Infection Control Manual

INFECTION
PREVENTION AND CONTROL
MANUAL
February 7, 2013
VIHA Infection Prevention and Control Manual, February 7, 2013
TABLE OF CONTENTS
(Click here to see recent changes/additions)
PART 1: INTRODUCTION .................................................................................. 8
1. Purpose ........................................................................................................................ 8
2. Scope of the Document ................................................................................................ 8
3. Guiding Principles ......................................................................................................... 8
PART 2: UNDERSTANDING HOW INFECTIONS ARE SPREAD ...................... 9

1. The Chain of Infection................................................................................................... 9
Figure 1: Chain of Infection ................................................................................... 9
A. Causative Agents ............................................................................................... 10
B. Reservoirs .......................................................................................................... 11
Table 1: Human Reservoirs and Transmission of Infectious Agents .............. 12
C. Portal of Exit ....................................................................................................... 12
D. Transmission ...................................................................................................... 13
1. Contact Transmission ............................................................................................. 13
2. Droplet Transmission .............................................................................................. 13
3. Airborne Transmission ............................................................................................ 13
4. Common Vehicle Transmission ............................................................................... 14
5. Vector Borne Transmission ..................................................................................... 14
E. Portal of Entry ..................................................................................................... 14
F. Susceptible Host................................................................................................. 15
PART 3: INFECTION PREVENTION AND CONTROL PRACTICES AND

PRECAUTIONS................................................................................................. 18
1. ROUTINE PRACTICES .............................................................................................. 18
A. Risk Assessment ................................................................................................ 18

Figure 2: Risk Assessment Decision Tree - Acute Care ................................... 20
Table 2: Risk Assessment .................................................................................... 21
Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 2
B. Risk Reduction ................................................................................................... 22

1. Hand Hygiene ......................................................................................................... 22
Indications for Hand Hygiene .................................................................................. 22
Figure 3: The Four Moments for Hand Hygiene .................................................. 23
Nail and Skin Care .................................................................................................. 24

Type of Cleansing Agent ......................................................................................... 24
Alcohol Based Hand Rub ........................................................................................ 24
Soap and Water ...................................................................................................... 25
Handwashing Technique......................................................................................... 25
Table 3: Levels of Hand Disinfection .................................................................. 26
Hand Hygiene Procedure ........................................................................................ 26

Alcohol based hand rub technique .......................................................................... 26
Soap and Water hand washing technique ............................................................... 26
Surgical asepsis (scrub) technique with an alcohol based hand rub ........................ 27
Surgical asepsis technique with a medicated soap ................................................. 27
2. Respiratory Hygiene/Cough Etiquette ..................................................................... 28
3. Patient Placement ................................................................................................... 29
4. Personal Protective Equipment ............................................................................... 29
Gloves .................................................................................................................... 29
Table 4: Examples of Tasks that Require the Wearing of Gloves .................... 30
Table 5: Glove Use in Patient Care...................................................................... 31
Figure 4: Choosing the Correct Glove ................................................................ 32
Gowns/Aprons ........................................................................................................ 33
Masks, Visors and Protective Eyewear ................................................................... 34
5. Hair/Jewelry/Uniforms ............................................................................................. 35
Hair ......................................................................................................................... 35
Jewelry ................................................................................................................... 35
Footwear ................................................................................................................. 35
Dress Code for Staff Who Do Not Wear a Uniform, Including Medical Staff ............ 35
Dress Code for Staff Wearing a Uniform ................................................................. 35
6. Safe Handling of Sharps ......................................................................................... 36

7. Decontamination ..................................................................................................... 37
Table 6: Reprocessing Decision Chart ............................................................... 37
Table 7: Classes of Organisms in Order of Susceptibility to Disinfectants ... 40
Table 8: Disinfection Requirements for Equipment .......................................... 41
Table 9: Advantages and Disadvantages of Major Chemical Disinfectants ... 41
8. Housekeeping ......................................................................................................... 45
9. Laundry ................................................................................................................... 45
10. Waste ..................................................................................................................... 48
11. Managing Dishes, Glasses, Cups and Eating Utensils ............................................ 50
12. Recreational Reading Material and Games ............................................................. 52
13. Play Equipment and Toys ....................................................................................... 52
14. Healthy Workplace .................................................................................................. 53
C. Education............................................................................................................ 54
2. ADDITIONAL PRECAUTIONS ................................................................................... 55
A. Contact Precautions ........................................................................................... 55
B. Droplet Precautions ............................................................................................ 58
C. Airborne Precautions .......................................................................................... 59

Table 10: Air Exchanges ...................................................................................... 63
D. SUMMARY OF PRECAUTIONS ........................................................................ 64

Table 11: Precautions Table ................................................................................ 64
E. Protective (Reverse) Precautions ....................................................................... 65
F. Management of Cases on Additional Precautions in Diagnostic Areas .............. 65

Figure 5: Management of Infected Patients/Residents on Precautions in
Diagnostic Areas .................................................................................................... 67
G. Discontinuing Additional Precautions ................................................................. 68

Table 12: Procedure for Discontinuing Additional Precautions ...................... 68
PART 4: HOUSEKEEPING............................................................................... 69
1. Clean Environment ..................................................................................................... 69
A. CLEANING ......................................................................................................... 69
1. Nursing/Housekeeping Responsibilities .................................................................. 69
2. Nursing Responsibilities: ......................................................................................... 70
3. Housekeeping Responsibilities: .............................................................................. 71
Table 13: Cleaning Solutions Used in Various Types of Cleaning ............... 71
Table 14: Some Equipment/Environmental Surfaces to be Cleaned Daily .. 73
B. EVALUATING PRODUCTS ................................................................................ 77
2. Bed Bug Infestation .................................................................................................... 77
A. Pests and Infestations in Home and Community Care ....................................... 77
PART 5: ANTIBIOTIC RESISTANT ORGANISMS............................................ 78

1. Introduction ................................................................................................................. 78
2. Definitions ................................................................................................................... 78
3. Acute Care Screening Protocol .................................................................................. 78

Table 15: List of Organisms with Corresponding Precautions and Other
Considerations ....................................................................................................... 79
4. ARO Screening and Collecting Swabs ....................................................................... 80

Table 16: Screening and Specimen Collection .................................................. 80
5. Overview of Antibiotic Resistant Organisms ............................................................... 81
A. Methicillin-Resistant Staphylococcus aureus (MRSA) ........................................ 81
B. Vancomycin-Resistant Enterococci (VRE) ......................................................... 82
C. Extended Spectrum Beta-Lactamase (ESBL) Organisms .................................. 82
6. ARO Room Placement ............................................................................................... 83

Figure 7: ARO Room Placement .......................................................................... 83
7. Key Management Issues ............................................................................................ 85

Table 17: Key Management Issues for MRSA and ESBL ................................... 85
PART 6: OUTBREAK MANAGEMENT ............................................................. 91

1. Introduction ................................................................................................................. 91
2. General Guidelines for Outbreak Management .......................................................... 92
A. Reporting a Suspected Outbreak ....................................................................... 92

Table 18: Contact List ............................................................................................ 92
Figure 8: Suspected Respiratory Infection or Gastroenteritis Outbreak

Algorithm ................................................................................................................ 94
B. Influenza-Like Illness (ILI) Outbreaks ................................................................. 95

Table 19: Common Differences between Influenza and Common Cold
Symptoms ............................................................................................................... 96
Table 20: Respiratory Infections .......................................................................... 97
Table 21: Case Definition for ILI and an ILI Outbreak ....................................... 99
C. Gastrointestinal Illness (GI) Outbreaks ............................................................. 106

Table 22: Common Bacterial and Viral Causes of Gastroenteritis ................ 107
Table 23: Gastrointestinal Illness Case Definition .......................................... 108
Figure 9: Requisition Form for GI Testing ........................................................ 114
D. Outbreaks Caused by Other Organisms ........................................................... 115

1. Clostridium Difficile Outbreak ................................................................................ 115
2. Work Restrictions .................................................................................................. 116
3. Scabies ................................................................................................................. 116
PART 7: DEPARTMENTAL GUIDELINES ...................................................... 120

1. Inpatient Mother and Baby........................................................................................ 120
Table 24: Common Conditions and Precautions Needed ............................... 120
Figure 10: Precautions Required When Caring for Mother with Non-Genital
Herpes ................................................................................................................... 121
Figure 11: Precautions Required When Caring for Mother with Genital
Herpes ................................................................................................................... 121
2. Neonatal Intensive Care and Special Care Baby Units ............................................ 123
Table 25: Common Conditions and Precautions Needed ............................... 125
3. Pediatrics .................................................................................................................. 126
4. Infection Prevention and Control Practices for Surgical Service Areas .................... 130
Figure 12: Surgical Booking Procedure ........................................................... 132
Table 26: Assessment for Increased Risk of Communicable Disease

Transmission ........................................................................................................ 132
Figure 13: Surgical Housekeeping Algorithm .................................................. 137
5. Burn Unit Recommendations .................................................................................... 145
6. Renal Dialysis Department ....................................................................................... 147

Table 27: Disinfection Procedures Recommended for Commonly Used
Items or Surfaces in Hemodialysis Units .......................................................... 155
7. Respiratory Department Guidelines .......................................................................... 159
PART 8: Specific Procedural Recommendations ............................................ 162

1. Asepsis ..................................................................................................................... 162
Table 28: Approved Antiseptic Agents and Procedures ................................. 164
2. Environment and Furniture ....................................................................................... 166
A. Storage of Decorative Items ............................................................................. 166
B. Furniture ........................................................................................................... 166
C. Fixtures and Fittings ......................................................................................... 167
APPENDICES ................................................................................................. 170

APPENDIX A: Type and Duration of Additional Precautions Where Recommended for
Selected Infections and Conditions ............................................................................... 170
APPENDIX B: Glossary of Terms .................................................................................. 194
APPENDIX C: Specific Cleaning Instructions ................................................................ 202
A. Procedure for Cleaning Agitator Tubs/Hydrotherapy Tanks ............................. 202
B. Procedure for Cleaning Fans ............................................................................ 202
C. Procedure for Cleaning Commodes ................................................................. 203
D. Procedure for Cleaning Suction Regulators...................................................... 203
E. Procedure for Cleaning and Use of Hot/Cold Pack and Ice Bags ..................... 204
Table 28 - Products currently acquired through VIHA purchasing
department: .......................................................................................................... 205
F. Recommendations for Bath Mats Prior to Purchase ......................................... 205
PART 1: INTRODUCTION
1. Purpose
This manual has been prepared to assist the healthcare worker by providing a succinct and
current guide to infection prevention and control strategies in various healthcare settings.
The principles and guidelines set out in the Manual are based on national and international
published best practices, which have been modified to reflect the specific needs of VIHA.
As new information becomes available, this document will be reviewed and updated, the most
current edition will be accessible on the VIHA website.
2. Scope of the Document

This document covers VIHA Acute, Residential care, Home & Community Care and other
community settings as the implementation of routine practices applies to all programs and
departments.
3. Guiding Principles
Infection prevention and control strategies are designed to protect patients/residents,
healthcare providers and the community from the risk of transmissible disease.
A systematic approach to infection prevention and control requires each health care provider
to play a vital role in protecting everyone who utilizes the healthcare system, in all of its many
forms: pre-hospital settings, hospital, clinics, residential and home and community care.
To protect patients/residents/clients, staff and visitors from transmitting and/or acquiring

hospital associated infections through ensuring adherence to best infection prevention and
control practices.
Healthcare providers must adhere to infection prevention and control guidelines and policies
at all times, and use critical thinking, risk assessment and problem solving in managing
clinical situations.
Reference: Ontario Ministry of Health and Residential care Infection Prevention and Control Core Competencies
Program, Reviewed and revised January, 2011
PART 2: UNDERSTANDING HOW INFECTIONS ARE

