health. If Infection Control is not available then report case to
Public Health via the CD Unit (1-877-778-7736) Monday to Friday 0830-1630 or the Medical
Health Officer On-Call (1-866-457-5648) after hours.
3.2. Transfer of the patient to any other department requires notification of CJD status. This is
especially important for departments who will do invasive procedures - Imaging, O.R., morgue.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS0900 (Creutzfeldt-Jakob Disease)
Page 2
3.3. As there is controversy about the effectiveness of sterilizing instruments used on CJD patients, a
minimum of reusable instruments should be used as they will need to be discarded following
use.
4.0 REFERENCES
4.1. Creutzfeldt-Jakob Disease in Canada Quick Reference Guide 2007 - Public Health
Agency of Canada.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS1000 (Respiratory Viruses)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
1.0 PURPOSE
2.0 DEFINITIONS
In general, respiratory viruses can cause acute upper respiratory tract infection in most people.
Lower respiratory tract infections are more common in children < 1 year old and in the elderly with
chronic pulmonary disease or functional disability.
Symptoms include:
Acute onset of illness with a fever (>38C) and cough
Sore throat
Nasal congestion
Malaise
Chills
Muscle/joint aches
Headache
Change in respiratory or mental status
**NOTE: In the elderly, fever may not be present
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS1000 (Respiratory Viruses)
Page 2
3.1 Healthcare workers are rarely at risk for acquiring respiratory viruses when using Routine
Practices appropriately, including a point of care risk assessment (PCRA). When the PCRA
indicates a potential respiratory illness, then Droplet & Contact Precautions should be
implemented.
3.2 Watch carefully for other patients or healthcare workers with developing respiratory
symptoms. If unit transmission is suspected, notify the Infection Control Practitioner.
4.0 PROCEDURE
5.0 REFERENCES
5.1 Provincial Infection Control Network of British Columbia (PICNet BC). (February 2011).
Respiratory Infection Outbreak Guidelines for Healthcare Facilities.
https://www.picnet.ca/practice-guidelines
5.2 Centre for Disease Control and Prevention (July 2010) Interim guidance of Infection
Control Measures for H1N1 Influenza in Healthcare Settings, Including protection of
Healthcare Personnel http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm
5.3 Public Health Agency of Canada (2010) Respiratory Syncytial Virus http://www.phac-
aspc.gc.ca/lab-bio/res/psds-ftss/pneumovirus-eng.php
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS1100 (Rabies)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
2.0 DEFINITION
Rabies is a preventable viral disease of mammals most often transmitted through the bite of a rabid
animal. The vast majority of rabies cases reported to the Centers for Disease Control and Prevention
(CDC) each year occur in wild animals like raccoons, skunks, bats, and foxes. Domestic animals
account for less than 10% of the reported rabies cases, with cats, cattle, and dogs most often
reported rabid.
Rabies virus infects the central nervous system, causing encephalopathy and ultimately death. Early
symptoms of rabies in humans are nonspecific, consisting of fever, headache, and general malaise.
As the disease progresses, neurological symptoms appear and may include insomnia, anxiety,
confusion, slight or partial paralysis, excitation, hallucinations, agitation, hypersalivation, difficulty
swallowing, and hydrophobia (fear of water). If vaccinations to prevent disease are not administered
before the onset of symptoms, death is almost certain.
2.2. Transmission
Virus-laden saliva of rabid animal introduced through a scratch or bite. Person to Person
transmission is theoretically possible, but rare and not well documented. Organ transplants
of persons dying of undiagnosed CNS disease have lead to transmission of rabies.
3.0 PROCEDURE
3.2. Reporting
Contact Infection Control.
If Infection Control is not available then please contact Public Health.The Medical Health
Officer of Health must be notified as Rabies is a Reportable Communicable Disease.
REFER TO IS0100 – REPORTABLE COMMUNICABLE DISEASES
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS1100 (Rabies)
Page 2
3.3.Prophylaxis
Please review the following BCCDC document.
4.0 REFERENCE
See B.C. Centre for Disease Control (BCCDC) for Rabies Protocol (July 2009):
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS1200 (Measles)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
2.0 DEFINITIONS
Measles (rubeola) is caused by a virus and is one of the most contagious of all infectious diseases,
with >90% attack rates among susceptible close contacts. Initial symptoms include 2-4 days of fever,
cough, runny nose and red inflamed eyes (prodromal period) followed by a maculopapular rash,
starting on the face and neck, spreading to the chest, arms and legs lasting at least 3 days. Koplik
spots may appear on the inside of the mouth.
Complications include ear infections, pneumonia and encephalitis (1 out of every 1000 cases) and
are most common in infants < 12 months of age. Measles during pregnancy results in a higher risk of
premature labor, spontaneous abortion and low birth weight infants.
In BC most clusters and outbreaks of measles occur in association with imported cases. BC has
experienced two larger outbreaks (2010 and 2014) in recent years, typically lasting not more than two
to three months.
Healthcare worker (HCW) contact identification – HCWs include students, physicians, facility
employees, emergency responders and others who were in a shared airspace with the case or for up
to 2 hours after the case left the room/space. All of these individuals should be assessed with
respect to their exposure.
2.4 Diagnostic testing - all specimens are sent to BCCDC for testing
Virus detection in nasopharyngeal swab and urine
Serology testing for measles specific IgM and IgG class antibodies
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS1200 (Measles)
Page 2
3.2 A baseline assessment of all healthcare workers immunity and vaccination status against
measles needs to be done by WH&S.
3.3 Only immune healthcare workers should enter a room where airborne precautions are in
place for measles; an N95 respirator is not required.
3.4 An N95 respirator must be worn if non-immune health care providers are required to enter
the room of a patient with measles when there are no qualified immune healthcare providers
available and patient safety would be compromised if they did not provide care.
4.0 PROCEDURE
4.3 Reporting
Investigate all clinically identified and laboratory reports of measles within 24 hours and
immediately notify the CD Unit (1-866-778-7736) Monday to Friday 0830-1630 or the
Medical Health Officer On-Call (1-866-457-5648) after hours
Report case to Infection Control who will complete the Communicable Disease Notification
Tool (Available to Infection Prevention Control Practitioners only)
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS1200 (Measles)
Page 3
5.0 REFERENCE
5.1 BC Centre for Disease Control Communicable Disease Control Manual – Measles;
June 2014.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS1300 (Mumps)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
2.0 DEFINITIONS
Mumps is a severe illness caused by the mumps virus. Mumps was previously a childhood disease
however, now it is more common in young adults. Symptoms include fever, aches and pains,
headaches and swelling of the salivary glands, especially in the parotid glands. Up to 1 in 5 people
do not have symptoms; however they can still spread the mumps virus to other people.
Complications of mumps includes painful swelling of the testicles in about 1:4 adult men and post-
pubertal boys and swelling of the ovaries in about 1:20 women – both of these conditions are
temporary and rarely result in permanent damage or sterility. Mumps can also cause temporary or
permanent deafness or serious illness such as encephalitis which can lead to convulsions or brain
damage. Mumps in early stages of pregnancy may increase the rate of miscarriage. Mumps do not
appear to cause birth defects.
Healthcare provider (staff) contact of a case of mumps – defined as individuals who have had
direct contact with oral/nasal secretions of an infectious case of mumps.
Prodomal period – the time during which the infectious process has begun but is not yet
clinically manifested by signs and symptoms.
WH&S - Workplace Health and Safety – provides the baseline assessment of all healthcare workers’
immunity and vaccination status and follow up in cases of an occupational exposure
2.2. Transmission
Direct contact with saliva or respiratory droplets that are aerosolized from the nose or throat
Spread through coughing, sneezing, sharing drinks, or kissing, or from contact with any surface
that has been contaminated with the mumps virus.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 08S – IS1300 (Mumps)
Page 2
4.0 PROCEDURE
4.3 Reporting
Investigate all clinically identified and laboratory reported cases of mumps as soon as
possible and immediately notify the CD Unit (1-866-778-7736) Monday to Friday 0830-
1630 or the Medical Health Officer On-Call (1-866-457-5648) after hours
Report case to Infection Control
Infection Control will ask Unit Managers to identify staff who meet the contact definition
with the patient since admission and report these names to WH&S for follow-up
Prior to return to work the healthcare provider should contact WH&S to ensure they are not
longer contagious.
5.0 REFERENCE
5.1 Communicable Disease Control Manual - Mumps. BC Centre for Disease Control Interim
June 2011.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section IS1400 – Bed Bugs
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVISED DATE:
REVIEWED DATE:
6.0 PURPOSE
7.0 DEFINITIONS
Bed bug – is a small reddish brown oval shaped insect with a flattened
body. The size is 5-7mm long or the size of a lady bug. Bed bugs are
classified as blood-sucking parasites on warm-blooded hosts.
Bed bugs ARE NOT ASSOCIATED with the transmission of human disease.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section IS1400 – Bed Bugs
Page 2
9.0 PROCEDURE
Patients should be instructed NOT to remove any belongings from sealed bags.
Instruct family to wash and dry washable items using high temperature.
Continue with routine cleaning and disinfection procedures. If any visible bedbugs noted in
the vicinity of the patient, wipe the area with a damp paper towel and discard in the garbage.
Seal the garbage bag and discard.
For patients in the Emergency Department who have suspected bed bugs and require
transfer to a unit, place that patient in a private room if possible until the source of the bug is
confirmed and treatment is complete.
Any decision to treat a room, evacuate a room or replace equipment will be made in
consultation with the unit staff involved, the unit leader, Housekeeping, Pest Control and
Infection Control as required and recommendations made on how to proceed will be
communicated with stakeholders.
A physician assessment can determine whether antihistamines and corticosteroids may be
prescribed to reduce allergic reactions, and antiseptic or antibiotic ointments to prevent
infection.
Infestations also may cause anxiety, embarrassment, and loss of sleep.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section IS1400 – Bed Bugs
Page 3
Equipment used on the client should be placed in a sealed bag and returned to the unit for
cleaning.
Inspect clothing and equipment for bedbugs after visit and remove any stragglers.
4.5 Staff
Contact Workplace Health and Safety if symptomatic.
10.0 REFERENCES
10.1 Providence Health Care Nursing Care Standards. 2007; Bed Bugs Protocol.
10.2 Vancouver Costal Health (VCH) - BED BUGS - VCH STAFF INFORMATION SHEET.
10.3 Vancouver Island Health Authority (VIHA) Infection Prevention & Control Manual.
2009; Bed Bug Infestation pg 78 – 79.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section IS1500 – Pertussis
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
1.0 PURPOSE
2.0 DEFINITIONS
Pertussis is an acute and prolonged infectious cough illness caused by Bordetella pertussis, a gram-
negative bacterium. The duration of pertussis illness is usually 6 to 10 weeks in children. The clinical
course of pertussis is divided into 3 stages:
Catarrhal stage (lasts 1 – 2 weeks); symptoms indistinguishable from a respiratory tract
infection; intermittent cough becomes paroxysmal
Paroxysmal stage (usually lasts 1 – 6 weeks but may persist for up to 10 weeks); individual
has repeated bursts or paroxysms of numerous, rapid coughs that follow each other without
inspiration and may end with an inspiratory “whoop” and may be followed with mucous
production and vomiting
Convalescent stage (lasts 2 – 6 weeks or longer); recovery is gradual with a paroxysmal
cough subsiding and decreasing frequency of coughing bouts
The most common complication of pertussis is secondary bacterial pneumonia.
Pertussis is highly infectious – the secondary attack rate exceeds 80% among susceptible persons.
Neither vaccination nor natural disease confers complete or lifelong protective immunity against
pertussis or re-infection.
The highest incidence of pertussis generally occurs in infants < one year of age.
Pertussis demonstrates cyclical peaks every three to five years.
Contact Identification – Identify contacts that had the following types of contact with the case during
the period of communicability:
High risk contacts – that had the following types of contact with the case during the period
of communicability: face-to-face contact > 5 minutes; shared the same confined air space for
> 1 hour; or direct contact with respiratory secretions of the infected person:
o Infants < 1 year of age
rd
o Pregnant women in the 3 trimester
o All household or family daycare contacts IF there is an infant < 1 year of age or
rd
pregnant woman in 3 trimester in household or daycare
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section IS1500 – Pertussis
Page 2
3.2 Chemoprophylaxis should be started as soon as possible - it may prevent contacts from
developing disease when it is given to contacts no later than 21 days after the contact's first
exposure to the case during the time the case was infectious.
3.3 Immunization following recent exposure is not effective against infection but will provide
protection if subsequent exposure occurs.
3.5 During community outbreaks, notification will be sent out to Infection Control Practitioners
(ICPs) by the CD Unit/MHO; ICPs will then notify hospital emergency rooms to heighten
awareness of potential pertussis cases.
4.0 PROCEDURE
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section IS1500 – Pertussis
Page 3
5.0 REFERENCES
5.1 BC Centre for Disease Control Communicable Disease Control Manual – Pertussis;
June 2010.
http://www.bccdc.ca/NR/rdonlyres/FEC42ABA-A725-4AD4-AE08-
893234733BEA/0/EPI_Guideline_CDChapt1Pertussis_20100625.pdf
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0100 (Surveillance for Healthcare Associated Infections)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
To reduce the occurrence of healthcare associated infections across the continuum of care (acute,
residential, community) and monitor the effectiveness of the infection prevention and control program.
2.0 DEFINITIONS
Community-Acquired Infections – infections present or incubating at the time of admission and with no
association to a recent hospitalization.
Device-associated Infection Rates – a rate of infection associated with exposure to a medical device,
such as a ventilator, central venous catheter or indwelling urinary catheter.
Epidemiology – the study of the frequency, distribution, cause and control of disease in populations that
forms the background for interventions to reduce transmission of infecting organisms, reduce the number
of HAIs and protect healthcare providers from infection.
Healthcare Associated Infections (HAIs) – infections that are not present or incubating at the time of
admission to the facility or program but are associated with admission to or a procedure performed in a
healthcare facility or program.
Surveillance – the comprehensive ongoing systematic collection, analysis and interpretation of outcome-
specific data for use in planning, implementing and evaluating healthcare practices closely integrated
with the timely dissemination of this data to those who need it
3.1 Surveillance activities identify risk factors for infection and other adverse events, implementation of
risk reduction strategies and monitor the effectiveness of the interventions.
3.2 HAIs are a major and continuing challenge in hospitals and residential care homes. It is estimated
that 220,000 infections are acquired in hospitals each year in Canada, resulting in 8,000 deaths.
3.3 It is estimated that between 30% and 50% of HAIs are preventable. Therefore, an infection
prevention and control program that is effective in preventing HAIs can substantially reduce
healthcare costs and, more importantly, the morbidity and mortality associated with HAIs. The
ultimate goal of surveillance is to have zero HAIs (while recognizing that not all HAIs are
preventable).
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0100 (Surveillance for Healthcare Associated Infections)
Page 2
3.4 The use of surveillance data does not only measure clinical outcomes such as infections, but also
guides performance improvement activities and demonstrates improvements in both clinical
outcomes and healthcare practices.
3.5 HAIs are expressed as a rate, (e.g.) the number of persons at risk over a particular period of time.
Three elements are required to generate these HAI rates:
the number of cases (i.e. persons developing a particular infection);
the number of persons at risk (i.e. population at risk for development of that infection);
the time period involved.
3.6 It is a recommended practice to adjust rates of HAIs for patient length of stay by using the number of
patient days as the denominator, rather than number of admissions or number of beds.
3.7 It is a recommended best practice to calculate rates of device associated infection that are adjusted
for duration of exposure to the device.
4.0 PROCEDURE
4.1 Surveillance for HAIs is an Interior Health wide program that is carried out by trained infection
prevention and control practitioners (ICP).
4.2 A computerized surveillance system is in place to track potential infection cases across the
continuum of care. In Acute Care settings, the system identifies potential infection cases based
on predetermined HAI case definitions.
4.3 In Residential and Community Care settings, ICPs collect data based on predetermined HAI case
definitions and enter the data into the computerized surveillance program.
4.4 Standardized electronic reports are generated on a regular basis and reviewed at site specific and
corporate Infection Control Committees. Analysis and interpretation of infection data may be
done with the facility’s Infection Prevention and Control Committee or other advisory body to the
Infection Control Team. Information is also disseminated to additional stakeholders with the
ability to change infection prevention and control practice.
5.0 REFERENCES
5.2 Best Practices for Surveillance of Healthcare Associated Infections in Patient and
Resident Populations. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario;
October 2011.
5.3 CDC/NHSN surveillance definition of health care–associated infection and criteria for specific
types of infections in the acute care setting; American Journal of Infection Control; 2008.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0200 (Definitions for Healthcare Associated Infections)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
Using standardized case definitions for Healthcare Associated Infections (HAI) provides opportunity
for generating surveillance data that can be compared to or pooled with other similar facilities and
settings using the same case definitions with the intent to improve patient outcomes.
2.0 DEFINITION
Case definitions for Acute Care – standardized definitions for each HAI based on the CDC/NHSN
(National Healthcare Safety Network) definitions and the Provincial Infection Control Network
(PICNet) of British Columbia definitions and allows for comparability of findings and benchmarking
with other similar hospitals.
Catheter
Case definitions for Residential Care – standardized definitions for each HAI that have been
developed based on The McGeer Criteria in addition to consensus opinions from infectious disease
physicians, epidemiologists, infection prevention and control professionals, geriatricians and public
health officials and is specifically aimed at persons living in Residential Care facilities.
3.1 To establish priorities for an HAI surveillance system, consideration must be taken for the
types of patients/residents that it serves, the key medical interventions and procedures that
they undergo and the types of infections for which they are most at risk for.
3.2 When defining HAIs, consider the frequency of the infection, the impact of the infection
(including case fatality and excess costs associated with the infection) and the preventability
of the infection. The outcomes selected for surveillance should be re-evaluated at least
annually.
3.4 In Acute Care when a particular infection meets a case definition, it should only be
considered health care associated if:
It was not present or incubating when the patient was admitted to the hospital;
The infection does not represent a complication or extension of an infectious process that
was present at admission;
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0200 (Definitions for Healthcare Associated Infections)
Page 2
The infection occurred more than 48 to 72 hours after admission, and within 10 days
following discharge or longer if it is related to a surgical procedure, a Clostridium difficile
infection or an antibiotic resistant organism.
4.0 PROCEDURE
4.1.1 Superficial Incisional Infection – occurs within 30 days of procedure and involves
only skin and subcutaneous tissue of incision.
Patient has at least 1 of the following:
1. Purulent drainage from superficial incision
2. Organisms isolated from aseptically-obtained culture of fluid or tissue from
superficial incision
3. Superficial incision that is deliberately opened by a surgeon and is culture-
positive or not cultured. (A culture negative finding does not meet criterion.)