SPREAD
1. The Chain of Infection
The spread of infection is best described as a chain with six links:
1. a pathogen or causative (infectious) agent
2. a reservoir
3. a portal of exit from the reservoir
4. a mode of transmission
5. a portal of entry into the host
6. a susceptible host
Figure 1: Chain of Infection
Infectious
Agents
Susceptible
Reservoirs
Host
Portal of
Portal of Exit
Entry
Mode of
Transmission
An infection can be prevented by breaking any link in the chain of infection. Infection
prevention and control measures are designed to break the links and thereby prevent new
infection. The chain of infection is the foundation of infection prevention and control.
A. Causative Agents
Bacteria, viruses, fungi and protozoa (microorganisms) are very common in the environment.
Most of these microorganisms cause people no harm, and can in fact be beneficial. Creating
an environment with no organisms is not a realistic goal.
Bacteria are single celled organisms, some of which can cause disease. We all live with
numerous bacteria, referred to as our ―normal flora‖ or ―resident bacteria‖, which usually do
not cause disease unless their balance is disturbed.
Most bacteria require an infectious dose to cause disease; that is, it usually takes thousands
to cause disease, not just one or two. Bacteria vary in infectivity (how easy they are to catch)
and virulence (the level of danger from the infection they cause).
Viruses are intracellular pathogens, either DNA or RNA, meaning they can only reproduce
inside a living cell. Viruses such as HIV and Hepatitis B and C have the ability to enter and
survive in the body for years before symptoms of disease occur. Other viruses, such as the
influenza viruses, quickly announce their presence through characteristic symptoms.
Fungi are prevalent throughout the world, but only a few cause diseases in humans, most of
which predominately affect the skin, nails and subcutaneous tissue. A common yeast,
Candida albicans, is normal human flora that can cause chronic or severe infections. Fungal
infections can be life threatening in critically ill patients/residents. Fungi such as
Pneumocystis carinii can be life threatening in persons with HIV/AIDS.
Prions are a form of infectious protein believed to be the cause of Creutzfeldt Jakob disease
(CJD).
Protozoa are single or multi-celled microorganisms that are larger than bacteria. Examples
of disease causing protozoa include Amoebas and Giardia, which cause diarrhea, and
Plasmodium species, the cause of malaria. They may be transmitted via direct or indirect
contact or the bite from an arthropod vector.
Parasites are larger organisms that can infect or infest people. Infestation with arthropods,
such as lice and scabies, occurs by direct contact with the arthropod or its eggs. Heminths
include roundworms, tapeworms and flukes. They infect humans principally through ingestion
of fertilized eggs or when the larvae penetrate the skin or mucous membranes.
Causative organisms can be eliminated by several methods, including:
Sterilizing surgical instruments and anything that comes into contact with sterile
spaces of the body
Using good food safety methods
Providing safe drinking water
Vaccinating people so they do not become reservoirs of illness
Treating people who are ill
Following good hand hygiene practices
B. Reservoirs
Microorganisms require water to grow and reproduce, so reservoirs are often moist areas.
Sometimes a reservoir includes our own normal flora as a contaminant, such as at a sink
faucet.
In some cases the environment can serve as the reservoir. For example, water supplies may
become contaminated by Legionella species. Inadequate air exchange can allow pathogens
such as Mycobacterium tuberculosis and Aspergillus to contaminate air supplies.
Environmental contamination by pathogens such as Staphylococcus aureus and
Enterococcus species also commonly occur in bathrooms and/or on equipment. Appropriate
infection prevention and control measures and engineering controls can prevent these
reservoirs.
Common reservoirs in healthcare facilities include:
Ill people
Well people. Our normal flora includes bacteria that can be pathogenic if in the wrong
part of the body
Food; raw meat may harbor pathogens
Water from fish tanks or flower vases may contain pathogens, which can cause harm
especially for compromised patients/residents
Actions we take to eliminate reservoirs include:
Treating people who are ill

Vaccination
Safe handling and disposal of body fluids appropriately
Handling food safely
Monitoring for water contamination, and restricting flowers in sensitive areas of the
hospital
Table 1: Human Reservoirs and Transmission of Infectious Agents

Reservoir Transmission vehicle Infectious agent
Blood Blood, needle stick, other Hepatitis B and C
contaminated equipment, HIV
splashes Staphylococcus aureus
Staphylococcus epidermidis
Skin and Soft Tissue Drainage from a wound or Staphylococcus aureus

incision Coliforms
Pseudomonas
Reproductive tract and genitalia Urine, semen, vaginal secretions Neisseria gonorrhoeae
Treponema pallidum
Herpes simplex virus
Hepatitis B
Respiratory tract Droplets from sneezing or Influenza viruses

coughing Group A streptococcus
Staphylococcus aureus
Tuberculosis
Gastrointestinal tract Vomitus, feces, bile, saliva Hepatitis A

Shigella
Salmonella
Norovirus
Rotavirus
Urinary tract Urine Escherichia coli

Enterococci
Pseudomonas
Note: This list is not exhaustive.
Reference: Public Health Agency of Canada. (1999) Routine Practices and Additional Precautions for
Preventing the Transmission of Infection in Health Care. (currently under revision)
C. Portal of Exit
The portal of exit is the way in which the causative agent gets out of the reservoir, and it is the
link of the chain that we can do the least about. Any break in the skin, including natural
anatomical openings and draining lesions, may be the portal of exit from a person; any bodily
fluid may carry microorganisms out of the body. Some potent germs live on the
patient/resident‘s skin, and thus can easily exit their reservoir.
Actions we take to reduce risk from portals of exit include:

Covering coughs and sneezes with appropriate measures (e.g. coughing into the
elbow)
Handling body wearing appropriate personal protective equipment (gloves and gowns)
then performing correct hand hygiene
Cover draining wounds covered with an appropriate dressing

Health care workers refraining from work when exudative (wet) lesions or weeping
dermatitis are present
D. Transmission
This is the weakest link in the chain of infection. Most efforts to prevent the spread of
infection are aimed at eliminating the mode of transmission.
Microorganisms are transmitted in healthcare settings by several routes, and the same
microorganisms may be transmitted by more than one route. There are five main routes of
transmission; contact, droplet, airborne, common vehicle and vector borne. For the purpose
of this manual, common vehicle and vector borne will be discussed only briefly, as neither
play a significant role in HCAI.
1. Contact Transmission
Direct contact transmission is the most important and frequent mode of transmission of
HCAI, and is divided into direct and indirect contact transmission.
Indirect contact transmission usually involves contact between a susceptible host and a
contaminated inanimate object, such as equipment, instruments or environmental surfaces.
This is often the result of contaminated hands touching an object or environment. For
example, activity staff who use a ball to pass from resident to resident.
2. Droplet Transmission
Theoretically, droplet transmission is a form of contact transmission. However, the
mechanism of transfer of the pathogen to the host is quite distinct from either direct or indirect
contact transmission. Droplets are generated from the source person primarily during
coughing, sneezing and talking, and during the performance of certain procedures such as
suctioning and administering nebulized medications. Transmission occurs when large
droplets containing microorganisms generated from the infected person are propelled a short
distance through the air (usually less than one metre) and deposited on the host‘s
conjunctivae, nasal mucosa or mouth. Because droplets do not remain suspended in the air,
special air handling and ventilation are not required to prevent droplet transmission; that is,
droplet transmission must not be confused with airborne transmission. Droplets can also
contaminate the surrounding environment and lead to indirect contact transmission.
3. Airborne Transmission
Airborne transmission occurs by dissemination of either airborne droplet nuclei; small particle
residue (five microns or smaller in size) of evaporated droplets containing microorganisms or
dust particles containing the infectious agent (e.g. dust created by rotary powered foot care
tools). Microorganisms carried in this manner remain suspended in the air for long periods of
time and can be dispersed widely by air currents. These may be inhaled by a susceptible
host within the same room, or over a longer distance from the source patient/resident,
depending on environmental factors. Environmental controls are important – special air
handling and ventilation help reduce airborne transmission.
4. Common Vehicle Transmission

Common vehicle transmission applies to microorganisms transmitted by contaminated items
such as food, water and medications, to multiple hosts, and can cause explosive outbreaks.
Control is through using appropriate standards for handling food and water, preparing
medications and appropriate hand washing.
5. Vector Borne Transmission

Vector borne transmission occurs when vectors such as mosquitoes, flies, rats and other
vermin transmit microorganisms. This route of transmission is of less significance in
healthcare facilities in Canada than in other settings.
E. Portal of Entry
The portal of entry can be thought of as the hole in the skin that allows the germ to get into
the body and cause disease. Pathogens cannot cause disease if they cannot get into the
body.
Examples of portals of entry include:

Mouth, nose and eyes
Other anatomical openings
Skin breaks (cuts, rashes)
Surgical wounds
Intravenous sites
Anatomical openings with tubes in place (these are more susceptible than those
without)
Needle puncture injuries
Actions to protect portals of entry include:

Dressings on surgical wounds
IV site dressings and care
Elimination of tubes as soon as possible
Masks, goggles and face shields
Keeping unwashed hands and objects away from the mouth (don‘t lick fingers to
turn pages)
Actions and devices to prevent needle stick injuries
Food and water safety
F. Susceptible Host
Susceptibility can be reduced in several ways. For some diseases there are effective
vaccines. Some diseases produce lasting immunity after illness. People have better
resistance to disease when they are well rested, well fed and relatively stress free. People
who have a healthy immune system are often able to resist infection, even when bacteria are
present.
Host factors that influence the outcome of an exposure include the presence or absence of
natural barriers, the functional state of the immune system and the presence or absence of an
invasive devise.
Natural barriers to infection include:

Intact skin and mucous membranes
Cilia (small, hairlike projections that line the respiratory system) that filter inhaled air
and trap microorganisms
Lung macrophages – large white blood cells that ingest microorganisms, other cells
and foreign particles, in a process called phygocytosis
Antibodies (humeral immunity) resulting from immunization or previous disease
Acidic environment of the stomach, urine and vaginal secretions
Normal flora provides competition to pathogens. An upset to the balance of normal
flora can allow pathogens to cause infection, such as when a yeast infection follows a
course of antibiotics
The immune system is a complex network of cells, tissues and organs that interact to
defend the body against infections. Defense mechanisms can be non-specific or
specific and include humeral immunity (antibodies that circulate in the blood), cell
mediated immunity (white blood cells) and the inflammatory response, which brings an
increase in these infection fighting defenses to the site of infection
A person with normal immune system function is described as immunocompetent.

Someone whose immune system is impaired by illness or age is said to be
immunocompromised. The very young and the very old are at risk with a compromised
immune system. Infections are a major cause of death among newborns. Although babies
receive certain temporary immunities from their mother through the placenta and in breast
milk, their immune systems are still developing, making them vulnerable to infection.
Examples of susceptible hosts include:

People with chronic diseases
People with invasive devices or tubes in place (e.g. catheters)
Malnourished people
The very old and the very young
People who are tired or under high stress

People with skin breaks such as surgical wounds, IV sites or chronic rash
People undergoing steroid therapy or treatment for cancer
People with HIV Infection
People who are well and healthy. No one is immune to all disease
Actions required to minimize risk to susceptible hosts include:

Vaccinating people against illnesses to which they may be exposed
Preventing new exposure to infection in people who are already ill, are receiving
immunocompromising treatment or are infected with HIV
Maintaining good nutrition
Maintaining good skin condition
Covering skin breaks
Encouraging rest and balance
The nature of healthcare settings makes patients/residents vulnerable to the spread of

infections, because it brings together many ill people who are both reservoirs and susceptible
hosts. Staff are also both reservoirs and susceptible hosts, so we cannot eliminate those two
major links of the chain of infection. This is why we must make such efforts to eliminate the
mode of transmission; hand hygiene is still the single most effective way to prevent the
spread of infection.
The reservoir and the susceptible host may reside in the same person, if the individual‘s
normal flora gets into the ―wrong‖ part of the body it may cause infection. Examples of this
situation include:
Fecal flora in the urinary tract, causing a urinary tract infection (UTI)
Oral flora in the lungs, causing aspiration pneumonia
Skin flora in an IV site, causing a site infection or a blood stream infection
To avoid providing the mode of transmission between different body sites of the same
patient/resident, one must change gloves and wash hands when moving from one site to
another, from a contaminated area to a cleaner one following the ―Four Moments for Hand
Hygiene‖
Preventing the spread of infectious organisms includes:

Early identification of the infectious organism
Prompt appropriate precautions put in place for patients/residents
Initiation of appropriate treatment
Precautions have disadvantages to the facility, patients/residents, personnel and visitors,

including the cost of specialized equipment and environmental controls, which inconvenience
healthcare workers and force solitude for patients/residents. However, these disadvantages
must be weighed against the facilities mission to prevent the spread of infection.
Source: Evans, N and McDonald, M. Infection Control Guidelines for Healthcare Professionals.
Routine Practices are to be applied at ALL times by ALL staff.
PART 3: INFECTION PREVENTION AND CONTROL

PRACTICES AND PRECAUTIONS
1. ROUTINE PRACTICES
Infection prevention and control measures are designed to break the links in the Chain of
Infection and thereby prevent new infection. In healthcare settings, because agent and host
factors are more difficult to control, interruption in transfer of microorganisms is directed
primarily at transmission. Routine practices play a key role in preventing the transmission of
infectious disease.
The Public Health Agency of Canada (PHAC) has used the term ―Routine Practices‖ since
1999, for the process of risk assessment and risk reduction strategies. Routine practice,
previously known as Standard Precautions, is to be used with all patients/residents at all
times. Routine practices supersede, and are more encompassing than, previous Blood Borne
Pathogen Precautions or Universal Precautions.
Based on the assumption that all blood and certain body fluids (urine, feces, wound drainage,
sputum) contain infectious organisms (bacteria, viruses or fungi), routine practices reduce
exposure (both volume and frequency) of blood and body fluids to healthcare providers.
Furthermore, routine practices reduce the risk of cross infection through the reduction in
contamination and transmission of microorganisms.
The key to implementing routine practices is to assess the risk of transmission of

microorganisms before any interaction with patients/residents.
The elements of routine practices are summarized here into three parts:
a. Risk Assessment
b. Risk Reduction
c. Education
Modified from: The Canadian Committee on Antibiotic Resistance (2007) Infection Prevention and Control
Best Practices for Residential care, Home and Community Care including Health Care Offices and Ambulatory
Clinics.
A. Risk Assessment
Risk assessment is performed principally to rule out the presence of infectious disease, but it
is also necessary to ensure that appropriate precautions are initiated for the various
procedures.
1. Admission
Assessment should be standardized during the admission process to include:
Recent exposures to infectious diseases such as Chickenpox, Measles or
Tuberculosis
Recent travel history, particularly travel abroad
New or worsening cough, and are unable to follow respiratory/cough etiquette
Fever
New undiagnosed rash
Sudden onset of diarrhea
Drainage or leakage not contained in a dressing and/or medical appliance
Any risk of colonization and/or infection with an Antibiotic Resistant Organism (ARO).
See the ARO Screening Questionnaire (catalogue number 28125) on the Forms
Navigation Bar.
2. Ongoing
A risk assessment should be completed on an ongoing basis, assessing the following:
Is the patient continent?
How susceptible is the patient to infection? Is their immune system intact?
Does the patient have any invasive devices or open areas?
What is the risk of exposure to blood, body fluids, microorganisms, mucous
membranes or non-intact skin in the task about to be performed?
Does the patient have a new or worsening cough, and are unable to follow
respiratory/cough etiquette?
Does the patient have a fever?
Does the patient have a new undiagnosed rash?
Does the patient have sudden onset of diarrhea?
Does the patient have any drainage or leakage not contained in a dressing and/or
medical appliance?
How competent is the healthcare provider in performing the task?
How cooperative will the patient be while the task is performed?
Figure 2: Risk Assessment Decision Tree - Acute Care
Table 2: Risk Assessment
Based on the assumption that all