AND Patient has at least 1 of the following S&S: - Pain or tenderness -
Localized swelling - redness – heat
4. Diagnosis of SSI by surgeon or attending MD
4.1.2 Deep Incisional Infection - occurs within 30 or 90 days of surgery and has implant if
after the 30 days and involves deep soft tissues of incision (i.e. fascial and muscle
layers)
Patient has at least 1 of the following:
1. Purulent drainage from deep incision
2. Deep incision that spontaneously dehisces or deliberately opened by
surgeon & is culture positive or not cultured. (A culture negative finding does
not meet criterion.) AND patient has at least 1 of the following S&S: - fever
(>38°C) - localized pain or tenderness
3. Abscess or other evidence of infection involving deep incision found on direct
exam, during invasive procedure, or by histopathologic exam or imaging test
4. Diagnosis of SSI by surgeon or attending MD
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0200 (Definitions for Healthcare Associated Infections)
Page 3
4.2.2 Criteria for New CDI associated with OTHER Healthcare Facility
1. Symptoms onset in community or occurring ≤ 72 hours after admission to
your facility AND
Pt was admitted to another healthcare facility (including acute/ LTC) for at
least overnight (or ≥24 hours) in past 4 weeks before current hospitalization
AND
Symptom onset was less than 4 weeks after discharge from that facility with
another facility
4.3.1 Criteria for Healthcare associated with current admission to Your Facility
1. Not previously positive for ARO AND
Identified > 48 hours after patient admitted to your facility Or Newborn
4.3.2 Criteria for Healthcare associated with previous encounter with Your
Facility
Not previously positive for ARO AND identified ≥48 hours after admission and meets
one criteria:
1. Admitted to your facility at least over night (≥24 hours) within the last 12
months OR
2. Indwelling catheters or medical device at time of admission, which was
inserted by your facility OR
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0200 (Definitions for Healthcare Associated Infections)
Page 4
Newborn: Less than 28 days considered case for Your Facility if the mother was not
known or suspected to be ARO positive on admission. In the case of a newborn
transferred from another facility and ARO identified ≤ 48 hours after admission the case
is classified as healthcare associated with Another Facility
4.4 Ventilator Associated Pneumonia (VAP) – includes the classifications of both Possible and
Probable VAPs
On a ventilator ≥ 3 days and > 14 days since last Ventilator Associated Condition (VAC)
(VAC - After a period of stability or improvement of 2 or more days, requires one of
the following: 1. Increase FIO2 of ≥ 20 points for ≥ 2 days
2. Increase in PEEP ≥ 3cm for ≥ 2 days)
Within window period (2 days before + 2 days after VAC date – 5 days total) meets
BOTH Criteria:
1. Has a temp>38 ̊ C or <36 ͦ C OR white blood cell count ≥12.0 x 10⁹/l or 4.0 x 10⁹/l
AND
2. A new antimicrobial agent(s) is started and continued for ≥ 4 days
AND
Within window period meets ONE of the following criteria:
1. Purulent respiratory secretions (1 or more specimens) defined as gram stain of
4+ WBC & 1 to 2+ epithelial cells
2. Positive culture of sputum endotracheal aspirate, BAL, lung tissue or protected
specimen brushing
AND
the organism is NOT excluded: “Normal respiratory flora,” “normal oral
flora,” mixed respiratory flora,” “mixed oral flora,” “altered oral flora” or
other commensal flora of the oral cavity or upper respiratory tract:
Candida species or yeast not otherwise specified; coagulase-negative
Staphylococcus species; and Enterococcus species, when isolated from
cultures of sputum, endotracheal aspirates, bronchoalveolar lavage, or
protected specimen brushings
OR
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0200 (Definitions for Healthcare Associated Infections)
Page 5
4.6 Lower Respiratory Tract Infection (LRI) / Pneumonia Definition in Residential Care
Review chart to rule out other conditions that could account for symptoms (CHF, COPD)
For an LRI:
Are there TWO or more Signs & Symptoms:
new or increased cough
new or increased sputum production
oxygen saturation < 94% or <3% from baseline
abnormal lung exam new or changed
pleuritic chest pain
respiratory rate > 25 breaths/min
AND
Is there 1 or more constitutional criteria: fever, leukocytosis, confusion or
functional decline?
For a Pneumonia:
Does the chest x-ray indicate pneumonia?
AND
Are there ONE or more Signs & Symptoms:
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0200 (Definitions for Healthcare Associated Infections)
Page 6
4.7 Skin & Soft Tissue Infection (SSTI) Definition in Residential Care
Criteria: Must have ONE of the following:
Pus present at a wound, skin, or soft tissue site OR
Are there FOUR or more signs and symptoms:
- serous drainage at site
- site swelling
- heat at site
- site tenderness or pain
- site redness
- one constitutional criteria : fever, leukocytosis, confusion, acute functional
decline?
Was the wound secondary to an injury?
5.0 REFERENCES
5.1. CDI Surveillance Protocol – Provincial Infection Control Network (PICNet) BC, June 2014.
5.2. MRSA Surveillance Protocol – Provincial Infection Control Network (PICNet) BC, June
2014.
5.3. CDC/NHSN surveillance definition of healthcare associated infection and criteria for
specific types of infections in the acute care setting; 2013.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0200 (Definitions for Healthcare Associated Infections)
Page 7
5.4. Stone, Nimalie D. et. al. Surveillance Definitions of Infections in Long-Term Care
Facilities; Revisiting the McGeer Criteria. Infection Control and Hospital Epidemiology,
Vol. 33, No. 10 (October 2012), pp. 965-977.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0300 (Surgical Site Infections -SSIs)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
To identify the potential risks associated with surgical procedures and Surgical Site Infections (SSIs)
and include this information in the risk stratification and data analysis of SSIs with the intent to
improve patient outcomes.
2.0 DEFINITIONS
SSIs – Surgical Site Infections occur as a complex interaction between the microbial contamination
of the surgical site, the host response, and the local environment at the site of contamination. An SSI
is generally considered to be present when purulent drainage is identified at the surgical site. SSI
rates are the percentage of surgical operative sites that are infected and are usually stratified based
on the Surgical Wound Classification.
Surgical Wound Classification – a system of categorizing surgical procedures into risk groups
based on the likelihood of contamination of the surgical site at the time of the operative procedure.
Each operative wound is assessed and categorized as per the classes noted below
and is to be done upon completion of the surgery in consultation with the surgeon.
If a change in wound classification occurs, the reason must be documented on the OR Case Record
(i.e. gross break in technique, glove perforation, etc.).
Clean-Contaminated Wounds (Class II) – an operative wound in which the respiratory, alimentary,
genital or urinary tracts are entered under controlled conditions and without unusual contamination.
A minor break in surgical sterile technique in an otherwise clean procedure would fit into this class.
Operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category,
provided no evidence of infection or major break in technique is encountered.
Contaminated Wounds (Class III) – carry a high risk (e.g. 10 to 15%) of infection often because
they involve unusual contamination from a non-sterile site. Examples include:
Open, fresh, accidental wounds less than 8 hours old from a relatively clean source
Gross spillage from the gastrointestinal tract
Incisions in which acute, non-purulent inflammation is encountered
Acute inflammation seen – without frank pus
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0300 (Surgical Site Infections -SSIs)
Page 2
The GU or biliary tracts are entered in the presence of infected bile or urine
Operations with major breaks in sterile technique
Examples of major breaks in sterile technique include: open cardiac massage, gross
spillage from the GI tract, use of unsterile instruments, drapes or supplies,
perspiration in the wound, unsterile foreign bodies in the wound, and insects in the
OR suite.
Dirty or Infected Wounds (Class IV) – Old traumatic wounds (over 12 hours) with retained
devitalized tissue or wounds where there is an existing clinical infection or perforated viscera or
fecal contamination.
Superficial Incisional Infection – occurs within 30 days of procedure and involves only skin and
subcutaneous tissue of incision.
Patient has at least 1 of the following:
1. Purulent drainage from superficial incision
2. Organisms isolated from aseptically-obtained culture of fluid or tissue from superficial
incision
3. Superficial incision that is deliberately opened by a surgeon and is culture-positive or not
cultured. (A culture negative finding does not meet criterion.) AND Patient has at least 1
of the following S&S: - pain or tenderness - localized swelling - redness - heat
4. Diagnosis of SSI by surgeon or attending MD
Deep Incisional Infection – [occurs within 30 or 90 days of surgery and has implant if after the 30
days] and involves deep soft tissues of incision (i.e. fascial and muscle layers)
Patient has at least 1 of the following:
1. Purulent drainage from deep incision
2. Deep incision that spontaneously dehisces or deliberately opened by surgeon & is culture
positive or not cultured. (A culture negative finding does not meet criterion.) AND Patient
has at least 1 of the following S&S: - fever (>38°C) - localized pain or tenderness
3. Abscess or other evidence of infection involving deep incision found on direct exam,
during invasive procedure, or by histopathologic exam or imaging test
4. Diagnosis of SSI by surgeon or attending MD
Organ/Space Surgical Site Infection – [occurs within 30 or 90 days of surgery and has
implant if after the 30 days] & involves any part of the body excluding the skin incision, fascia
or muscle layers, that is opened or manipulated during the operative procedure
Patient has at least 1 of the following:
1. Purulent drainage from drain that is placed into the organ/space
2. Organism isolated from an aseptically-obtained culture of fluid or tissue in the
organ/space
3. Abscess or other evidence of infection involving organ/space found on direct exam,
during invasive procedure, or by histopathologic exam or imaging test
4. Diagnosis of SSI by surgeon or attending MD
3.1 SSIs remain a substantial cause of morbidity and an associated mortality rate of 3% has
been attributed to them. Most SSIs are caused by the host’s own endogenous flora. The
Centres for Disease Control and Prevention (CDC) estimates that 2.7% of surgical
procedures are complicated by SSIs which translates into an extra hospital stay of
approximately 6.5 days for each SSI.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0300 (Surgical Site Infections -SSIs)
Page 3
4.0 PROCEDURE
5.0 REFERENCES
5.1 CDC/NHSN surveillance definition of healthcare associated infection and criteria for
specific types of infections in the acute care setting; 2013.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0400 (Gastrointestinal Outbreak Guidelines)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
This guideline has been developed in collaboration with the Communicable Disease (CD) Unit and
provides guidance for healthcare facilities when a Gastrointestinal Outbreak is suspected.
To link to the Communicable Disease Gastrointestinal Infection Outbreak in Health Care Facilities
Toolkit
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0500 (Respiratory Infection (RI) Outbreak Guidelines)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
This guideline has been developed in collaboration with the Communicable Disease (CD) Unit and
provides guidance for healthcare facilities when a Respiratory Infection Outbreak is suspected.
To link to the Communicable Disease Respiratory Outbreaks in Residential Care Settings Toolkit.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0600 (Communicable Diseases in Employees)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
To provide guidance in the prevention and management of healthcare provider exposures to and
infections with infectious diseases in the work place.
2.0 DEFINITIONS
Exposure – may occur when a healthcare provider is in direct or indirect contact with patient or co-
worker who has a known or suspected infection with a communicable disease. This contact may
occur through, but is not limited to, needle-stick, injuries, splashes, airborne droplets, contact with
nasal or throat secretions or close contact during examinations/treatment.
Healthcare Provider – includes Interior Health staff, physicians, students, volunteers, and all
persons who work within the Interior Health facilities.
Risk Assessment – healthcare providers are at risk of exposure to communicable diseases because
of their contact with patients or material from patients with infections both diagnosed and
undiagnosed. Use of immunization agents assists in protecting patients and healthcare providers
from becoming infected.
3.0 GUIDING PRINCIPLES – Refer to AV0900 – Prevention and Management of Occupational Exposure
to Communicable Diseases:
AV0900 – Prevention and Management of Occupational Exposure to Communicable Diseases
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0600 (Communicable Diseases in Employees)
Page 2
PROCEDURE
Neisseria meningitidis No restriction or treatment for carrier state required; for acute meningococcal
(meningococcus) disease, including meningitis, employees would be too ill to work.
Amebiasis, Salmonella,
Campylobacter, Shigella,
Food handlers are restricted. In other healthcare providers, evaluation by
Cholera,
Employee Health is necessary.
Worms/Parasites
Hepatitis A
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0600 (Communicable Diseases in Employees)
Page 3
Employees must be evaluated by Employee Health or their private physician regarding their work area
if they have certain signs or symptoms of the following conditions:
Draining abscesses, boils
Exudative dermatitis
Herpes simplex (whitlow, stomatitis)
See Workplace Health & Safety
Uncontrolled respiratory symptoms/infections
Impetigo
Conjunctivitis
Exposure of susceptible employees to specific communicable diseases may require restriction from
work during the incubation period, for example:
Chickenpox, Varicella Incubation period is 10-21 days after exposure; restriction would be
from day 8 after first exposure thru day 21 after last exposure (up to
28 days if given VZIG varicella zoster immune globulin) or, if
disease develops, until the last crop of vesicles is dried and
crusted.
Measles, Rubeola Incubation period is 7-18 days; restriction would be, as per BCCDC
Communicable Disease Manual update March 2010, from day 5
after first exposure to day 21 after last exposure; if disease
develops, until 4 days after onset of rash. Live vaccine given to
susceptibles within 72 hours of exposure may prevent illness.
Infection Control Practitioner will complete the Communicable Disease Notification Tool
and forward it to the CD Unit and IH Occupational Health.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 09V - IV0600 (Communicable Diseases in Employees)
Page 4
5.0 REFERENCES
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - IX0100 (Microbiology Specimen Collection)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
1.0 PURPOSE
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - IX0200 (Prevention & Control of Catheter Associated Urinary Tract
Infections -CAUTI)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
1.0 PURPOSE
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX0300 (Pneumococcal Vaccine for Residential Care)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE:
All persons being admitted to an Extended or Intermediate Care Facility are to be assessed for their
status of having received a pneumococcal vaccine in the past and this information will be recorded on
the resident’s chart. If they have not had a pneumococcal vaccine, they will be offered the vaccine
upon admission to the facility and this information will be recorded on the resident’s chart.
2.1 Streptococcus pneumoniae (pneumococcus) can cause serious invasive disease including
bacteremia, meningitis and pneumonia in people with high-risk medical conditions and the
elderly. Pneumococcal infection is spread by droplet/contact from one person to another by
coughing, sneezing, close face-to-face contact and direct contact through saliva.
2.2 The pneumococcal polysaccharide vaccine is offered free to seniors 65 years and older and
to persons 2 years of age and older with certain medical conditions including those who have
no spleen or a spleen that is not functioning properly*, sickle-cell disease*, immune systems
weakened by disease or medical treatment*, chronic liver disease including cirrhosis*,
chronic hepatitis B or hepatitis C*, chronic kidney disease*, chronic heart or lung disease,
transplant patients, diabetes, cystic fibrosis, chronic cerebrospinal fluid leak, cochlear implant
candidate or recipient, alcohol dependency, homelessness and/or illicit drug use.* People in
these groups should receive a second dose of vaccine five years after the first dose and this
requires a physician order.
2.3 Residents of any age living in residential care are considered an at risk population for
suffering complications from pneumococcal disease and should receive the vaccine upon
admission to the facility if they have not already had the vaccine previously.
2.4 Contraindications for the vaccine include anaphylaxis reaction to the vaccine or component of
the vaccine in the past. Possible reactions to the vaccine may include soreness, redness and
swelling at the site of injection. Headache and mild fever may also occur. These reactions
are mild and generally last 1 to 2 days.
3.0 PROCEDURE
3.1 All Residential Care facilities should have pre-printed physician orders for “pneumococcal
vaccine on admission if resident has not been immunized in the past”. Upon admission, staff
is to seek out and document information about the resident’s pneumococcal immunization
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX0300 (Pneumococcal Vaccine for Residential Care)
Page 2
status by asking the resident and/or family, the resident’s physician (contact office) and/or the
Public Health office. Document information according to facility guidelines.
3.2 Residents who do not have a record of pneumococcal immunization with Public Health or
their family physician require immunization by the facility – this should be done within two
weeks of admission.
3.3 Do not delay immunization if proof of prior immunization is not available within this
two week time frame - when in doubt, with no documented proof: IMMUNIZE.
3.4 It is recommended that facilities carry out yearly audits to ensure the procedure for
administering and documenting pneumococcal vaccination in Residential Care Facilities is
being implemented appropriately with the target being at least a 90% vaccination coverage
compliance rate.
4.0 REFERENCE
4.1 Public Health Agency of Canada. Seventh Edition Canadian Immunization Guide 2006.
4.2 BC Centre for Disease Control. Communicable Disease Control Immunization Program,
Section VII – Biological Products, January 2010.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - IX0400 (Pet Therapy and Visitation)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
1.0 PURPOSE
The purpose of a pet therapy & visitation program is to provide patients with the positive aspects of
stimulation, motivation and cooperation that human/animal interaction can offer in the hospital
environment. This form of therapy is used successfully with people in many healthcare settings and
literature supports the position that pet therapy increases cooperation with medical treatment and
feelings of well-being while decreasing the stress of illness and hospitalization. Our target audience
includes all eligible (as defined in this guideline) patients, with an emphasis on those patients who
experience long-term hospitalization, and/or demonstrate a need for unconditional love, positive
motivation and socialization while involved in their hospital experience.
To allow visitation of appropriately screened therapy dogs and their screened and trained handlers to
eligible patients. This guideline will cover residential pets, service, guide animals and patient owned
pets as well.
2.0 DEFINITIONS
Guide dog - this term shall refer to a dog which is in working harness and is certified to guide blind or
hearing impaired persons by an accredited canine school that is engaged in this specific type of
training.
Service dog - this shall mean a dog that is certified to assist disabled people by an accredited canine
school that is engaged in this specific type of training.
Therapy dog - this shall refer to animals that are brought by specially trained professionals, para-
professionals, and/or volunteers to provide opportunities for motivational, educational, recreational,
and/or therapeutic benefits to enhance quality of life.
Pet animal - this shall refer to any animal which belongs to a patient and whose presence in the
hospital is requested by the patient and his physician.
3.1 Visitation of any animals to critical care areas, rooms where Additional Precautions are being
implemented, medication or clean supply rooms, food storage or preparation areas, and
dining rooms is prohibited.
3.2 Service/guide animals care and health is the responsibility of their owners. They will be given
access to all areas in the facility except those noted in 3.1 above.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - IX0400 (Pet Therapy and Visitation)
Page 2
3.3 Rodents, reptiles, and other exotic pets are prohibited without special permission of Infection
Control.
3.4 All pet therapy/residential animals will have an approved handler who will be responsible for
their health and well being as well as ensuring that they are in compliance with this guideline
3.5 Handlers will perform hand hygiene after all visitations. The handler will assist the patient in
performing hand hygiene prior to leaving the room.
3.7 Appropriately Screened Dogs for the pet therapy or residential program will:
Be a minimum of one (1) year old.
Complete the required dog history.
Require that every animal receives a health evaluation by a licensed veterinarian at least
once per year and ensure that vaccinations are current, e.g.:
o Distemper.
o Hepatitis.
o Parainfluenza.
o Parvovirus.
o Rabies.
Defer to the animal’s veterinarian regarding an appropriate flea, tick and enteric parasite
control program which should be designed to take into the account the risks of the animal
acquiring these parasites specific to its geographic location and living conditions.
For the protection of both the animal and people, prevent the animal from entering the
Healthcare Facility from the onset of and until at least 1 week beyond the resolution of:
o Episodes of vomiting or diarrhea.
o Urinary or fecal incontinence.
o Episodes of sneezing or coughing of unknown or suspected infectious origin.
o Treatment with non-topical antimicrobials or with any immunosuppressive doses
of medications.
o Open wounds.
o Ear infections.
o Skin infections or ‘hot spots’ (i.e. acute moist dermatitis).
o Orthopedic or other conditions that, in the opinion of the animal’s veterinarian,
could result in pain or distress to the animal during handling and/or when
maneuvering within the facility
3.8 Dogs that do not meet screening requirements (regarding consequences for handlers not
following the above guidelines, policies or dogs that test positive for lab results):
The documents supporting these actions will be kept on file with the hospital volunteer
coordinator and must be kept up to date. Those in non-compliance with the timely testing
of their dogs will be immediately suspended from the program.
Dogs who test positive in the throat and/or fecal cultures will be immediately suspended
from the program.
One positive Salmonella culture will permanently retire a dog from the program.
A total of three positive cultures over any period of time, for any of the above stated
pathogens or parasites, will permanently retire a dog from the program.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - IX0400 (Pet Therapy and Visitation)
Page 3
If a dog has been removed from scheduling due to a positive test that dog will not be
scheduled again until the following criteria have been met and documented:
o For treated parasite or pathogen, a first retest will be performed no sooner than
seven (7) days following completion of the prescribed treatment. After two
consecutive negative retests (30 days apart), the dog will be able to resume
visits.
Appropriately Screened Cats/Birds for the pet therapy or residential program will:
o Be full grown animals and not juveniles.
o Complete the required history.
o Receive a yearly exam and certificate of good health with all appropriate
vaccinations.
o Have passed a standard temperament test.
o Be groomed (bathed, nails trimmed) within 24 hours prior to visitation.
o Not be in estrus (heat) when participating in therapy work.
4.0 PROCEDURE
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - IX0400 (Pet Therapy and Visitation)
Page 4
(All used materials will be put in the plastic bag which will be disposed of in
an appropriate waste container.)
If an animal should develop symptoms of any illness following a hospital visit, the handler
will immediately notify the Infection Control Department.
5.0 REFERENCE
5.1 Sandra L. Lefebvre, et al. Guidelines for animals – assisted interventions in health care
facilities. AJIC American Journal of Infection Control 2008; 36:2 pp 78-85.
5.2 Routine Practices and Additional Precautions for Preventing the Transmission of Infection in
Health Care Settings; Public Health Agency of Canada; 2013, P.32.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – I X0500 (Soiled Utility Rooms)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
1.0 PURPOSE
To minimize the risk of infection transmission in clinical areas that generate soiled equipment, soiled
linen and waste.
2.3. Items that should not be kept in a Soiled Utility room include:
Kleenex boxes.
Skin antiseptics/cleansers.
Personal hygiene supplies (soaps, mouth care products, lotions).
Sterile items such as wound dressings.
3.0 REFERENCES
3.1. Best Practice for Environmental Cleaning for Prevention and Control of Infections in All
Healthcare Settings; Provincial Infectious Disease Advisory Committee (PIDAC), Ontario,
May 2012.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - IX0600 (Equipment Cleaning)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE:
2.0 DEFINITION
3.2 Shared equipment must be cleaned and disinfected between patient uses.
3.4 Disinfectant wipes should be used for point of care cleaning and disinfection of patient
equipment; wipes must be kept wet and discarded if they become dry.