Hand Hygiene (4 moments) for all
blood and certain body fluids (urine,
patients
feces, wounds, and sputum) contain
Routine Dealing with blood and/or body fluids
infectious organisms (bacteria,
Practice Non-infectious diagnosed vomiting viruses or fungi). Routine practices
and/or diarrhea
reduce exposure and potential cross
Non-draining wounds infection.
Additional Secondary
Primary Reason Justification
Precautions Reason
Patient will remain on additional
Known ARO ARO disease alert on precautions if ARO disease alert is
positive/ patient chart present despite any negative sets of
results until reviewed by an ICP.
Contact Including known or Based on the assumption that feces
Precautions Diarrhea NYD recent history of contain infectious organisms
Clostridium difficile (bacteria, viruses or fungi)
Draining infected Weeping Based on the assumption that
wounds Cellulitis/Shingles infectious organisms are present
Known MRSA in
Potential for infectious organism
sputum with
Respiratory transmission via droplet route
productive cough
Infection with
symptoms and/or With one or more of
New or Worsening the following:
Potential for pneumonia, influenza A
cough fever, headache, sore
or B, Coronavirus, Rhinovirus, RSV,
throat, general aches
Adenovirus, etc.
and pains, lethargy,
Droplet chest discomfort
Precautions Potential for infectious organism
Vomiting NYD With Diarrhea NYD transmission via droplet route,
including Norovirus, etc.
With one or more of
Fever of >38.55 C the following:
(<35.6 or >37.4 C in cough/ Potential for Rubella (German
the elderly)) headache/rash (i.e. Measles), Neisserria meningitides
petechiae non
blanching
Potential for Rubeola, Variola,
Rash resembling With any of the
Chicken Pox, Varicella Zoster (that
vesicles/pustules/ following:
are widespread and cannot be
macules cough, head pain and
Airborne occluded by dressings)
malaise
Precautions
Query Pulmonary TB
With new or
or history of Potential for active Pulmonary TB
worsening cough
Pulmonary TB
B. Risk Reduction
Risk reduction consists of many elements, all aimed at assisting the healthcare provider to
minimize his/her exposure to and contamination with microorganisms. The degree to which
the elements of risk reduction (e.g. personal protective equipment (PPE), clean environment)
are implemented are dependent upon the findings of the Risk Assessment. For example, the
choice of PPE and cleaning solutions will be determined by whether a patient presents with
undiagnosed diarrhea or not.
1. Hand hygiene
2. Respiratory/cough etiquette
3. Patient placement
4. Personal Protective Equipment
5. Uniform and work clothing
6. Safe handling of sharps
7. Decontamination
8. Housekeeping
9. Laundry
10. Waste
11. Managing dishes/tray delivery
12. Recreational Reading Material
13. Play Equipment and Toys
14. Healthy workplace
1. Hand Hygiene
Hand hygiene is the single most important procedure for preventing cross infection. Body
secretions, excretions, environmental surfaces and hands of all healthcare workers can carry
microorganisms (bacteria, viruses and fungi) that are potentially infectious to them and
others. Hand washing is known to reduce patient morbidity and mortality from hospital
acquired infection. It causes a significant decrease in the carriage of potential pathogens on
the hands.
Indications for Hand Hygiene

The decision to decontaminate hands should be based on an assessment of the risk that
microorganisms have been acquired on the hands and transiently carried to another person
or location.
Figure 3: The Four Moments for Hand Hygiene
Reference: Government of Ontario (2006)
Hand hygiene must be carried out in the following situations:

At the beginning of every shift
Before contact with any patient
In between contact with each and every patient
After contact with a patient on Additional Precautions or one who is colonized with
microorganisms of special clinical significance, e.g. resistant to a number of antibiotics
Before performing mouth care
Before and after contact with susceptible sites, e.g. wounds, burns, IV sites
Before performing invasive procedures, e.g. where natural defenses against infection
are breached
After hands have been contaminated, e.g. contact with body fluids, soiled linen,
equipment or garbage
After gloves have been removed
Before handling food or medicines
Before handling clean linen
After using the toilet or after toileting others
Before and after eating
Prior to entering and leaving a nursing station
Prior to using computers and other electronic devices
Hand hygiene may also be desirable at other times. The Infection Prevention and Control
Team may request additional requirements for hand hygiene, e.g. during an outbreak of
infection.
Nail and Skin Care

The nails are the area of greatest contamination. Short nails are easier to clean and are less
likely to tear gloves. Please refer to VIHA‘s Policy 15.1 – Hand Hygiene Policy.
Nail varnish is prohibited, regardless of colour, for staff with direct patient contact, or who
work in areas where direct patient contact takes place
Nail extensions/nail art and acrylic nails are prohibited for staff with direct patient contact,
or who work in areas where direct patient contact takes place
Ensure the skin on your hands does not become dry or damaged. In these conditions the
hands show a higher bacterial load, which is more difficult to remove than with healthy, intact
skin.
Hand lotion may be used to prevent skin damage from frequent hand washing.
Note: skin lotions for patient and/or staff use have been reported sources of outbreaks,
so pump dispensers are preferable over tubes or jars. If a pump dispenser is not
available, individualized containers must be used1
Creams that have been taken into a patient‘s room should be dedicated to that patient and
either disposed of or sent home with the patient on discharge
Compatibility between lotions and antiseptic products, and lotion‘s potential effect on glove
integrity should be checked (i.e. lotions should not be petroleum based). Please check
with Infection Prevention and Control or Occupational Health and Safety to ensure lotion is
approved for use
Type of Cleansing Agent
Alcohol Based Hand Rub

Indications:
Use routinely when hands are not physically soiled
1
Skin lotion and cream containers for patients are classified as single patient use items
Alcohol based hand rubs2 (ABHR) can be used in place of soap and water, except where
hands are visibly soiled (e.g. feces, blood, etc.). They are especially useful in situations
where hand washing and drying facilities are inadequate or where there is a frequent need for
hands to be decontaminated (such as in client‘s homes). Every effort should be made to
install these products as close to point of care as possible.
Alcohol based surgical scrubs are used in situations where a reduction in the resident
microbial flora is considered desirable, such as in an operating theatre or similar department,
and before performing an invasive procedure, especially the placement of an indwelling
medical device.
Reference: WHO, World alliance for Patient Safety (2006) WHO guidelines on hand hygiene in healthcare
(advanced draft). April 2006. Report No: WHO/WPI/QPS/05.2
Soap and Water

Indications:
When hands are physically soiled
When hands look or feel dirty
Following contact with blood or body fluids
Following contact with any patient with diarrhea/vomiting, and their environment,
including bathroom facilities
In clinical areas, soap is supplied as liquid or foam, in sealed containers, where the
dispensing nozzle is integral to the container, and changed when the unit is empty. Soap
dispenser pumps are never to be reused, refilled or ―topped up‖ and must be disposed of
once empty.
It is recommended that hands are washed with soap and water if in contact with spores (e.g.
Clostridium difficile), because the physical action of washing, rinsing and drying hands has
been proven to be more effective than alcohols, chlorhexidine, iodophors and other antiseptic
agents.
Handwashing Technique
A brief wash will remove the majority of transient microorganisms, but the technique should
aim to cover all surfaces of the hands. Where soap or a surgical scrub has been used, hands
should be rinsed under running water and thoroughly dried with a disposable towel. The soap
and hand towels should be of a quality acceptable to users, so as not to deter hand washing.
The skin should be maintained in good condition to discourage the accumulation of bacteria.
2
The optimal concentration of ABHR is 70-90% with added emollients; a minimum of 70% ethanol will protect
against Norovirus. If the ABHR is a gel, a minimum of 80% ethanol is recommended. ABHR dispensers should
read volume per volume, not weight per volume.
Hand hygiene should include the cleaning of arms to the elbow, especially when wearing a
sleeveless apron.
Table 3: Levels of Hand Disinfection

Method Solution Task
Social Alcohol based hand rub For Routine Practices
or
Soap and Water hand wash (if visibly soiled
and/or contact with spores likely)
Hygienic hand Soap and Water hand wash followed by an Prior to invasive procedures performed at
disinfection alcohol based hand rub unit level
Aseptic (Surgical A 2 minute antiseptic wash (i.e. chlorhexidine Prior to surgical procedures
scrub) (CHG 4%)) and dry on sterile towels
or
Soap and water hand wash followed by
surgical alcohol based hand rub
Hand Hygiene Procedure

The areas of the hands that are often missed are the wrist creases, thumbs, fingertips, under
the fingernails and under jewelry. For this reason, only a plain wedding band with no stones
is acceptable (please refer to VIHA‘s Policy 15.1 – Hand Hygiene Policy).
Alcohol based hand rub technique

Soap and water hand wash must be performed if hands look or feel dirty
Apply an application to fill cupped palm of one hand
Rub into all surfaces of hands (finger tips and nails, wrists, palms, backs of hands and
between fingers)
There must be sufficient wetness on all skin surfaces that it takes 15 or more seconds to
dry
Rub hands together until rub has evaporated prior to gloving or touching the patient
Soap and Water hand washing technique

Wet your hands up to the wrists ensuring all surfaces of the hands are covered by water
Apply the cleanser/soap
Smooth it evenly all over your hands, including the thumbs and in between fingers, lather
well rubbing vigorously. Place fingertips and nails into the lathered palm and rub. Repeat
with opposite hand
Rinse off every trace of lather under running water, to prevent skin irritation
Dry thoroughly, taking special care between the fingers. More than one paper towel may
be necessary
Surgical asepsis (scrub) technique with an alcohol based hand rub

Use sufficient product to keep hands and forearms wet with the alcohol based surgical scrub
(ABSS) throughout the procedure (usually at least a cupped hand filled with ABSS).
Apply ABSS to clean, dry hands and nails:
Cup hand and hold 1–2 inches from the nozzle

PUMP 1
o Dispense first full pump into the cupped palm of one hand (fill cupped hand)
o Dip fingertips of the opposite hand into the ABSS and work in under the nails
Wipe the excess solution from the fingertips back onto the palm of the same
hand
o Spread the remaining amount from the palm from wrist to elbow of the opposite
arm, covering all surfaces
PUMP 2
o Place another full pump into the opposite, dry palm and repeat the above
procedure with the other hand
PUMP 3
o Dispense a final full pump into either palm and reapply to all aspects of both
hands up to the wrist
o Proceed to the operating room suite holding hands above elbows
After applying ABSS allow hands and forearms to dry thoroughly before donning sterile
gloves and gown.
Surgical asepsis technique with a medicated soap

Wash hands and arms up to elbows with a non-medicated soap before entering the
Operating Room area or if hands are visibly soiled
Start timing
o Scrub each side of each finger, between the fingers and the back and front of the
hands for 2 minutes
o Scrub the arms, keeping the hand higher than the arm at all times. This helps to
avoid recontamination of the hands by water running from the elbows, and prevents
bacteria laden soap and water from contaminating the hands
o Wash each side of the arm from wrist to elbow for 1 minute
o Repeat this process on the other hand and arm, keeping the hands above the
elbows at all times. If the hand touches anything except the brush at any time, the
scrub must be lengthened by 1 minute for the area that has been contaminated
o Rinse hands and arms by passing them through the water in one direction only;
from fingertips to elbow
o Proceed to the operating room suite, holding hands above elbows
At all times during the scrub procedure, care should be taken not to splash water onto
surgical attire
Once in the operating room suite, hands and arms should be dried using a sterile towel
before putting on gown and gloves.
Aseptic technique must be maintained at all times
2. Respiratory Hygiene/Cough Etiquette