3.5 Never reuse single use equipment that is not appropriate to dedicate to single patient use
(i.e. critical equipment) – discard immediately after use.
3.8 Do NOT stockpile supplies and equipment in patient room – clutter increases the risk of cross
contamination in patient care areas (including hallways).
3.9 Personal care items (i.e. lotions, skin cleansers, razors) are single patient use and not to be
shared between patients.
3.11 Foot care equipment must be sterilized between patient use – if the equipment is assigned as
single patient use, it can be low level disinfected between use on that same patient.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 2
4.0 PROCEDURE
4.1 Wear appropriate personal protective equipment (PPE) for the task.
4.3 Wipe equipment thoroughly – if cloth/wipe comes away dirty, repeat until it comes away
clean.
4.5 Designate a location for clean equipment (ideally, clean storage rooms or clean service
rooms) where they are transported after cleaning.
Implement a process where the item is identified as clean, disinfected and ready for
use on another patient.
4.9 Toys
REFER TO IX0700 TOY M ANAGEMENT
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 3
Establish a schedule for regular cleaning of “blue ware” (i.e. wash basins, denture
cups).
4.13 Appendix C – information on hydrotherapy tubs and use of public pools for therapeutic
interventions.
5.0 REFERENCES
5.1 Best Practices for Cleaning, Disinfection and Sterilization in all Health Care Settings.
Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; February, 2010.
5.2 Hand Washing, Cleaning, Disinfection and Sterilization in Health Care. Health Canada -
Canada Communicable Disease Report. 1998; 24 Supplement 8: i-xi, 1-55.
5.3 Infection Control Guideline for the Prevention of Healthcare Associated Pneumonia.
Public Health Agency of Canada; 2010.
5.4 Infection Prevention and Control Manual. Capital Health. Cleaning and disinfection of
non-critical patient care equipment. Policy IC 08-001; July 2012.
5.5 Montana State Hospital. Policy and Procedure Manual. Cleaning of non-critical, reusable
patient care equipment. Policy IC-19; March 2010.
5.6 Saskatoon Health Region. Infection Prevention and Control Manual. Non-critical Patient
Care Equipment – Cleaning and Disinfection. Policy 20-80; October 2006.
5.7 Seven Oaks General Hospital. Policy and Procedure Manual. Cleaning of non-critical,
reusable patient care equipment. Policy Code: 7311-07-01; December 2007.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 4
APPENDIX A
Antiseptic
An antimicrobial chemical designed for use on the skin or mucous membranes that inhibits the growth
and reproduction of microorganisms (i.e.) alcohol based hand rub (ABHR) for hand hygiene.
Bioburden
The number and types of viable microorganisms that contaminate the equipment/device.
Cleaning
The physical removal of dirt, dust or foreign material. Cleaning usually involves soap and water,
detergents or enzymatic cleaners. Thorough cleaning is required before disinfection or sterilization
may take place.
Disinfectant
A product that is used on medical equipment/devices, which results in disinfection of the
equipment/device. Disinfectants are applied only to inanimate objects. Some products combine a
cleaner with a disinfectant.
Reprocessing
The steps performed to prepare used medical equipment/devices for re-use (e.g., cleaning,
disinfection, and sterilization).
Sterilization
The complete elimination or destruction of all forms of microbial life. Accomplished by either physical
or chemical processes.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 5
APPENDIX B
Recommended Minimum Cleaning and Disinfection Level and Frequency for Non-
critical Client/Patient/Resident Care Equipment and Environmental Items
The following chart relates to non-critical patient care equipment only, i.e.,
equipment that comes into contact with intact skin.
This chart also includes environmental surfaces and items that do not come
into contact with skin.
CL = Physical removal of visible soil dust or foreign material (may use soap and
water, detergent or hospital grade disinfectant with detergent properties)
LLD = Soak item in or wipe surfaces with hospital grade disinfectant (wipe or
cloth dampened with disinfectant), allow disinfectant to dry prior to reuse to
allow item “contact time” for disinfection to occur
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 6
Bed
Bedrail and extender LLD ▪ daily
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 7
between patients
Blood Pressure Cuff LLD ideally stays with patient
when soiled until discharge
Cast cutting
Blades CL or ▪ when soiled ▪ send for sterilization if
contact with blood or body
disposable
fluids
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 8
Clippers (handle)
Surgical LLD ▪ between patients ▪ disposable heads
Commode Chairs
Single patient use LLD ▪ when soiled ▪ ideally dedicated to each
patient
▪ patients with VRE or
C.difficile must have
dedicated commode
▪ for C.difficile, consider
cleaning with a sporicidal
agent
▪ remove gross soil and
fluids before cleaning and
disinfection
Multiple patient use LLD ▪ when soiled ▪ remove gross soil and
fluids before cleaning and
▪ between patients
disinfection
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 9
Portable - portable grid/ LLD ▪ between patients if not ▪ ideally should be covered
covered (e.g., pillowcase)
film cassette
ECG
between patients
Machine and Cables LLD
Electric Razor
Razor body and Handle LLD ▪ as required ▪ must be single patient use
Electronic Devices
Single patient use LLD ▪ when soiled ▪ ideally dedicated to each
patient
(e.g. Bedside monitors) ▪ between patients
▪ patients with VRE or
C.difficile should have
device cleaned daily
regardless of soilage
▪ for C.difficile, consider
cleaning with a sporicidal
agent
▪ remove gross soil and
fluids before cleaning and
disinfection
▪ consult manufacturers
instructions for screen
cleaning
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 10
Multiple patient use/ LLD ▪ when soiled ▪ remove gross soil and
fluids before cleaning and
Personal Devices used in ▪ between patients
disinfection
patient areas (i.e.
Tablets) ▪ consult manufacturers
instructions for screen
cleaning
▪ cleanable covers are
highly recommended for
difficult to clean
components
Glucometer LLD ▪ after each use
Hydraulic Lift
Machine LLD ▪ as required
Sling Launder ▪ between patients and ▪ dedicated to patient if
when soiled possible
▪ launder if visibly soiled
Hydrocollator ▪ drain and thoroughly clean
Interior LLD ▪ every week ▪ allow 10 mins contact time
with disinfectant for
interior surfaces then
rinse well prior to refilling
with water
▪ allow fresh water to reach
appropriate temp prior to
re-immersing packs
▪ regular temperature
monitoring required as per
manufacturers
recommendations
Exterior LLD ▪ every week
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 11
between patients
Intravenous (IV) LLD
when soiled
Pumps, Poles, Warmers
weekly
Isolette LLD
when soiled
Laryngoscope
Handle LLD between patients
Measuring Container
(urine)
CL ▪ after each use
Single patient use
Multiple patient use LLD ▪ after each use ▪ one container per patient,
labelled with name
Otoscope
Handle LLD between patients
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 12
between patients
Otoacoustic Emission Disposable or HLD
(OAE) screening tips
Oxygen Delivery
Systems dedicated to patient
Disposable:CL
Masks daily
discard when damaged or
when soiled
heavily soiled
rinse all disinfectants from
surface before reuse with
same patient
dry completely before
reuse with same patient
dedicated to patient
daily
Disposable:CL discard when damaged or
NP/tubing when soiled heavily soiled
(externally only)
handle condensate
carefully – remove from
tubing, do not drain back
towards patient
Nebulizers after use dedicated to patient
Disposable:CL
discard when damaged or
heavily soiled
rinse after cleaning using
sterile water
dry completely before
reuse with same patient
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 13
OT assessment Areas CL
(e.g. kitchen/bathroom) ▪ after use
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 14
Scales
daily and when soiled
Adult LLD
after each use
Diaper LLD
Table
when soiled
Bedside LLD
between patients
Over bed daily
Telephone
daily
Bedside/Nursing Station LLD
when soiled
between patients
daily
when soiled
Portable LLD
between patients
Telemetry Equipment
Monitor and Cables LLD between patients
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 15
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 16
This document /excerpt was adapted with permission from the Ontario Agency for Health Protection
and Promotion (Public Health Ontario)/Provincial Infectious Diseases Advisory Committee (PIDAC).
PIDAC documents contain information that requires knowledgeable interpretation and is intended
primarily for use by health care workers and facilities/organizations providing health care including
pharmacies, hospitals, long-term care facilities, community-based health care service providers and
pre-hospital emergency services in non-pandemic settings. Public Health Ontario assumes no
responsibility for the content of any publication resulting from changes /adaptation of PIDAC
documents by third parties.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 17
APPENDIX C
Recommendations for Hydrotherapy are required to prevent infections to pool participants and staff, as
well as to prevent contamination of the pool.
1. Contraindications: According to the BC Swimming Pool, Spray Pool and Wading Pools
Regulations, it is contraindicated for residents, staff, community clients or their attendants to
enter the pool with the following:
Open areas of the skin (unless covered by a waterproof bandage).
Fungal infections (i.e. Athlete’s foot, fungal infections of the groin).
Unmanaged fecal incontinence.
Fever, diarrhea or vomiting.
Any other identified infections may be a contraindication. Appropriateness of swim
session for these cases will be at the discretion of the nurse, physiotherapist, doctor,
health care assistant, in consultation with the lifeguard.
2. Hand Hygiene: Hand hygiene is the single most effective measure available to prevent
infections. Hand hygiene should be done:
Before and after direct care with a client.
Before and after working with gloved hands.
Before and after working with open areas/dressings, urinary equipment, ostomy
equipment or body fluids.
Between working with different clients.
3. Urinary Incontinence:
The bladder must be emptied before entering the pool.
4. Fecal Incontinence:
Swimmers with fecal incontinence are requested to arrange their pool time around
their bowel habits.
Swimmers are requested to have a bowel movement prior to bathing.
Swimmers should wear properly fitting waterproof pants/incontinence product.
5. Ostomy Appliances:
Must be firmly secured and able to withstand pool related activities (temperature,
moisture, body movements and exercises).
It is the responsibility of the client, or the client’s attendant, to ensure that the bag is
secured to the body and free from seepage.
Ostomy bags must be clean before entering the pool.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 18
Non waterproof bandages, tape, dressings, etc… must be removed before entering
the pool. Rationale: These items, if dislodged, become trapped in the pool filter
system resulting in mechanical breakdown. Also, if an open area is covered by an
inadequate dressing, the pool will potentially be contaminated.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 19
Pool users are required to adhere to the following practices when using the pool:
1. All pool users are required to wash their hands upon arrival and before leaving the pool facility.
An antiseptic hand sanitizer solution is an option, if the hands are not visibly soiled.