The transmission of SARS-CoV in emergency departments by patients and their family
members during the widespread SARS outbreaks in 2003 highlighted the need for vigilance
and prompt implementation of infection prevention and control measures at the first point of
encounter within a healthcare setting.
Respiratory hygiene/cough etiquette is targeted at patients/residents and accompanying

family members and friends with undiagnosed transmissible respiratory infections, and
applies to any person with signs of illness, including cough, congestion, rhinorrhea or
increased production of respiratory secretions when entering a healthcare facility.
The elements of respiratory hygiene/cough etiquette include:

Education of healthcare facility staff, patients/residents and visitors
Posted signs, in languages appropriate to the population being served, with
instructions to patients/residents and visitors
Source control measures (e.g. covering the mouth and nose with a tissue when
coughing and prompt disposal of used tissues, using surgical masks on the coughing
person when tolerated and appropriate)
Hand hygiene after contact with respiratory secretions
Spatial separation, ideally more than 6 feet between persons with respiratory infection
in common areas, when possible
It should be noted that although fever will be present in many respiratory infections,
patients/residents who are very old or very young and patients/residents with pertussis and
mild upper respiratory tract infections are often afebrile. Therefore, the absence of fever does
not always exclude respiratory infections.
Patients/residents who have asthma, allergic rhinitis or chronic obstructive lung disease also
may be coughing and sneezing. While these patients/residents often are not infectious,
cough etiquette measures are prudent.
Healthcare personnel are advised to observe droplet precautions and hand hygiene when
examining and caring for patients/residents with signs and symptoms of respiratory infection.
Healthcare personnel who have a respiratory infection are advised to avoid direct patient
contact, especially with high risk patients/residents. If this is not possible, then a mask should
be worn while providing patient care.
Modified from: Siegel, J.D., Rhinehart, E., Jackson, M. Chiarello, L. and the Healthcare Infection Control
Practices Advisory Committee (2007) Guideline for isolation precautions: preventing transmission of infectious
agents in healthcare settings. June 2007
3. Patient Placement
A further aspect of routine practices is the decision making process for patient placement.
Options include single patient rooms, two patient rooms and multi-bedded rooms/bays.
Single room accommodation is always the preferred option. However, most facilities have
limited resources in this area, and competing considerations when determining the
appropriate placement of patients/residents.
Single patient rooms are always preferred when there is a concern about the transmission of
an infectious agent. In situations that require prioritization of such accommodation, it is
prudent to prioritize these rooms for patients/residents who pose a high cross infection risk to
other patients/residents, particularly for those who are at increased risk of an adverse
outcome from the acquisition of an infection.
Occasionally, due to the number of patients/residents who are colonized or infected with the
same organism, cohorting the group of patients/residents in the same area may be an option
(see ARO Room Placement).
4. Personal Protective Equipment

Personal protective equipment (PPE) is used for two reasons:
To protect staff from blood or body fluid contamination
To reduce the risk of cross infection through the reduction in contamination and
transferring of microorganisms to other patients/residents, staff, visitors and the
environment
Gloves
The hands of clinical staff are the most likely means of transmission of healthcare associated
infection. Through hand washing and the appropriate use of gloves the risk of cross infection
is minimized.
There are a number of materials used in the manufacture of gloves, including latex, nitrile and
vinyl (PVC). The choice of material will depend on the type of task being performed, contact
with chemicals and the risks associated with latex sensitization. The use of vinyl gloves is not
recommended for prolonged tasks that require manual dexterity or when contact with blood or
body fluids is anticipated.
The purpose of wearing gloves is to either prevent the hands becoming contaminated with dirt
or microorganisms, or to prevent the transfer of organisms already present on the skin or the
hands. It is essential to ensure that hands are washed before putting on gloves and following
the removal of gloves.
Table 4: Examples of Tasks that Require the Wearing of Gloves
Gloves must be worn: Gloves should not be worn:

When touching mucous membrane When there is no risk of exposure/ splash/
contact with blood, body fluids and non-intact
skin
When changing a dressing, or having contact When assisting or feeding a patient
with non-intact skin
When changing diapers or adult briefs For social touch
When performing personal hygiene for clients When pushing a wheelchair
When performing mouth care When delivering meals, mail, clean linen
When indicated for Additional Precautions For providing care to clients with intact skin,
e.g. taking temperature
Staff must ensure that the appropriate type of glove is selected for particular procedures with
the purpose to ensure safety and protection for staff and patients/residents. When
considering the nature of the task, the need for sterile or non-sterile gloves should be
assessed.
Sterile gloves are worn to protect the patient during aseptic invasive procedures.
Non-sterile gloves, latex or latex alternative (e.g. nitrile) are worn to protect the healthcare
worker where direct exposure to blood or body fluids and other microorganisms is anticipated.
Storage of disposable gloves: it is important to store latex and nitrile gloves separately at
all times. This will include, and not be exclusive to, the clean utility room and within all clinical
area where the gloves are available for use. Although latex gloves are low protein, there is
still a risk of transfer of this protein to nitrile gloves.
Nitrile gloves are recommended as an alternative product to latex in the presence of allergy.
Table 5: Glove Use in Patient Care
Types Specifications Advantages Disadvantages Recommended use Storage
Latex Material Natural rubber Poor against oils, Most common DO NOT
Level of Long standing greases and glove type for a STORE near
protection barrier qualities organics sterile glove and Nitrile gloves
Allergen content Powder free are Not for significant
Strength and lower in allergens recommended exposures to
durability Very strong and for individuals blood and blood
Puncture durable who have contaminated
resistant Has re-seal allergic reactions body fluids
Fit and comfort qualities or sensitivity to Recommended
Chemical Provides latex for weak acids,
resistance excellent comfort weak bases,
and fit alcohols, water
Good protection solutions
from most
caustics and
detergents
Nitrile Material Synthetic rubber Not Used as a DO NOT
Level of Excellent physical recommended general purpose STORE near
protection properties and for aromatic glove when Latex gloves
Allergen content dexterity solvents, many additional
Strength and Contains no latex ketones, esters, strength and
durability protein many dexterity are
Puncture Very strong and chlorinated required
resistant durable solvents Recommended
Fit and comfort Excellent for oils, greases,
Chemical puncture acids, caustics,
resistance resistance aliphatic solvents
Good fit due to Alternative to
high elasticity latex for those
Excellent with a latex
resistance allergy for tasks
where exposure
to blood and
body fluids is
likely
Vinyl Material Polyvinyl chloride Not Most common
(PVC) Level of Good level of recommended type of general
protection protection, but for aliphatic, purpose glove for
Allergen content based on the aromatic and procedures of
Strength and quality of the chlorinated short duration
durability manufacturer solvents, and minimal
Puncture Punctures easily aldehydes, exposure to
resistant when stressed keytones blood and body
Fit and comfort Rigid – non Quality varies fluids
Chemical elastic with Recommended
resistance Medium chemical manufacturers for strong acids,
resistance bases, salts,
other water
solutions, and
alcohols
Adapted from: Sunnybrook Hospital (Toronto) June 2008
Figure 4: Choosing the Correct Glove
Examination Glove
Latex /
Polyethylene/
latex alternative Vinyl (PVC)
Polythene
(e.g. nitrile)
Only used in
Sterile Non-Sterile Non-Sterile
catering
 All aseptic  Non-aseptic  Tasks which are

procedures with procedures with short and non-
potential a high risk of manipulative
exposure to exposure to  Tasks which will
blood or body blood or body not pull or twist
fluids. fluids. the glove
 Sterile  Procedures  Tasks where
pharmaceutical involving sharps contact with
preparations.  Handling blood or body
cytotoxic fluids is unlikely
material  For cleaning
 Handling tasks
chemicals and
disinfectants
Note: when handling chemicals and liquids, follow the manufacturer‘s guidelines on glove selection.
Non-disposable household gloves are worn for tasks other than direct patient care (e.g.
laundry, or for all work requiring chemicals, cleaners and disinfectants).
Where the use of non-disposable household gloves is required, the:

Employee‘s department will provide them
Department is responsible for maintaining written protocols on the use of gloves and
ensuring that employees are aware of and comply with these protocols
Gloves must meet WorkSafe BC standards for the task
o Non-disposable gloves must be designated to the individual worker, and must be

inspected by the worker daily to ensure that the gloves have no holes or tears in
them. If gloves are damaged, they must be discarded and replaced
o They must be dried and stored in a clean, dry area
o Disposable gloves must not be used as a liner
o If disposable gloves are used, then they must be changed regularly to ensure
integrity and cleanliness
o Regardless of type of glove, they must be washed between clean and dirty tasks
and whenever the floor bucket disinfectant solution is changed.
Gowns/Aprons
Disposable gowns and/or plastic aprons should be worn when there is a risk that clothing may
become exposed to blood, body fluids and excretions, with the exception of sweat, or when
close contact may lead to contamination by microbes from the patient, materials or
equipment.
Long sleeved impermeable gowns should be worn where there is a risk of contamination or
splashing of blood, body fluids, secretions or excretions, onto the skin or clothing of the
healthcare worker.
Gowns and aprons are worn as single use items, and must be disposed of after one
procedure or episode of patient care.
Hand hygiene following apron use must include cleaning of exposed arms to the elbows.
Scrubs or laboratory style coats/jackets worn over clothing are not considered to be PPE and
must not be worn in place of a disposable gown. Their long sleeves also inhibit correct hand
hygiene, and can be a source of contamination.
Cloth gowns do not provide the required protection and should not be used.
Gowns/aprons must be worn when the caregiver‘s clothing is likely to become

contaminated with blood, feces, urine or any other secretions
They must be worn when the uniform is likely to become contaminated by
microorganisms, e.g. during bed making
They must be worn when giving direct patient care
Gowns/aprons must only be worn for the duration of the task and disposed of as waste
Personal Protective Equipment should be changed following procedures, between
patients/residents, and if they become heavily contaminated or torn/split during a
procedure
Hand hygiene must be performed when the gown or apron is removed
Hand hygiene must include cleaning of exposed arms to elbows if using an apron
Masks, Visors and Protective Eyewear

The mucous membranes of the mouth, nose and eyes are susceptible areas for infectious
agents. Therefore, the use of masks, visors or protective eyewear and full-face shields are
important parts of routine practices. Some masks are supplied with the additional protection
of a visor.
Masks with the additional protection of a visor are single use and must be disposed of when a
period of care has finished. Some visors are also supplied as single use, and as such must
not be decontaminated. However, reusable visors and goggles can be decontaminated using
a Hydrogen peroxide solution, or ready to use Hydrogen Peroxide 0.5% wipe.
Masks are worn:

By healthcare personnel when engaged in procedures requiring sterile technique to
protect patients/residents from exposure to infectious agents carried in the healthcare
worker‘s mouth or nose
By coughing/sneezing patients/residents to limit potential dissemination of infectious
respiratory secretions from the patient to others
By healthcare personnel when engaged in aerosol generating procedures with a patient
with a droplet infection, e.g. open suctioning, nebulized medication, bronchoscopy
A fit tested3 N95 mask is to be worn:

During the care of patients/residents who are diagnosed or suspected as having an
airborne infection (e.g. Pulmonary Tuberculosis)
N95 masks must be used during the entire period of infectiousness (consult with Infection
Prevention and Control)
A single-use N95 mask must only be worn once
Masks and eye protection or a visor are worn:

By healthcare personnel to protect them from contact with infectious material from
patients/residents, e.g. respiratory secretions and sprays of blood or body fluids,
consistent with Routine Practices and Droplet Precautions.
Please refer to Donning & Doffing PPE posters
3
Fit tests are performed by Employee Occupational Health & Safety.
5. Hair/Jewelry/Uniforms
Hair
Hair should be clean, neat and tidy
Hair fastenings should be minimal
Long hair should be tied up off the collar when working in the clinical setting
Jewelry
Rings with stone settings must not be worn in clinical situations, as they compromise
hand hygiene
Wrist watches, bracelets, bangles or other wrist adornments must be removed when
caring for patients/residents (exception: Medical Alert Bracelets) as they inhibit correct
hand hygiene. Please refer to VIHA‘s Policy 15.1 - Hand Hygiene Policy for more
information
Footwear
Suede or fabric shoes are not acceptable as these cannot be shoe polished or
machine washed
Dress Code for Staff Who Do Not Wear a Uniform, Including Medical Staff
Long sleeves (i.e. scrubs, tee shirts or white coats with long sleeves) should not be
worn in the clinical setting and when assessing patients/residents due to the increased
potential of the cuffs coming into contact with patients/residents and becoming
contaminated4
Ties and lanyards (e.g. hanging nametags) should be tucked in prior to taking part in
clinical procedures
Dress Code for Staff Wearing a Uniform

Sleeves should end above the elbow. Long sleeves (white coats with long sleeves)
should not be worn in the clinical setting and when assessing patients/residents due to
the increased potential of the cuffs coming into contact with patients/residents and
becoming contaminated 5
4
If these requirements cannot be met for religious reasons, alternative options will be determined through
discussion with Infection Prevention and Control and area Manager.
5
If these requirements cannot be met for religious reasons, alternative options will be determined through
discussion with Infection Prevention and Control and area Manager.
Material should be such that it may be laundered on a HOT WASH (above 65

degrees C) to ensure adequate decontamination. A clean uniform must be worn every
shift/ working day
Sweaters or jackets should not be worn over the uniform, as they are likely to become
contaminated with microorganisms
Uniform should be changed as soon as possible after finishing work
Uniforms should not be worn when visiting public areas such as stores
References:
Department of Health 2007 UNIFORMS AND WORKWEAR An evidence base for developing local policy
Halls, F. et al 1984 ‗A question of uniform‘. NURSING TIMES Vol 87: No50, pp 53-54
6. Safe Handling of Sharps

The term ―sharps‖ includes items such as needles, scalpels, scissors, broken glass and other
items that may cause laceration or puncture to the skin.
Sharps are responsible for a significant number of injuries to staff each year. Safe
management of sharps can help to reduce the risk of injury, and therefore the acquisition of
infections such as blood borne viruses by both staff and patients/residents. A high proportion
of sharps injuries occur during disposal and waste collection.
Many sharps hazards have been removed through the introduction of safety engineered
sharps. Nonetheless, the prevention of sharps injuries is an essential part of routine
practices, including handling and disposing of sharps in a manner that will prevent injury to
the user and others. IV tubing should not be cut for disposal, as this will create a sharp end
and risk aerosolising the contents. It is the responsibility of the user to ensure the safe
disposal of a sharp.
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
Sharps must not be recapped after use, prior to disposal directly into a disposal container
Never bend or break needles after use
Do not disassemble needles from syringes or other devices; always dispose of as a single
unit
IV tubing should be placed directly into a sharps disposal container without cutting it
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
7. Decontamination
Transmission of infectious agents can occur during casual contact from inanimate object to
clean surfaces. Micro-organisms can survive on surfaces for long periods.
All items of reusable equipment and furnishing in healthcare settings must be cleaned and
disinfected/sterilized according to the manufacturer‘s instructions between patient use (e.g.
stretchers, BP cuffs, etc). Items that cannot be appropriately decontaminated must not be
purchased. Discuss possible new equipment with IPC Practitioner prior to purchasing it in
order to assess its suitability for the clinical area with regard to decontamination.
Cleaning
Definition: cleaning is the physical removal of dirt and organic matter. Cleaning removes up
to 80% of microorganisms and is an essential part of infection prevention and control.
Organic matter can inactivate certain disinfectants, and therefore must precede disinfection
and sterilization.
It is important to ensure that multi-use equipment is cleaned properly between

patients/residents. Equipment that is classified as critical or semi-critical must be
disinfected at the appropriate level following each use (See Disinfection Requirements for
Equipment).
Non-porous non-critical and other items, for example scales or stethoscopes, can be easily
cleaned with an intermediate or low-level disinfectant (see Reprocessing Decision Chart
Table below and Classes of Organisms in Order of Susceptibility).
Non-critical and other items made of fabric material should be cleaned when visibly soiled
and following exposure to blood or body fluids. These items should also have an established
routine cleaning with an intermediate or low-level disinfectant. Items such as blood pressure
cuffs, which come into contact with the patient, should be wiped between patients/residents
using a disinfectant wipe.
Patients/residents on additional precautions require dedicated equipment wherever possible.

If this is not possible, all equipment must be thoroughly decontaminated following each use,
regardless of its classification.
If equipment/device cannot be immediately disinfected, all soil must be immediately removed

from the device.
Table 6: Reprocessing Decision Chart

Process Item Examples Products and methods
Cleaning All reusable All equipment requires cleaning after Physical removal of soil, dust, or
Some items equipment use and before further disinfection foreign material. Chemical, thermal,
may require processes are initiated or mechanical aids may be used.
low level Soap and water
Process Item Examples Products and methods

disinfection Specific environmental surfaces that Enzymatic agents
are touched by personnel during Quaternary ammonium
procedures involving parenteral or compounds
mucous membrane contact (e.g. Some iodophors (e.g. 3%
dental lamps) hydrogen peroxide)
Bedpans, urinals, commodes
Stethoscopes
Blood pressure cuffs
Ear specula
Hemodialysis surfaces in contact
with dialysate
Cleaning Some After large environmental blood spills Alcohols

followed by Semi-critical
or spills of microbial cultures in the Hypochlorite solutions
intermediate items laboratory Iodophors
level Glass or electronic thermometers
disinfection Hydrotherapy tanks for
patients/residents whose skin is
not intact
Cleaning Semi-critical Flexible endoscopes, Items intended for sterilization in the
followed by items laryngoscopes, respiratory plasma or EO sterilizers must be
high level therapy equipment meticulously cleaned prior to
disinfection Nebulizer cups sterilizing.
Anaesthesia equipment
Nasal specula Pasteurization
Tonometer food plate 2% gluteraldehyde
Ear syringe nozzles 6% hydrogen peroxide
Vaginal specula Peracetic acid
Vaginal probes used in Chlorine or chlorine compounds
sonographic scanning
Pessary and diaphragm fitting
rings
Cervical caps
Breast pump accessories
Cleaning Critical items All items coming into contact with Glass or electronic thermometers
followed by sterile tissue Steam under pressure
sterilization Surgical instruments Dry heat
All instruments used for foot care Ethylene oxide gas
All implantable devices 2% glutaraldehyde
Cardiac and urinary catheters 6-25% hydrogen peroxide
All intravascular devices peracetic acid
Biopsy forceps or biopsy chlorine dioxide
equipment associated with 6-8% formaldehyde
endoscopy equipment
Bronchoscopes, arthroscopes,
laparoscopes
Cystoscopes
Transfer forceps
High speed dental hand pieces
Adapted from: Health Canada, CCDR Hand Washing, Cleaning, Disinfection and Sterilization in Health Care,
December 1998, Volume 24S8
Disinfection
Definition: Removal and destruction of most pathogens (or disease-causing organisms) by
the use of friction (cleaning) and a use of a disinfectant.
Usually disinfectants are ―cidal‖ in that they kill the susceptible potential pathogenic agents.
Generally, disinfectants used throughout VIHA both clean and disinfect. The selection of a
disinfectant should be based on the function the disinfectant is expected to perform, not
necessarily on a sales pitch or on what has always been used. Ideally, a disinfectant should
be broad spectrum (eliminates bacteria, viruses, protozoa, fungi and spores). The Table on
Classes of Organisms in Order of Susceptibility to Disinfectant – outlines the classes of
organisms and what is required in the way of disinfectants to eliminate them.
Disinfectants are necessary in healthcare settings to kill potentially infectious microorganisms,

but may be harmful to staff/patients/residents/public if used inappropriately.
All disinfectants used in VIHA facilities are to be approved for use in healthcare
facilities and possess a drug identification number from the Health Protection Branch
of Health Canada
Disinfectants should be compatible with the equipment/device to be disinfected
The use of the device should be considered when deciding the type of disinfectant to
use
Personal and environmental safety should also be considered when selecting a
disinfectant
The manufacturer‘s instructions for use and storage must be followed
Disinfectants should also be:

Non-irritating
Non-toxic
Non-corrosive
Inexpensive
Selection decisions should include effectiveness against the potential pathogenic agent,
safety to people, impact on equipment, the environment, and expense.
Table 7: Classes of Organisms in Order of Susceptibility to Disinfectants
Organism Type Level of Disinfectant

Bacteria with Spores
Hardiest (B. subtitles, C. tetani, C. difficile, C. botulinum,
Organisms B. anthracis)
Chemical Sterilant
Protozoa with Cysts
Giardia lablia, Cryptosporidium parvum)
Mycobacteria
(M. tuberculosis, M. avium-intracellulare,
M. abscessus)
High Level
Non-Enveloped Viruses
(Coxsackievirus, poliovirus, rhinovirus, Norwalk-like
Virus, hepatitis A virus)
Fungi
Candida species, Cryptococcus species, Aspergillus Intermediate Level
species, Dermatophytes)
Vegetative Bacteria
(Staphylococcus aureus, Salmonella typhi,
Pseudomonas aeruginosa, coliforms)
Enveloped Viruses (Herpes simplex, varicella-zoster Low Level

Most virus, cytomegalovirus, measles virus, mumps virus,
Susceptible rubella virus, influenza A and B virus, respiratory
syncytial virus, hepatitis B & C viruses, hantavirus
Organisms and human immunodeficiency virus)
The effectiveness of a disinfectant depends on many factors. These include:

Type of contaminating microorganism. Each disinfectant has unique antimicrobial
attributes
Degree of contamination. This determines the quality, efficacy and time of exposure of
the disinfectant required
Amount of protein based material present. High protein based materials absorb and
neutralize some chemical disinfectants
Presence of organic matter and other compounds such as soaps may neutralize
disinfectants
Chemical nature of disinfectant. It is important to understand the mode of action in
order to select the appropriate disinfectant
Concentration and quantity of disinfectant. It is important to choose the proper
concentration and quantity of disinfectant that is best suited to each situation
Contact time and temperature. Sufficient time and appropriate temperature must be
allowed for action of the disinfectant and may depend on the degree of contamination
and organic matter load
Residual activity and effects on fabric and metal should be considered for specific
situations
Application temperature, pH and interactions with other compounds must be
considered
Source: BCCDC Laboratory Services, A Guide to Selection and Use of Disinfectants, 2003
Table 8: Disinfection Requirements for Equipment

Category Level of Disinfection Examples
Critical Sterilization Surgical instruments
Items that come in Acupuncture needles
contact with the blood Foot care instruments
stream or sterile body
High Level Disinfection Internal scopes
tissues
Semi Critical Contact lenses
Items that come in High Level Disinfection Reusable Peek Flow Meters
contact with mucous Mouthpieces
membranes or non-intact Intermediate Level Thermometers
skin Disinfection Ear syringe nozzles
Non-Critical Intermediate Level Examination tables
Items that come in Disinfection Stethoscope
contact with intact skin Blood pressure cuff
Skin probes
Items that do not come in Furnishings
contact with the patient‘s Low Level Disinfection Dishes
skin Scales
The advantages and disadvantages of the various chemical disinfectants are highlighted
below.
Table 9: Advantages and Disadvantages of Major Chemical Disinfectants

Disinfectant Level of Uses Advantages Disadvantages
Disinfection
Manufacturers‘ Recommendations for Concentration and Exposure Time must always be followed
Alcohols Interme- External surfaces · Fast acting · Flammable – keep away from
(70% Isopropyl – diate of patient · No residue sources of ignition
undiluted) assessment · Non staining · Dilution with water will diminish
equipment, e.g. concentration and efficacy
O2 saturation · Inactivated by organic material
monitors, finger · May harden rubber or cause
clips, deterioration of glues
thermometers, · Use in the OR near cautery is
stethoscopes discouraged; can be on
and glucometers. anesthetic carts or wall mounts

Disinfection
6
Chlorines Interme- Disinfect · Low cost · Corrosive to metals
Household bleach diate hydrotherapy · Fast acting · Inactivated by organic material,
(5% Sodium tanks, dialysis · Readily e.g. blood, feces
Hypochlorite) equipment, available in non- · Irritant to skin and mucous
mixed at a ratio of cardiopulmonary hospital settings membranes
1 part bleach to 9 training manikins · Have sporicidal · Use in well-ventilated areas
parts water, for a and properties · Unstable when diluted and
total of 10 parts) environmental exposed to light (must be kept in
surfaces. an opaque container)
· For effective use, the following
Effective must be considered:
disinfectant - Appropriate dilution;
following blood - Stability/shelf life prior to
spills. dilution;
- Stability/shelf life of product
after dilution
· Follow manufacturer‘s
instructions for duration of shelf
life, both before and after
reconstitution
· Tablets and mixed solutions
remain stable < 24 hours after
reconstitution
· Bottles of bleach normally remain
stable < 30 days after opening if
in an opaque container.
Household For cleaning of

bleach personal laundry
(5% Sodium
Hypochlorite)
mixed at a ratio of
1 part bleach to
499 parts water,
for a total of 500
parts)
(1 cup per
laundry tub)
(100 ppm)
6
Also available in tablet and granule form. Follow manufacturer‘s instructions for proper dilution.