2. All pool users are required to place a clean towel or other adequate barrier on the change bench
to sit on as well as place their clothing on while changing.
3. All clothing and personal belongings are to be stored neatly away in either the lockers or
underneath the benches after changing and while using the pool.
4. All pool users are required to take a cleansing shower using warm water and soap before
entering the pool.
5. No person shall enter the pool whom:
Is obviously ill.
Has an open wound that has not been appropriately covered.
Has sore or infected eyes.
Has a discharge from the ears or nose.
6. Disinfecting wipes should be supplied in each change room and should be used to wipe benches
between each use. Clients and staff are encouraged to use these wipes before and after using
the benches. The wiped surface is left to air dry for effective disinfecting.
7. Disinfecting wipes are also used to wipe the grab bars and lifts after each use.
8. Disinfecting wipes are used to wipe the sling back and lift after each use. Lift slings should be
washed after each use.
9. Change rooms should be cleaned and sanitized thoroughly once daily, or more often, as needed.
10. The pool deck should be cleaned and sanitized thoroughly once daily, or more often, as needed.
11. Wheelchairs that have been contaminated with body fluids are cleaned in the following manner:
excess contaminant is absorbed with paper towel. The chair is then rinsed under a shower with a
continuous flow of clean water. Disinfectant is then sprayed on the item and left for a minimum of
10 minutes (or per manufacturer instructions). The chair is then rinsed under clean water again,
before storing it its regular location.
12. Head floats that have been contaminated with feces or blood will be thrown out. Other body
fluids contaminating the head floats can be either wiped with a hospital approved disinfectant or
washed in the washer.
13. Body fluid spills, (outside the pool basin) are first soaked up using paper towel. Dispose of the
paper towel in the garbage. A hospital approved disinfectant is then used to wipe the area, which
is left to air dry. A mop can be used for large spills after the paper towels have absorbed as
much of the spill as possible. Mop head must be washed and disinfected before reuse on
another surface.
14. Vomit in the pool may create a higher risk for infection.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 20
1. Staff are expected to follow the same infection control guidelines set out for community clients.
These include washing hands upon arriving at work, protecting open wound with waterproof
dressings, putting a towel down on any bench you use to change on, ensuring your belongings are
tucked away while working and having a cleansing shower before and after using the pool.
2. Staff are also expected to ensure a clean environment by doing the following:
Remind community clients to wash their hands upon arrival.
Remind community clients to take a cleansing shower before entering the pool.
Remind community clients to place their towel down upon the bench to sit on while changing.
Wipe the benches in the change room with a hospital approved disinfectant as often as time
permits, preferably between each client.
3. Staff are expected to wear appropriate footwear around the pool following the footwear guidelines for
pool staff.
4. Staff should encourage clients to wear appropriate footwear around the pool facility.
5. Do not allow any open wounds that are not appropriately covered in the pool.
Information from the Center for Disease Control (Atlanta, Georgia) addresses fecal accidents in pools. In
recent times, there have been increasing concerns about the transmission of Cryptosporidium parvum in
swimming pools. While this parasite can cause self-limited diarrhea in healthy people, the diarrhea can be
much more significant in those with severe immunosuppresion. The infecting dose of Cryptosporidia is quite
small, and even a small visible fecal spill of liquid can contaminate an entire pool. Most bacteria are very
susceptible to low concentration of free chlorine, however, Cryptosporidia are not. Chlorine (2ppm) kills
Escherichia coli in less than 1 minute, while Cryptosporidia may require as long as 8 hours.
Although Cryptosporidia may be found in the stool of people who have persistent diarrhea and nausea,
investigators from the CDC have demonstrated Cryptosporidia are not carried as normal human enteric flora,
and is not found in formed stool.
In order to address the potential hazards of Cryptosporidia parvum, pool protocols have been designed to
combat this organism. This has lead to the recommendation of raising chlorine concentrations for up to 8
hours, and to maintain the pool unused for 3-4 filtration cycles for 24 hours.
The consequences of these policies have been significant on pools used for rehabilitation patients. Many
individuals may have incompetent sphincter control, resulting in minor incontinence without diarrhea or being
unwell. Small accidents, which have been totally contained within the bathing suit, are a relatively common
occurrence. Unfortunately, these occurrences have been sufficient to trigger pool-closure responses, which
last 24 hours. The consequence is that pools may be closed as often as they are open. This results in
severe restrictions, inconvenience, and loss of valuable therapeutic pool time for many individuals.
To address pools potential contaminated with feces or vomit, please refer to the “Fouled Pool Remedial
Procedure”.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - 1X0600 (Equipment Cleaning)
Page 21
REFERENCES
BC Health Act, “SWIMMING POOL, SPRAY POOL AND WADING POOL REGULATIONS”, B.C. Reg.
289/72,O.C. 4190/72 Responding to fecal accidents in disinfected swimming venues. CDC MMWR weekly.
May 25, 2001. 50(20); 416-417.
Provincial Infection Control Network of British Columbia. Appendix 7: Pools. PICNet Antibiotic Resistant
Organism Provincial Guidelines. Draft Two. April 18, 2008.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - IX0700 (Toy Management)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE:
To prevent transmission of infections by contact routes, toys used in any department, inpatient unit or
practice for therapeutic, diagnostic or entertainment purposes will be cleaned/disinfected on a routine
basis and when visibly soiled .Recognizing the importance of play and education to a hospitalized
child and realizing the potential of spread of infection with shared toys, hands and person-to-person
contact, the following guidelines are recommended.
2.1. Only toys that can be easily cleaned (plastic or non-porous) are provided.
2.2. Stuffed toys are not permitted. If a child must have a stuffed toy, it must be labeled with the
child’s name, used only by that child and sent home or discarded at discharge.
2.4. No special precautions are needed for magazines or books, unless visibly soiled. Items that
cannot be cleaned with hospital-approved disinfectant or soap and water should be
discarded.
2.5. Rooms with children on Additional Precautions will remain there throughout hospitalization.
When the patient is discharged, toys should be disinfected with hospital-approved
disinfectant before return to a central storage area.
2.6. Stuffed toys in common areas such as halls, waiting rooms, family rooms that are used to
enhance the décor are not permitted.
2.7. Communal toys including large wheel toys are cleaned weekly and when visibly soiled.
2.8. Toys used for testing will be cleaned after each use.
3.0 PROCEDURE
3.1. Use regular soap and water for cleaning visible dirt/soil.
Wash toys with soap using friction.
Rinse with water and dry.
3.2. Hospital approved disinfectant for cleaning toys that are mouthed or contaminated and those
used with children on Additional Precautions.
Wipe toys with disinfectant.
Allow 10 minutes contact time.
Rinse with water and dry.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X - IX0700 (Toy Management)
Page 2
4.0 REFERENCES:
4.1. Guidelines for Isolation Precautions in Hospitals, Hospital Infections Program, Center for
Infectious Diseases, Center for Disease Control, U.S. Department of Health and Human
Services, Atlanta, Georgia, 1996.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX0800 (Personal Care Supplies Best Practice Guidelines)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on
IHNET at the Policies & Procedures Home Page
1.0 PURPOSE:
To ensure that personal care supplies are not shared and are kept clean and prevent transmission of
microorganisms to other patients and healthcare providers.
2.0 DEFINITION
Personal care supplies include items used for bathing, skin care, nail care, oral hygiene, denture
care, dressing care and incontinence care.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX0800 (Personal Care Best Practice Guidelines)
Page 2
3.3 Foot care clinics or contractors coming into Interior Health facilities
Shared foot care equipment must be sterilized between residents/clients. This includes
clippers, files, and scissors.
4.0 PROCEDURE
4.1 Labeling
Each patient’s personal supplies should be identified with his/her name and kept at
his/her bedside in a clean container (e.g. in a washable cosmetic bag or plastic
container). Toothbrush and oral hygiene products should be kept in a separate bag or
container at the bedside.
Patient’s personal care items must be sent with the patient when discharged.
Soaps:
Bar soap must be kept in a clean, dry soap dish that allows the bar to drain between
uses.
Personal liquid body soap is preferred because it is more easily stored between uses.
Wound/Skin Cleansers:
Wound and skin cleansers must not be shared. Each patient should have a personal
cleanser labeled with the patient name.
Each resident should have a personal incontinence care cleanser labeled with their
name.
Creams:
Use a tongue depressor to dispense cream from jar to avoid contaminating the cream.
Toothbrush:
Change every three months and after an illness. Keep in a plastic toothbrush container.
Ensure it is stored protected from toilet aerosols.
Denture box:
Label with patient name. Rinse and dry daily.
Hair Rollers:
Wash in hot soapy water between residents.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX0800 (Personal Care Best Practice Guidelines)
Page 3
Razors:
Clean electric razors after each use with a personal razor brush. Don’t share.
Personal disposable razors can be used and must be disposed of in designated waste
receptacles.
Bedpans:
Clean and disinfect after each use. Never place on the floor.
Disposable bedpans are acceptable.
5.0 REFERENCE:
5.1 Infection Prevention and Control Best Practices For Long Term Care and Community Care
Including Health Care Offices and Ambulatory Clinics. June 2007 Sponsored by Canadian
Committee on Antibiotic Resistance.
5.2 Routine Practices and Additional Precautions for Preventing the Transmission of Infection in
Health Care Settings; Public Health Agency of Canada; 2013.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX0900 (Construction Projects)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
REVIEWED DATE:
1.0 PURPOSE
Construction projects, in particular renovation projects, pose potential health risks for patients,
staff, visitors and construction personnel that may lead to healthcare associated infections.
These risks most commonly develop when dust particles contaminated with bacteria and/or fungi
are dispersed into adjacent patient care areas. The primary fungus associated with these
infections is Aspergillus while the main bacterium is Legionella.
Note
CSA Z317.13-12 Dec 2012 shall be used to determine population risk group,
construction activity type, and preventative measures.
Prevention Measures will be outlined in the construction documentation prior to
the construction project starting and prior to the project going to tender.
Class of Preventative Measure Level I and II will be determined by the Plant
Services staff in the facilities. If Plant Services staff has questions pertaining to
the stratification of the risk groups, the Infection Prevention and Control
Practitioner will be contacted.
Infection Prevention and Control Practitioners will be involved in all discussions
involving the Class of Preventative Measure Level III and IV and the ICP will sign
off the Infection Control Construction permit.