Disinfection
Hydrogen Low Equipment used · Available to use · Can be corrosive to aluminum,
peroxide for home in ready-to-use copper, brass or zinc
3% concentrate healthcare, wipes · Cannot be used on anesthetic
diluted at a ratio patient · Strong oxidant hosing
of 1 part assessment and with good · Limited sporicidal activity
Hydrogen care at the cleaning · Wet contact time must be more
Peroxide to 16 bedside and properties than 5 minutes
parts water for other treatment · Fast acting
patient care settings. · Bactericidal in
surfaces. less than 1
minute
· Viricidal in less
than 5 minutes
· Environmentally
friendly
Hydrogen Cleans floors,

peroxide walls and
3% concentrate furnishings.
diluted at a ratio
of 1 part
Hydrogen
Peroxide to 64
parts water for
floors
Quaternary Low Routinely used in · Inexpensive · Limited use as disinfectant

ammonium facilities for · Generally non- because narrow microbiocidal
compounds environmental irritating to spectrum
(Usually diluted at cleaning in hands in diluted · Non-sporicidal
1 part quaternary patient care form
ammonia to 256 areas (e.g. · Contain
parts water) floors, walls and cleaning
furnishings). properties
· Mildly corrosive
Modified from: Health Canada. Canadian Communicable Disease Report, Dec 1998, Vol. 24S.
Sterilization
The highest level of asepsis is defined by the removal of all microorganisms. It is achieved by
autoclaving or by another sterilization process. Items must be thoroughly cleaned before
sterilization can occur. For information on sterilization techniques used in your facility contact
your local Central Sterilizing/Processing department. (Reprocessing Policy Manual)
Storage
Storage of Contaminated Equipment
Storage of contaminated equipment is to be held in a designated area/container
Gross soil must be removed before storage prior to cleaning
The storage area must be physically separated (by walls where possible) from a clean
area, and be cleaned daily
Hand hygiene must be performed before leaving the ―dirty‖ area
Once items are cleaned, they should be labeled as such, and moved to a clean
storage area
Storage of Clean/Sterilized Equipment

Areas designated for clean equipment should have a sign displayed identifying the
area, and/or cleaned equipment should be labeled as clean
Shelf life is event related, not always time related. Sterilized equipment/devices are no
longer considered sterile if there is a disruption in the integrity of the packaging (e.g.
packaging tear, the packaging becomes wet, or the item is dropped)
Items purchased as sterile must be used before the expiration date. If the expiration
date has passed, the item must be discarded
The areas in which medical devices are stored or handled should be used for storage
only, protected from vermin, moisture and the entry of dust from adjacent areas and
ventilation systems. There must be sufficient storage space to prevent damage to the
packages
Sterile items should be stored in an area with limited traffic and a door
Sterile medical devices should be stored at least:
25 cm from the floor
45 cm from the ceiling
5 cm from the wall
Cardboard boxes must not be used for storage
All storage should be above floor level to allow appropriate cleaning
Storage must be away from a sink area, to prevent contamination from splashing
Event Related Sterility

Devices that are received sterile must be maintained sterile until used or until the
expiration date has passed, and they are discarded
Shelf life of sterile items is event related. Event related factors that may cause
contamination and decrease shelf life are:
Method and frequency of handling (e.g. dropping a sterile item on the floor renders
it contaminated)
Method and conditions of storage, such as location (e.g. shelves located below
knee level are considered at risk for contamination and are not appropriate for
storage of sterile items)
Space (e.g. sterile items stored beside a sink are at risk for splashing with water
which compromises the integrity of packaging)
Temperature, humidity and exposure to moisture, dirt, dust or vermin
All sterile items must be checked for sterility before use. The date of expiration relates
to product ingredients and stability. For packaged items, check to ensure the integrity
of the package is intact and the sterile indicator is white with black stripes
All cleaned and disinfected/sterilized devices must be covered and protected from
moisture and dust during transport
8. Housekeeping
The environment acts as a suitable reservoir for many microorganisms, and therefore the
provision of a clean environment for patient care is an integral part of infection prevention and
control. (Housekeeping Section)
9. Laundry
All laundry is treated the same regardless whether a patient is on routine or additional
precautions. Soiled linen shall be handled and transported in a manner in which
contaminants are confined and contained. Clean linen that has been dropped on the floor is
considered soiled.
Soiled Linen
Using the guidelines of routine practices, soiled or used linens generated from all sources are
considered to be contaminated.
Soiled linen from all patients/residents or areas will be handled in the same manner:
Wear non-sterile gloves and disposable gown or apron
Position hamper/tote/laundry bag in room (i.e. locate centrally in room and open lid) or
as close to the room entrance as possible
Ensure that linen is free of biomedical waste, sharps, instruments, and patient‘s
personal belongings
Separately fold linen into itself. Avoid shaking or fluffing
Dispose of into linen tote/hamper
Remove PPE and perform appropriate hand hygiene
Dirty linen is not to be placed on the bedside tables, floor or in the sink
Soiled linen is to be handled as little as possible:

Following removal from the patient bed space, linen must be immediately placed into a
hamper/tote/laundry bag
To prevent staff injuries, the soiled linen hamper/tote/laundry bags should not be
overfilled. Close when ⅔ full
Linen that is heavily soiled, saturated or dripping should be placed in a leak proof clear
plastic bag and then placed inside the regular hamper/ tote/ laundry bag
The laundry hamper/tote/bags, particularly the large laundry bins should be stored in a
predetermined dirty area that is at least one meter from any clean items and at least
one meter from any fire equipment
Mattresses and pillows that are covered with impervious plastic do not have to be sent to the
Regional Laundry for cleaning and disinfecting as they can be effectively cleaned on-site
using an appropriate disinfectant (see the Reprocessing Decision Chart). Mattresses and
pillows must also be monitored for wear points, and replaced as necessary.
Remove PPE after handling soiled linen and

perform hand hygiene before handling clean linen
Laundering on the Units

Laundering on units is not advocated in acute care setting. However, in some areas such as
residential care settings it may be necessary. In these cases, the following is recommended:
The outside of the machines (i.e. washer and dryer) should be cleaned with
disinfectant prior to each use
If hot-water laundry cycles are used, wash with detergent in water of at least 71o C (at
least 160o F) for a cycle of 25 minutes or more
Once washed, items should be dried quickly in a dryer (i.e. not air dried)
The laundry area should be in a dedicated space and must not be located in the same
area as a dishwasher or fridge (used for food)
Clean Linen
Soiled linen must never come into contact with clean linen.
Perform hand hygiene prior to removing clean linen

from central supply area or from carts.
Clean linen should be unpacked on return from the laundry and stored in a designated
area within each department
The linen room should have a door, which should be kept closed. If this is not possible
then the linen cart covers should remain closed around the linen racks when not being
accessed
Clean linen must be stored at least one meter away from any ―dirty area/items‖ or fire
equipment
Clean linen must be stored at least one meter from any dirty items
Clean linen is to be handled as little as possible

Linen which is removed from the clean supply area/cart is not to be returned to that
cart
The clean supply cart should only be stocked with one day‘s supply, which should be
used before restocking the cart
Linen carts are to be dedicated for linen only. The clean linen carts are not to contain
other supplies
Staff involved in the handling of linen shall ensure that there is no cross contamination of
clean and soiled linens during transportation and storage.
Handling Soiled Linen contaminated with Hazardous Materials

When hazardous materials are used, stored or disposed of, written safe work procedures
must be developed and implemented for preparation, administration and waste handling.
Departments intending to return soiled linens that are contaminated with hazardous materials
must ensure that there is no potential risk to staff or patients/residents.
Hazardous materials include, but are not limited to:

Chemicals that are a risk due to being toxic, poisonous, carcinogenic, noxious,
flammable, combustible, corrosive or reactive with other chemicals.
Radioactive substances that are present on soiled linen will be decontaminated at the
site at which the patient resides. Linen contaminated by radioactive substances will
not be sent to the Laundry until it is decontaminated by removing the radioactive
nuclide contaminants or setting it aside for the appropriate time (i.e. ten half lives).
Chemotherapy drugs (i.e. Antineoplastics).
Any contaminated linen identified by the user site as not able to be safely laundered will be
disposed of by the original hospital. For replacement purposes, the originating hospital will
inform the Regional Laundry of the disposal of its linen. If disposal of linen products
contaminated by hazardous material is inevitable, the user hospital will consider the use of
either disposable products or specific ―discard linen‖ which are linens that are usable but near
the end of their life cycle.
Note: Items of linen from patients/residents with unusual infections (e.g. Anthrax, Lassa Fever) should not be
disposed of without consulting either the Medical Microbiologist in the first instance or the Infection Control
Practitioner.
Reference: Fraser Health Authority, Acute Care Infection Prevention and Control Manual, 2008
10. Waste
VIHA is committed to the safety of the general public, patients/residents and staff. This is of
the utmost importance and, therefore, procedures will be adopted whereby any risks
associated with waste disposal will be minimized. The object of this section is to provide
guidelines and give procedures for the safe disposal of hospital waste.
All garbage must be placed in leak proof bags and closed securely before removal from
patient‘s room. When garbage bags are ⅔ full it should be secured and removed.
All housekeeping staff will wear personal protective clothing when handling clinical waste.
This clothing in normal circumstances will take the form of their general uniform, disposable
apron and protective gloves. All staff who need to move bags of waste by hand should:
Ensure the bags are effectively sealed and are intact
Handle bags by the neck only
Know the procedure in case of accidental spillage
Waste items such as used bandages, briefs and garbage are

not to be placed on the bedside tables, floor or in the sink
Yellow Bag Containers of blood or other blood saturated body fluids.

Disposable containers which are not emptied prior to
Clinical / Biohazardous disposal, should be securely taped shut and tubing clamped
Waste Secretions or exudates whose contents cannot be
hygienically emptied into toilet (e.g. Hemovac, sputum vial)
Transfusion lines or bags containing blood
All body tissue – including ‗Exempt body tissue‘ derived from
the operating room
Items saturated and dripping with blood and body fluids
Microbiology cultures
Black Bag Waste derived from the clinical and non clinical areas which
is not mentioned above and is not heavily contaminated with
Domestic/ General blood or body fluids
Waste Urinary drainage bags and catheters
Feces
Office waste
Kitchen waste
For chemotherapy disposal, see appropriate reference.
Biohazardous Waste
Biohazardous waste bags should only be filled to ⅔ full, as overfilling will prevent bags
from being tied securely
The containers for removal of biohazardous waste should be easily recognized, leak
proof, and have a durable fitted lid. They must be sealed prior to transport and stored
in areas unavailable to untrained staff, patients/residents or the public.
Gloves and disposable apron should be worn when handling biohazardous waste.
Hands should be decontaminated appropriately following removal of gloves
Goggles or face shields should be worn when disposing of body fluids if there is a
possibility of splash exposure to eyes or mucous membranes.
NOTE: Final disposal of Biohazardous waste will be either by incineration or by autoclaving followed by landfill
disposal.
Spillage of Blood or Body Fluids

(Body Fluids, Secretions and Excretions)
Wear gloves and disposable apron
Gross soil must be removed prior to cleaning and disinfecting
Use paper towels for small spills, mop for large spills
Clean the area
Disinfect with approved hospital disinfectant or a fresh solution of household bleach
(one part 5% bleach added to 9 parts water). Used paper towels, gloves and apron
should be placed in Biohazardous Waste bag
Mop heads should be placed in leak proof laundry bags
Bucket contents should be poured down the hopper, and the bucket rinsed and wiped
with the chlorine solution
Hands must be washed at the end of the procedure
Waste Containers
Only impervious waste containers dedicated for the transporting of clinical waste should be
used to minimize the potential for spillage and subsequent contamination of work place areas.
Garbage bins used in all non-office environments should all have lids that ideally open with a
foot-operated mechanism.
Waste trolleys must be such that they can be easily cleaned and drained, do not offer
harbourage to insects, and particles of waste do not become lodged in their fabric. The waste
must be easily loaded, secured and unloaded. Clinical waste must not be transported in any
other type of trolley. Biohazardous waste, sharps and general waste must never be mixed.
11. Managing Dishes, Glasses, Cups and Eating Utensils

Dishes/utensils are managed in the same manner, regardless whether a patient is on routine
or additional precautions.
Food Service workers must wash hands before leaving the kitchen and upon returning
to the kitchen, after both delivery and pick-up of trolleys
Food Service workers must decontaminate hands using an ABHR or wash hands
upon entry and exit of each unit and as needed before handling the next tray in the
event the patient‘s personal effects were touched to allow placement of the tray on the
over bed table. Gloves are not required in the delivery of trays
For removal of trays, Food Service Workers must decontaminate hands upon entry to
each unit and before putting on gloves. Trays are picked up from the over bed tables
and returned to the trolley. Gloves are removed upon completion of tray pick-up,
discarded appropriately, and hands decontaminated before leaving the unit. Carts
must be covered prior to leaving the unit
All trays and wares are washed, rinsed and sanitized in the kitchen area in accordance
with standard dishwashing procedures
Trolleys are washed, rinsed and sanitized by Food Services personnel between each
meal period, and allowed to air dry before reuse
Trolleys left on the unit for late trays are to be washed, rinsed and sanitized when
taken to the food services area, and at a minimum on a weekly basis
Note: Food Service Workers will not pick up any trays that contain bodily fluids or sharps.
They will bring this to the attention of the nursing staff.
Routine Practices Tray Delivery Tray Pick-up

Wash hands prior to tray delivery. Wear disposable gloves.
Disposable gloves not required.
Unit Staff Over bed table must be free of No preparations required.

equipment and debris.
Food Service Worker Food Service worker does not clear With gloved hands, pick-up the tray
over bed table. Place the tray on and return it to the tray cart. Gloves
the over bed table following are removed upon completion of tray
standard tray delivery procedures. pick-up, discarded, and hands
washed or alcohol based hand rub
applied before leaving the unit.
Managing Tray Delivery – Procedures Specific to Additional Precautions

The automated decontamination washing process effectively deals with all microorganisms.
Disposable dishes and utensils will not be used. Food Services personnel wear
aprons and gloves to strip all trays as all patient trays are considered contaminated
Food trays must never be bagged. On the rare occasion that a patient vomits onto the
tray, nursing staff (using droplet precautions) rinse off the vomit prior to returning the
tray to the kitchen for disinfection
Note: Food Service Workers will not pick up any trays that contain bodily fluids or sharps.
They will bring this to the attention of the nursing staff.
Contact Precautions Tray Delivery Tray Pick-up

(Yellow Sign) Wash hands prior to tray delivery. Wear disposable gloves
Disposable gloves not required
Unit Staff Over bed table must be free of No preparations required.
equipment and debris.
Food Service Worker Food Service worker does not clear With gloved hands, pick-up the tray
over bed table. Place the tray on the and return it to the tray cart. Remove
over bed table following standard gloves, wash hands or use ABHR
tray delivery procedures. and put on clean gloves prior to
collecting any other trays.
Droplet Precautions Tray Delivery Tray Pick-up

(Green Sign) Wash hands prior to tray delivery. Wear disposable gloves
Note: Food Service Personnel will not deliver/collect trays for anyone
with gastro-intestinal symptoms
Unit Staff Over bed table must be free of Nursing staff return the tray to the
debris. Tray is taken directly from trolley for anyone on droplet
the trolley and delivered by nursing precautions. Ensure the trolley is left
staff to patients/residents on droplet uncovered.
precautions.
Food Service Worker Trolley is brought to the unit. Trays Trays are not removed from patient
for patients/residents on droplet rooms for anyone on droplet
precautions are left on the trolley precautions. With gloved hands,

and unit staff are notified. Trays are collect trays from patients/residents‘
delivered to patients/residents on on routine practices or contact
routine practices or contact precautions. Gloves are removed
precautions. upon completion of tray pick-up,
discarded, and hands washed or
ABHR applied before leaving the
unit.
Airborne Precautions Tray Delivery Tray Pick-up

(Blue Sign) Wash hands prior to tray delivery. Wear disposable gloves
Unit Staff Over bed table must be free of Nursing staff return the tray to the
debris. Tray is taken directly from trolley for anyone on airborne
the trolley and delivered by nursing precautions. Ensure the trolley is left
staff to patients/residents on uncovered.
airborne precautions.
Food Service Worker Do Not Enter the room. Trays for Trays are not removed from patient
anyone on airborne precautions are rooms for anyone on airborne
left on the trolley and the unit staff precautions. With gloved hands,
notified. Trays are delivered to collect trays from patients/residents‘
patients/residents on routine on routine practices or contact
practices or contact precautions. precautions. Gloves are removed
upon completion of tray pick-up,
discarded, and hands washed or
ABHR applied before leaving the
unit.
12. Recreational Reading Material and Games

For normal operations outside of an outbreak situation: Magazines, book and puzzles in
optimal condition may be placed in waiting areas and patient lounges for everyone‘s
enjoyment. If magazines/books/puzzles are torn, soiled or wet they must be removed and
discarded.
For operations during an outbreak situation: Magazines/books/puzzles/clutter will be

removed from waiting rooms and patient lounges, in order to ensure required additional
cleaning can be achieved. The Infection Prevention & Control Program will provide direction
for the removal of magazines/books/puzzles/clutter from waiting rooms and patient lounges,
during these times.
13. Play Equipment and Toys

Toys can be a reservoir for potentially pathogenic microorganisms that can be present in
saliva, respiratory secretions, feces or other body substances. Toys referred to in this section
include infant and toddler toys, dolls, games, books, puzzles, cards, craft supplies, electronic
equipment and teaching toys/dolls.
There will be written procedures (developed by each department) regarding the

frequency and method for cleaning the toys
Before and after playing with toys, children should be encouraged to or assisted in
cleaning their hands with alcohol-based hand rub or soap and water
Toys that are in a general play area must be easily cleanable or dedicated to a single
child
Toys will be nonporous and able to withstand rigorous mechanical cleaning
Smooth/non-textured toy surfaces are essential to facilitate cleaning
Water-retaining bath toys will not be used
All toys will be cleaned and disinfected between users
Playhouses/climbers will have their high touch surfaces cleaned on a daily basis. A
thorough cleaning will be done on a regular schedule (developed by each department)
Shared electronic games, video equipment and computers will be cleaned on the outer
surface between users
Playrooms or play areas that are used by more than one child will have an area for
segregation of dirty toys (e.g., a bin into which children/parents/staff can place used
toys), this area will have clear signage
Clean toys will be stored in a manner that prevents contamination (e.g., dust and water
splatter) and will be clearly marked as clean
Toy storage boxes/cupboards will be emptied and cleaned weekly or earlier if visibly
soiled
Please Note: For a child on Additional Precautions, the items are to be

dedicated to that particular child and terminally cleaned upon discharge or
when precautions are discontinued.
Please Note: Toys should be removed from general waiting rooms if an

adequate process cannot be established to ensure their daily inspection,
cleaning and disinfection. Any toy that is found to be damaged, cracked or
broken will be discarded.
Modified from:
CHICA-Canada Practice Recommendations for Toys, November 20 2011
14. Healthy Workplace

Worksafe BC refers to the term "workplace contaminants" as meaning chemical or
biological substances arising from workplace processes, and may include airborne
contaminants or contaminants on surfaces, such as tables, benches, eating utensils,
clothing, or skin. The employer must ensure food is not stored or consumed in areas
where the presence of these contaminants could result in a hazard to workers as a
result of ingestion with food or beverages.
Reference: Worksafe BC, OHS Regulation and Related Materials. General Conditions 4.84 Eating Areas,
accessed December 5 2011
Please Note: Staff will refrain from keeping or consuming food in an area of a
workplace where it could become unwholesome because of workplace contaminants
C. Education
The final, and it could be argued the most important, element of routine practices is
Education. The ongoing acquisition of knowledge related to what are the best infection
prevention and control strategies and the communication of that knowledge to fellow
professionals, patients/residents and visitors, followed by the demonstration of these skills in
day to day practice, and are the keystones to ensuring the ongoing safety of VIHA
patients/residents and staff.
The following are ways in which education can be used to break the chain of transmission.
Understanding infection prevention and control practices.

Understand and demonstrate work practices that reduce the risk of infection (e.g. hand
hygiene, proper use of PPE, be immunized, and do not come to work with a
communicable disease).
Who provides infection prevention and control expertise to your setting? Who would
you call for help? (See list of VIHA Infection Control Practitioners on the Contact Us
navigation bar.)
Educate patients/residents/families about hygiene and infection prevention strategies such

as hand hygiene.
Know where to find in your facility (or who to ask for) standardized education materials
on infection reduction strategies such as hand hygiene, respiratory etiquette, and
influenza vaccination
Be able to identify unusual clusters or illnesses (e.g. respiratory, gastrointestinal, skin);
and be aware of person, time, place tracking; and report to the appropriate person
Infection prevention and control health promotion

Attend in-services and read scientific literature on infection prevention and control
Provide leadership and act as a role model to other healthcare providers,
patients/residents and visitors with regard to infection prevention and control principles
(e.g. communicate new/current material to other health professionals and
patients/residents/families)
Demonstrate work practices that reduce the risk of infection (e.g. use hand hygiene,
use proper equipment, be immunized, and do not come to work with a communicable
disease)
Modified from: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices
Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in
Healthcare Settings, June 2007
2. ADDITIONAL PRECAUTIONS
Additional Precautions are required when routine practices are not sufficient to prevent
transmission of certain microorganisms. 7
For example, additional precautions are warranted for:

Diseases, either suspected or confirmed, during the infectious state
Situations in which contamination of the patient‘s environment is likely (e.g. a patient
with diarrhea that cannot be contained)
Patients/residents infected (and/or colonized in acute care) with certain organisms of
interest that may be transmitted easily by direct or indirect contact with the patient
(intact skin, wounds, or coughing) or with their environment
Reference: Public Health Agency Canada (1999) Infection Control Guidelines; routine practices and additional
precautions for preventing transmission of infection in healthcare. Health Canada.
A. Contact Precautions
1. Purpose
Contact Precautions are intended to prevent transmission of infectious agents, including
epidemiologically important microorganisms, which are spread by direct or indirect contact
with the patient or the patient‘s environment, e.g. scabies, antibiotic resistant bacteria (MRSA,
ESBL).
The application of contact precautions for patients/residents infected or colonized with

Antibiotic Resistant Organisms.
Contact Precautions also apply where the presence of excessive wound drainage, fecal
incontinence, or other discharges from the body suggest an increased potential for extensive
7
It is important to be sensitive to the effect that Additional Precautions have on patients and others. Patients
can feel stigmatized by all the paraphernalia (e.g. gowns, masks, etc) and other patients/visitors may be
concerned about their own personal safety. It is best to advise all concerned that the interventions are taken to
protect everyone – patients, staff and the public alike.
environmental contamination and risk of transmission of microorganisms. The specific agents

and circumstances for which contact precautions are indicated are found in Appendix A.
2. Requirements – Signage and Placement

Contact precautions signage must be posted on the door and by patient‘s bed in multi-
bed rooms. (See Contact Precautions poster, Catalogue # 0040506, on the
Precaution Signs navigation bar on the Infection Prevention and Control website)
A single-patient room is preferred for patients/residents who require contact
precautions
The door may be left open
When a single-patient room is not available, consultation with the Infection Control
Practitioner is recommended to assess the various risks associated with other patient
placement options (e.g. cohorting, keeping the patient with an existing roommate)
In multi-patient rooms, at least two meters (6 feet or more) spatial separation between
bed and curtain is advised to reduce the opportunities for inadvertent sharing of items
between the infected/colonized patient and other patients/residents
3. Contact Precautions – Staff, Patients/Residents, Visitors
Staff Patients/Residents Visitors

Routine practices to be followed Patients/residents leaving room Hand hygiene will be performed
at all times for tests/mobilization/ upon entering/leaving the facility
rehabilitation will do so with and the patient‘s room
permission of healthcare provider
Healthcare personnel will wear Patients/residents will perform Visitors/relatives will wear
appropriate PPE for all hand hygiene upon exiting and appropriate PPE when providing
interactions that may involve re-entering unit/room care or very close patient
contact with the patient/patient contact, as directed by
environment responsible nurse
PPE will be changed following Patients/residents will wear a Visitors will not visit multiple
procedures, between clean nightgown/house coat or patients/residents/rooms during
patients/residents or when clothes a visit
heavily contaminated/torn/split
during a procedure
Ensure single use and Patients/residents‘ wounds will Visitors must not visit public
dedicated patient equipment for be covered with a fresh dressing areas within the facility (unit
the duration of precautions -i.e. kitchen, cafeteria, shops/kiosks
dedicated commode in main entrance etc.) and
SHALL NOT use the
patient/resident bathroom
Shared equipment will be

decontaminated appropriately
prior to removal from precaution
room and before further use
All dedicated equipment will be

on discharge of patient /
discontinuation of precautions
and prior to removing from
patient room
Diagnostic procedures will not

be postponed, inform receiving
department of necessary
precautions on the requisition or
advising by telephone. Attempt
should be made to book
infectious cases at the end of
the day
Linen and garbage will be

placed in regular bags and
closed securely prior to removal
from room
B. Droplet Precautions
1. Purpose
Droplet Precautions are intended to prevent transmission of pathogens spread through
close respiratory or mucous membrane contact with respiratory secretions. Droplet route
means spread by large particle droplets when patients/residents cough, sneeze or talk (i.e.
within a radius of two meters, or 6 feet).
Because these pathogens do not remain suspended over long distances in a healthcare
facility, special air handling and ventilation are not required to prevent droplet transmission.
Infectious agents for which droplet precautions are indicated are listed in Appendix A and
include B. pertussis, influenza virus, adenovirus, rhinovirus, N. meningitidis, and Group A
streptococcus (prior to and for the first 24 hours of antimicrobial therapy).

Droplet Precautions sign must be posted on the door and next to patient‘s bed in multi-bed
rooms. (See Droplet Precautions poster, Catalogue #0040508, on the Precaution Signs
navigation bar on the Infection Prevention and Control website.)
During periods of high census, patients/residents on droplet precautions might be placed in a

two or four-bed room. A green Droplet Precaution sign will be posted outside the room as
well as on the curtain of the affected patient within that room.
Single Room: the doors to single rooms can be kept open

When a single-patient room is not available, consultation with infection prevention and
control personnel is recommended to assess the various risks associated with other
patient placement options (e.g. cohorting patients/residents with the same infection,
keeping the patient with an existing roommate)
Spatial separation of at least two meters (6 feet or more) from patient to curtain and
drawing the curtain between patient beds is especially important for patients/residents
in multi-bed rooms with infections transmitted by the droplet route
3. Droplet Precautions – Staff, Patients/Residents, Visitors

Routine practices to be Patients/residents leaving Hand hygiene will be performed
followed at all times. Gown, room for tests/mobilization/ upon entering/leaving the facility
gloves and a surgical grade rehabilitation will do so with and the patient‘s room
mask (120 mmHg) with visor permission of healthcare
will be worn within 2 metres (6 provider
feet) of the patient. Particularly
important when care promotes
respiratory secretions, e.g.
nebulisers, suctioning

PPE will be changed following Will wear a surgical grade Visitors/relatives who are
procedures, between mask (120 mmHg) without providing care or very close
patients/residents or when visor with ear loop design, patient contact within 2 metres (6
heavily contaminated/torn/split fitted to the face feet), will wear a surgical grade
during a procedure mask (120 mmHg) with ear loop
design and attached visor.
Additional appropriate PPE will
be worn when directed by
responsible nurse
Ensure single use and Patients/residents will perform Visitors will not visit multiple
dedicated patient equipment hand hygiene upon exiting patients/residents/rooms during a
for the duration of precautions - and re-entering unit/room visit
i.e. dedicated commode
Shared equipment will be Patients/residents will wear a Visitors must not visit public
decontaminated appropriately clean nightgown/house coat or areas within the facility (unit
prior to removal from clothes kitchen, cafeteria, shops/kiosks in
precaution room and before main entrance etc.) and SHALL
further use NOT use the patient/resident
bathroom
All dedicated equipment will be Patients/residents‘ wounds will

decontaminated appropriately be covered with a fresh
on discharge of patient / dressing
patient room

precautions on the requisition
or advising by telephone.
Attempt should be made to
book infectious cases at the
end of the day
Linen and garbage will be

placed in regular bags and
closed securely prior to
removal from room
C. Airborne Precautions
1. Purpose
Airborne Precautions prevent transmission of infectious agents that remain infectious over
long distances when suspended in the air (e.g. measles virus, varicella zoster virus
[chickenpox], pulmonary tuberculosis, smallpox and possibly SARS-CoV). See Appendix A
for detailed list.