The Infection Control Practitioner must be given a minimum of 48 hours
.
notice by anyone requesting a permit before the scope of work can be
assessed and a permit issued.
The IX1000 Construction and Renovation Guidelines are the specifications that are provided
to the consultants in the tender package. This document will be included in the Request for
Proposal as well as the “front end” document that Facilities Management provides to the
consultants when preparing tenders.
All new projects or renovations shall ensure that appropriate infrastructure is in place to support
the IH hand hygiene program and will follow the CSA Z8000-11 standards.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX0900 (Construction Projects)
Page 2
2.0 References
2.1 CSA Standard: Canadian health care facilities. CSA Z8000-11 September 2011.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX1000 (Construction & Renovation Guidelines)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
2.0 GUIDELINE
Assessment of the risks to occupants of the health care facility is necessary before
construction or renovations begin. The Planning Department and Engineering or
operations and maintenance will keep the Infection Control Service informed regarding
the location of all areas of renovation and construction as soon as possible, during the
planning stages.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX1000 (Construction & Renovation Guidelines)
Page 2
2.2. Approval
The Infection Control /Construction Form will be used by the Infection Control
Practitioner, or designated person, when assessing projects. All construction and
renovation shall utilize CSA Z317.13-12 to determine risk group, construction activity
type, and preventative measures( Appendix 1-3).
The Infection Control Service must review all planned projects falling under the category
of Class of Preventative Measure Level III and IV. All construction workers must follow
the infection control procedures described in this guideline.
Engineering or operations and maintenance and/or the Planning Department in
collaboration with the Infection Control Service will determine the Class of Construction
Activity for each project.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX1000 (Construction & Renovation Guidelines)
Page 3
For preventative measures III and IV (includes new construction projects, construction on
vacant land, facility additions, and space redevelopment) the following shall apply:
Prior to construction the constructor shall present an infection control plan to the
multidisciplinary team including selection, design, application, specification, and
assembly of construction materials to be used in the project.
Constructor proposed infection prevention and control measures must encompass
the duration of the project and ongoing maintenance and operations.
The multidisciplinary team shall communicate its policies and procedures to the
constructor before construction begins.
The constructor should designate an individual responsible for infection control to
liaise with the multidisciplinary team and monitor and coordinate the infection
control procedures. The multidisciplinary team should designate a representative to
communicate with the constructor and attend construction meetings as necessary.
On approval of the infection control plan by the multidisciplinary team, the
constructor should coordinate infection control education sessions for all suppliers
and subcontractors participating in the project. A copy of the infection control plan
shall be provided to all subcontractors and compliance will be imposed in all
subcontracts.
Infection Prevention and Control Practitioners will be involved in all discussions
involving the Class of Preventative Measure Level III and IV and the ICP will
sign off the Infection Control Construction permit.
Infection prevention and control measures shall be constantly monitored and shall
be reviewed at every construction and project management meeting.
If, during construction, events that can present infection risks occur, intervention
procedures shall be implemented immediately to resolve the problems.
Plumbing and HVAC systems shall be supplied, installed, and commissioned in
accordance with CAN/CSA-Z317.1, CAN/CSA-Z317.2, and CAN/CSA Z318.0.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX1000 (Construction & Renovation Guidelines)
Page 4
An ICP shall
ensure that the appropriate preventative measures are initiated and adhered to.
As a member of the multidisciplinary team, the ICP shall have the authority to stop
construction if there is a significant failure to adhere to the required preventative
measures. The multidisciplinary team shall have a procedure in place for notifying
relevant HCF and construction management personnel in the event of a construction
stop.
2.4. Infrastructure
All projects, both new construction and renovation, shall utilize CSA Z8000-11 standards
to ensure that appropriate infrastructure is in place within IH healthcare
facilities(Appendix 4.)
3.0 REFERENCES
3.2. CSA Standard: Infection Control during Construction or Renovation of Health Care
Facilities. CSA Z317.13 – 12 Dec 2012
3.3. CSA Standard: Canadian health care facilities. CSA Z8000-11 September 2011.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX1000 (Construction & Renovation Guidelines)
Page 5
APPENDIX 1
Infection Control Construction Permit / Sign Off Form
Location of Construction:___________________ Supervisor:____________________
Supervisor:___________________ Telephone:____________________
Area Free of Hazardous Materials: Yes No (if No, attach description and abatement requirements).
Visual Checklist for work within existing building to check for Mold Presence completed.
________________________________ ________________________________
Interior Health – Infection Control Professional Construction Representative
________________________________ ________________________________
Interior Health – Infection Control Professional Construction Representative
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX1000 (Construction & Renovation Guidelines)
Page 6
Schedule 1
Type of Construction Activity for Risk Assessment: (Table 3: taken from CSA Guideline Z317.13-12
Dec 2012)
Construction Level Type A: a)activities that require removal of not more than one ceiling tile
or require wall or ceiling panels to be opened;
Inspection, non-invasive activities
b)painting (but not sanding) and wall covering;
c)electrical trim work;
d)minor plumbing work that disrupts the water supply to a
localized patient care area (i.e. one room) for less than 15 min.;
and
e)other maintenance activities that do not generate dust or
require cutting of walls or access to ceiling other than for visual
inspection.
Construction Level Type B: a) activities that require access to chase spaces;
Small scale, short duration activities b) where dust migration can be controlled, cutting of walls or
that create minimal dust. These ceilings for installing or repairing minor electrical work,
include, but are not limited to, ventilation components, telephone wires, or computer cables;
c) sanding or repair of a small area of a wall; and
d) plumbing work that disrupts the water supply of more than
one patient care area (i.e. two or more rooms) for less than
thirty min.
Construction Level Type C: a) activities that require sanding of a wall in preparation for
painting or wall covering;
Activities that generate a moderate to
high level of dust, require demolition, b) removal of floor coverings, ceiling tiles, and case work;
require removal of affixed facility
c) new wall construction;
component (e.g. sink) or assembly
(e.g. countertop or cupboard), or d) minor duct work;
cannot be completed in a single work
shift. These include, but are not e)electrical work above ceilings;
limited to, f) major cabling activities; and
g) plumbing work that disrupts the water supply of more than
one patient care area (i.e. two or more rooms) for more than 30
min but less than 1 h.
Construction Level Type D: a) activities that involve heavy demolition or removal of a
complete cabling system;
Activities that generate high levels of
dust, and major demolition and b) new construction that requires consecutive work shifts to
construction activities requiring complete; and
consecutive work shifts to complete.
These include, but are not limited to, c) plumbing work that disrupts the water supply of more than
one patient care area (i.e. two or more rooms) for 1 h or more.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX1000 (Construction & Renovation Guidelines)
Page 7
Border Risk Groups Assessment (Table 2: taken from CSA Guideline Z317.13-12 Dec 2012)
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX1000 (Construction & Renovation Guidelines)
Page 8
Please notify the Infection Control Service when work is being done on hallways adjacent to patient
care areas that fall into a Population Risk Group of 3 or 4.
Circumstances may necessitate changing the Class of Preventative Measure Level at any time during
the project. Any changes to the scope of work, the Infection Control Practitioner assigned to the
project, must review to determine if there is a further impact on infection control.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX1000 (Construction & Renovation Guidelines)
Page 9
Population I II III IV
Risk Group 2
See Table 3 for Construction Activity and Table 2 for Population Risk Group.
Shaded activity areas indicate increased risks to population and implementation of stringent Infection
Control precautions. Infection Control Construction Permit/Sign Off Form required for all Construction
Activity.
When the Class of Preventive Measure is Level III/IV, a multidisciplinary team shall determine the
appropriate prevention measures required, either Level III or Level IV.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Infection Prevention and Control
Section 10X – IX1000 (Construction & Renovation Guidelines)
Page 10
APPPENDIX 3
CLASS OF
PREVENTATIVE MEASURE
Level I Engineering or Operations and Maintenance Staff or Constructors
Minimize dust during construction operations.
Clean the work area with a HEPA vacuum cleaner if necessary.
Wipe work surfaces with a hospital approved disinfectant after the project is completed.
Immediately replace any ceiling tile or access panel displaced for visual inspection.
Plumbing Activities
Schedule water interruptions during low activity.
Flush water lines for a minimum of 10 minutes prior to reuse - check for discolored water.
Ensure that gaskets and items made of materials that support the growth of Legionella are not
being used.
Ensure faucet aerators are not installed or used.
Maintain as dry an environment as possible and report any leaks that occur to walls and
substructures.
Environmental Services
Report discolored water and water leaks to Maintenance and Infection Control.
Medical/Nursing Staff
Minimize patients' exposure to construction/renovation area.
Ensure that patient care equipment and supplies are protected from dust exposure.
After construction
The multidisciplinary team shall review the preventive measures that were undertaken and
assess their effectiveness.
Level II Note: In addition to following preventative measure I the following measures shall be met.
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Contain debris in covered containers or cover with a moistened sheet before transporting it for
disposal.
Place supplies and equipment in covered containers during transportation through the healthcare
facility to prevent contamination in other areas.
Remove debris in the evening when patients are in their rooms and visitors have left. If this is not
possible debris should be removed at the end of the work day.
Wipe work surfaces with a hospital approved disinfectant at end of project
Plumbing Activities
Avoid collection tanks and long pipes that allow water to stagnate.
Hyper chlorinate (to a minimum of 50 parts per million) or superheat (to a minimum of 70 degrees
Celsius) stagnant domestic water (especially if Legionella is already present in the domestic water
supply). The water lines in the construction area and adjacent patient care areas shall be flushed
for a minimum of ten minutes before reuse; and note: Preventative technologies (e.g. silver-copper
ion treatments) may be considered in lieu of the techniques specified above.
Be aware of the impact of techniques to remove bacterial growth and choose the approach that
minimizes the risks associated with such work
Medical/Nursing Staff/Administration
Identify high-risk patients who may need to be temporarily moved away from the construction
zone.
After Construction
The multidisciplinary team shall
a. Review the preventive measures that were undertaken and assess their effectiveness;
and
b. Conduct a final inspection to ensure that the ventilation system is functioning properly
in the construction area and adjacent areas.
Infection prevention and control personnel shall ensure that the construction area has been
thoroughly cleaned before building occupants are readmitted to the completed construction
area.
Environmental services and healthcare staff shall
a. Ensure that the construction area has been cleaned with a HEPA filter-equipped
vacuum cleaner, a wet mop, or both, as necessary, and that horizontal work surfaces
have been wiped with a disinfectant; and
b. Report discolored water and water leaks to the maintenance and infection prevention
and control departments.
Level III Note: In addition to following preventative measures I and II the following measures shall be
met.
Minimization of dust generation and dispersal
Engineering or Operations and Maintenance Staff or Constructors
Erect an impermeable dust barrier, from the floor to the underside of the deck (including the
areas above false ceilings) consisting of two layers of 0.15mm (6 ml) fire-retardant polyethylene
(or an equivalent barrier) and gypsum wall board protection approved by the multidisciplinary
team. The dust barrier shall remain in place until the project is complete and the area has been
cleaned thoroughly and inspected. After construction has been completed, the dust barrier shall
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Infection Prevention and Control
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be removed to prevent the spread of dust and other debris particles adhering to the barrier;
Use impermeable vessels constructed to contain contaminants. Such vessels shall have a
monolithic (one-piece) exterior shell constructed of a minimum of 0.20 mm (8 ml) fibre-
reinforced, fire-retardant polyethylene. The construction of the vessel shall allow for
containment of contaminants within the vessel and have ports through which HEPA-filtered
vacuum cleaners or portable construction HEPA-filtered air units can be easily attached to draw
the unit under negative pressure;
Vacuum mechanical and electrical systems and spaces above drop or false ceilings, if
necessary; and
Remove protective clothing before entering patient care areas.
Ventilation Systems
Engineering or Operations and Maintenance Staff or Constructors
Disable the ventilation system and seal duct openings in the construction area until the project
is completed;
Maintain a negative pressure of 7.5pa (0.03 in wc) within the construction area using portable
HEPA filter-equipped air filtration units that include pressure gauges and an alarm. Filters shall
be monitored and replace if clogged or functioning below the manufacturers specifications;
Ensure that the air is exhausted directly outside and away from intake vents and filtered
through an HEPA filter. In conditions that prohibit exhausting exhaust outside, air may be
recirculated in accordance with Clauses 6.6 and 7.2.3.6 (CSAZ317.13-12); and
Ensure that the ventilation system is functioning properly and cleaned if contaminated by soil or
dust after the construction project is complete.
Portable construction HEPA-filtered air units
Construction area exhaust shall be HEPA filtered. Filters shall be visually inspected by the
constructor at least daily, condition documented, and replaced when loaded.
HEPA filtered air units shall be certified at the beginning of any preventative level III or IV
construction activity. Units shall be recertified at least every 12 months and the recertification
shall be documented.
Construction, maintenance, and repair area exhaust air shall not be discharged to areas
occupied by Population risk group 3 or 4. Measures related to recirculated air shall require
approval from the multidisciplinary team.
The relative space pressures between areas occupied by Population risk group 3 or 4 shall be
continuously monitored.
Impact on the facility HVAC system
Portable air filtration units may affect a facility’s HVAC system; therefore,
The main facility system shall be verified for operation in accordance with design during
construction work.
The healthcare facility and constructor shall verify the pressure relationships for critical areas
near the construction area.
Construction air handling
Permanent air handling systems should not be used for exhausting air from construction or
renovation work areas. Temporary duct work may be installed for such purposes. However, it
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Note: in this document the term “patient” is inclusive of patient, resident or client.
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c. Ensure that the construction area has been cleaned with a HEPA filter-equipped
vacuum cleaner, a wet mop, or both, as necessary, and that horizontal work surfaces
have been wiped with a disinfectant; and
d. Report discolored water and water leaks to the maintenance and infection prevention
and control departments.
Level IV Note: In addition to following preventative measures I, II, and III the following measures shall be
met.
Engineering or Operations and Maintenance Staff or Constructors
Ensure that all access shall be from outside the occupied areas of the healthcare facility, or
construct anterooms at access points to the construction area if access is from within the
healthcare facility;
Place a walk-off mat outside and inside the anteroom to trap dust from equipment, debris, and
the shoes of personnel leaving the construction area. Walk off mats shall be of sufficient size to
ensure that constructors have to place both feet on the mat at least once on exiting the
construction area;
Ensure that the constructors
a. Leave the construction area through the anteroom so that they can be vacuumed with
a HEPA filter-equipped vacuum cleaner before leaving; or
b. Wear protective clothing that is to be removed each time they leave the construction
area and before going into patient care areas;
c. Repair holes in walls within 8 hours or seal them temporarily;
d. Ensure that ventilation systems are working properly in adjacent areas; and
e. Carefully remove barrier walls and use short term protection to minimize environmental
contamination during removal.
Environmental services staff shall ensure that the construction area is thoroughly cleaned when
work is complete.
Infection prevention and control personnel shall regularly visit the construction area to ensure
that preventative measures are followed. The frequency of their visits shall be determined by
the multidisciplinary team
Infection prevention and control measures shall be constantly monitored and shall be reviewed
at every construction and project management meeting
If, during construction, events that can present infection risks occur, intervention procedures
shall be implemented immediately to resolve the problems
Plumbing and HVAC systems shall be supplied, installed, and commissioned in accordance
with CAN/CSA-Z317.1, CAN/CSA-Z317.2, and CAN/CSA Z318.0
Before substantial completion and occupancy, the constructor shall have satisfied all infection
control measures. Detailed inspections shall be performed by the multidisciplinary team
After construction
In addition to preventative measures II and IIl before the completed construction area is
occupied any portions of the infection control plan still in effect shall be reviewed by the
multidisciplinary team.
If necessary such portions shall be incorporated into the healthcare facilities ongoing operating
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Note: in this document the term “patient” is inclusive of patient, resident or client.
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APPENDIX 4
Quick Reference Guide for CSA Z8000-11 Guidelines
Infection Prevention & Control shall be involved from the design phase through to commissioning
in both new construction and renovations of existing facilities.
This includes:
1. CSA Z317.2 – 10: Special requirements for heating, ventilation, and air conditioning (HVAC)
systems in health care facilities, 2010.
The need for facility renovations shall be identified by the mandatory use of the biennial audit tool Best
Practices for Hand Hygiene in all Healthcare Settings: Supplementary checklist for facilities and
infrastructure needed to support healthcare providers; Provincial Hand Hygiene Working Group –
Facilities/Infrastructure Team (2012)
Ambulatory Care For complete information see pages > Page 174-183
Ceilings For complete information see pages > Page 354, Page
361-362
Clause 11 Table of common requirements Page 327-353
Clean supply/utility room Clean and soiled utility rooms shall be separate Page 329
Supplies shall be stored in mobile shelving that is
cleanable, smooth, non porous, and tolerant of
hospital disinfectants; or automated dispensers
Equipment and supplies shall not be exposed to
direct HVAC air flow, or stored by windows
See section on floors/walls/ceilings
Dialysis For complete information see pages > Page 184-191
Dining Room For complete information see pages > Page 333
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Services
Emergency For complete information see pages > Page 209-223
Hand hygiene sinks Dedicated hand hygiene sinks shall be provided Page 96-97
A hand hygiene sink is required:
In each inpatient bedroom
Where treatments/exams/assessments are
provided
Locations designed for one patient: one sink
Locations designed for three or more patients:
one sink per three patients, with 6 m. or less
between any patient and sink
Inside(if plastic pipes used), or adjacent to each
diagnostic MRI room
Stainless steel hand hygiene sinks shall be used
in areas handling radioactive materials
In each soiled utility/soiled holding room
In any food prep area
Inside or within 6 m. of each nursing station
Inside or within 6 m. of each staff lounge
In medication preparation areas
Within 6 m. of each laboratory work station and
within each work room
Where soiled linen is handled
Any area where hands are likely to be
contaminated
In each airborne isolation room and each
anteroom
For complete information on materials, size,
construction, location, controls, backsplash, Page 337-339
dispensers and hand dryers see pages >
Sinks must have water supply & drainage
separate from hemodialysis piping Page 186
Housekeeping closet For complete information see pages > Page 339
Infection Control general For complete information see pages > Page 21-24, 91-
information 94
Inpatient room Shall be single bedded rooms, unless the Page 22, 340-
functional program, with supporting 342
documentation, demonstrates the necessity of a
two-bed arrangement
Shall have one washroom per patient
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Inpatient isolation rooms For complete information see pages > Page 343-344
Inpatient washrooms For complete information see pages > Page 342-343
Laboratory For complete information see pages > Page 248-266
Laundry for Rehab and For complete information see pages > Page 344
LTC
Maternal and Newborn For complete information see pages > Page 128-135
Medical Imaging For complete information see pages > Page 278-284
Medication Room For complete information see pages > Page 345
Operating Rooms and For complete information see pages > Page 224-243
Procedure Rooms
Pharmacy The mixing of parenteral therapy solutions requires Page 285-290
special work stations and air handling
Chemo prep requires negative pressure
Sterile medication prep requires positive
pressure
Anterooms are recommended
Satellite pharmacy Page 348
Soiled utility room Shall be separate from clean utility room Page 348-349
Separate hand hygiene sink shall be provided
No storage of clean equipment
May store patient waste disposal equipment and
stool/urine/vomit specimen supplies
Shall have human waste management system
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Surfaces – ceilings, Shall be smooth, non porous, seamless, resilient and Page 86 - 89
floors, walls, doors, impact resistant, cleanable and compatible with facility
window, furniture approved disinfectants, water impermeable
Tub/Shower room Shall have a hand hygiene sink at the Page 351-352
entrance/exit just inside room
Each room shall have storage space for supplies
and PPE
Waiting rooms Zones shall be created so that the more Page 352
infectious persons are in a separate area
Public washrooms shall be provided in close
proximity
Washroom - public Toilet, sink, and paper towel dispensers shall be Page 352
hands free
Toilets with tanks shall not be used, due to risk of
condensation
Waste management One washroom with toilet and sink for each Page 94-95
inpatient. A closed waste management
mechanism with hand hygiene sink shall be
installed where toilet not required (e.g. ICU,
NICU or nursery)
Each inpatient service shall be equipped with at
least one closed waste management system
Waterless hand hygiene Waterless hand hygiene station shall be provided in each Page 97
stations of the following locations: Page 339
All entrances and exits to the healthcare facility
Immediately adjacent to the entrance of each
patient bedroom
Immediately adjacent to the entrance of each
patient care area (e.g. exam or procedure room)
Adjacent to the bedside at point of care unless
risk to patient
Where Personal Protective Equipment (PPE) is
donned or doffed
Shall be mounted approximately 1 m. from floor and shall
be in compliance with fire regulation guidelines
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Note: in this document the term “patient” is inclusive of patient, resident or client.