Airborne Precautions sign should be posted on the door indicating N95 mask and other
appropriate precautions. (See Airborne Precautions poster, Catalogue #0040504, on the
Precaution Signs navigation bar on the Infection Prevention and Control website.)
The preferred placement for patients/residents who require Airborne Precautions is in

a Negative Pressure Room. A Negative Pressure Room is a single-patient room that is
equipped with special air handling and ventilation capacity.
Negative Pressure Rooms have:

Monitored negative pressure relative to the surrounding area
6 air exchanges per hour for existing facilities
For all new construction and renovations, 12 air exchanges per hour are required
Please access the Infection Prevention and Control internal web site for a list of
Negative Pressure Rooms throughout VIHA
Reference: http://www.cdc.gov/hicpac/2007ip/2007ip_part3.html.
For patients within negative pressure room:

Nursing staff will document that the room is compliant with negative pressure
standards every shift
FMO will ensure that the room is compliant with negative pressure standards daily
In settings where airborne precautions cannot be implemented:

Place the patient in a private room
Keep the door to the room closed
Have the patient wear a surgical grade mask (if possible)
Staff must wear a high efficiency N95 mask –for which they have been fit tested
Visitors must wear a surgical grade (120 mmHg) fluid resistant mask (without visor)
when in patient room (N95 respirators are only effective if they have been fitted
properly)
Arrange for transfer of patient to a facility with a Negative Pressure Room and
contact Infection Prevention and Control. (See list of Infection Control Practitioners
on the Contact Us navigation bar on the Infection Prevention and Control website)
Please Note: Facilities Maintenance and Operations Department must be contacted

when a Negative Pressure Room is required to verify that the room is monitored and
airflow remains negative to surrounding areas.
3. Airborne Precautions – Staff, Patients/Residents, Visitors

Routine practices to be Patients/residents must remain Hand hygiene will be performed
followed at all times. All staff in the room unless medical upon entering/leaving the facility
entering patient‘s room, condition warrants and the patient‘s room
escorting , treating or urgent/emergent procedure
examining the patient must /intervention.
wear a high efficiency N95
mask – the type and size for
which they have been fit tested
Wherever possible, non If the patient is required to Visitors/relatives will wear

immune health care workers leave the room for diagnostic appropriate PPE when providing
should not care for procedures, patient will wear a care or very close patient
patients/residents with vaccine surgical grade (120 mmHg) contact, as directed by
preventable airborne diseases fluid resistant mask (without responsible nurse. All visitors,
visor), fitted to the face – if whether or not providing care,
their respiratory status permits must wear a surgical grade (120
mmHg) fluid resistant mask
(without visor)
The doors to the room must be Patients/residents on airborne Instructions on application of

kept closed precautions are not permitted surgical grade (120 mmHg) fluid
to go outside for a cigarette – resistant mask (without visor)
alternative nicotine source must be provided and use
ordered by MRP encouraged
Following a risk assessment, Patients/residents will perform Visitors will not visit multiple
routine practices may dictate hand hygiene upon exiting patients/residents/rooms during a
the use of gloves and gown and re-entering unit/room visit
during the episode of care
PPE will be changed following Visitors must not visit public

procedures, between areas within the facility (unit
patients/residents or when kitchen, cafeteria, shops/kiosks in
heavily contaminated/torn/split main entrance etc.) and SHALL
during a procedure NOT use the patient/resident
bathroom
Ensure single use and

dedicated patient equipment
for the duration of precautions -
i.e. dedicated commode.
Individual sharps container
must be in the room/ante room.
Limit equipment and personal
items. Used equipment is
placed in Central
Sterilizing/Processing bin.
Items must be cleaned prior to
placing in the bin
Shared equipment will be

prior to removal from
precaution room and before
further use
All dedicated equipment will be
on discharge of patient /
patient room

precautions on the requisition
or advising by telephone.
Attempt should be made to
book infectious cases at the
end of the day
Linen will be placed in regular

bags and closed securely prior
to removal from room
Garbage will be placed in

regular bags and closed
securely prior to removal from
room. Use of biomedical waste
bags is not necessary
Dietary staff do not deliver or

remove food trays for rooms
with patients/residents on
airborne precautions. Regular
dishes are to be used
4. Actions when Negative Pressure Room Not Available or

Malfunctions
If a negative pressure room is either not available or is non-functioning at your facility, the
following steps should be taken:
Consult with Infection Prevention and Control to determine risk
Place patient in private room
Ensure windows and door remain closed, even if the patient is not in the room
Ensure bathroom fan is off and remains off
Patient will wear surgical grade mask( if possible) when healthcare staff and/or
visitors are in the room
Staff must wear a high efficiency N95 mask –for which they have been fit tested
when in patient room
Visitors must wear a surgical grade (120 mmHg) fluid resistant mask (without visor)
when in patient room (N95 respirators are only effective if they have been fitted
properly)
Arrange for transfer to facility with Negative Pressure Room and contact Infection
Prevention and Control
The following steps should be followed when the Negative Pressure Room monitoring system
indicates a failure with the system:
Check that windows and doors are closed
Contact Facilities Maintenance and Operations (FMO) immediately
If FMO determines the problem cannot be fixed, follow the above policy for a facility
with no Negative Pressure Room
Please Note: FMO must post, or have available, a record of inspection and
maintenance verifying the efficient operation of these negative air pressure room
technologies. A regular schedule of inspections of such rooms must be established
and maintained. There should be daily monitoring of negative pressure by nursing
staff when room is in use.
5. Negative Pressure Room Following Patient Discharge or Transfer

All Health Care Workers entering a room occupied by or vacated by a suspect or
confirmed infectious TB case shall wear appropriate respiratory protective device
until 99% of the airborne contaminants have been filtered.
Upon discharge or transfer, the door of a room occupied by a suspect or confirmed
infectious TB case should remain closed and another patient should not be placed
in the room until 99% of the airborne contaminants have been removed (see chart
below).
Table 10: Air Exchanges

Air changes per hour and time in minutes required for
removal efficiency of 99% of airborne contaminants
Minutes Required 99%
Air Exchange Per Hour
Removal Efficiency
1 276
2 138
3 92
4 69
5 55
6 46
7 39
8 35
9 31
10-15 28
D. SUMMARY OF PRECAUTIONS
Table 11: Precautions Table
Contact Droplet Airborne
N. menigitidis,
Mumps, Pertussis,
Organism Based * Pulmonary Tuberculosis,
MRSA, Clostridium difficile , Norovirus, vomiting,
Precautions (not Measles, Chickenpox,
lice, scabies Influenza,
complete list) disseminated Zoster
invasive Group A
streptococcus
Toxic Shock,
2 or more of the following:
Draining wound, Stiff neck Fever, weight loss+ cough,
Syndromic
diarrhea NYD, Fever high TB risk,
Precautions
infestation Headache disseminated rash + fever
Malaise
Acute cough
Preferred.
Private Room Preferred If in multi-bed room YES
draw curtains
Negative Pressure
NO NO YES
Room
Gown + Gloves +
Staff Personal
Surgical grade (120 mmHg) Gown + Gloves +
Protective Gown + Gloves 8
fluid resistant mask with face N95 mask
Equipment
shield
Surgical grade (120 mmHg)

Surgical grade (120 mmHg)
Visitor Personal fluid resistant mask with
Gown + Gloves fluid resistant mask
Protective 9 attached face shield
if providing direct care (gown + gloves if providing
Equipment (gown + gloves if providing 2
2 direct care )
direct care )
Transporting patient Patient – YES (if condition

(need for Surgical Patient – NO Patient – YES (if condition
allows)
allows)
grade 120 mmHg Staff - NO Staff – YES (with attached face Staff – NO (must wear N951)
fluid resistant mask) shield)
8
Fit tested
9
Direct care = hands on care (i.e. bathing, dressing changes, toileting)
Cleaning Precaution Clean Precaution Clean Precaution Clean
E. Protective (Reverse) Precautions

Patients/residents with a suppressed or deficient immune system may be at increased risk of
acquiring infection during hospitalization. Gowns, gloves and masks are not routinely
required. Instrumentation (e.g. catheters and other devices) is to be used only when
essential.
The physician decides whether or not the patient requires Protective Precautions. Variables
the physician may consider are:
Severity of immune system depression
Length of time patient has been neutropenic
Absolute neutrophil count of 0.5 x 109/1 or less (Neutropenia)
Procedure
Routine practices are to be followed at all time including strict hand washing prior to all
patient contact
Place in a single room (preferably a Positive Pressure Room if available). Keep door
closed. Place sign on door to notify other staff
Limit raw vegetables and fruit. Fresh flowers are not allowed in the room
Offer bottled/filtered water and commercially prepared single serving fruit juices
Staff aware of incubating or having infection must not care for these patients/residents
Visitors with any signs and symptoms of infection should be encouraged to avoid
patient contact
F. Management of Cases on Additional Precautions in

Diagnostic Areas
Medical intervention and investigation should not be delayed because a patient requires
additional precautions (however, if the test or treatment can be provided in the patient room
this should be the first consideration).
Use PPE and precautions as indicated on the Additional Precautions sign on the door
of the patient‘s room
Porters must comply with precautions noted on signage, and must be instructed to
remove attire and wash hands upon completion of transport. All equipment used must
be appropriately cleaned following transport
Charts should not be left on patient‘s bed or given to patient to hold. If no other option
is available, charts can be housed in a disposable bag or pillowcase for transport
purposes
For actively infected patients/residents (if unsure consult with Infection Prevention and
Control), follow these procedures:
The patient should be taken directly to the procedure room and not left in the
corridor
For non-urgent cases, book as the last case of the day; this facilitates cleaning
of equipment
Limit the number of moves and exposure to surfaces whenever possible
Remove as much equipment as possible from the room
Close all cupboard doors to protect equipment from exposure
Use sheets to cover any equipment that cannot be encased or removed
Should staff require equipment from a cupboard or from under a cover while
performing diagnostic tests on infectious patients/residents, ensure that staff
remove gloves and wash hands prior to obtaining this equipment. It is important
that contamination of other packages does not occur, as many organisms can
survive in the environment for long periods
Upon completion of the procedure the patient should be returned to the unit as
quickly as possible
Figure 5: Management of Infected Patients/Residents on Precautions in Diagnostic Areas
Use Routine Practices for all care.

Is patient on Additional Precautions? NO
Routine Cleaning
YES
Apply Precautions as identified on

Can test/procedure be done in
YES signage. Clean equipment post
patient's room?
procedure.
NO
Is patient having an invasive

interventional procedure? (i.e. YES Protocol B
Imaging)
NO
What Personal Protective

Equipment is required?
Gloves and Gloves, Gown

Gown and Mask
Can patient wear a

NO Protocol B
mask?
YES
PROTOCOL B:
Protocol A Protocol A Prepare environment:;

 Schedule as last case
 Close cupboard doors
 Move unnecessary equipment as far from
patient as possible and cover with a sheet
PROTOCOL A:
 Prepare tray/equipment
Use clean circulator only to access supplies
Minimize patient and staff contact with equipment.
TerminalClean post procedure all contact
Clean patient and staff contact areas post-procedure.
surfaces. (Closed cupboards which were not
entered and covered/untouched equipment do
not require cleaning.)
G. Discontinuing Additional Precautions

The table below outlines the criteria for discontinuing the use of additional infection control
precautions without prior consultation with an Infection Control Practitioner. Please notify
your Infection Control Practitioner when this occurs.
Table 12: Procedure for Discontinuing Additional Precautions

Routine Practices are used at all times. Additional precautions are in effect when symptoms of infection are
present or when concerning infectious diseases are diagnosed.
Additional Precautions may ONLY be discontinued when the following criteria are met:
Notify your IPC Practitioner when this occurs
PRECAUTIONS REASON CRITERIA
ARO positive ONLY when authorized by Infection Prevention & Control
48 hours without diarrhea and formed/normalized stools are

C.difficile positive
documented
Contact Diarrhea NYD Stools formed/normalized x 48 hours and
Precautions* (no vomiting) Negative C.difficile toxin
Wound culture results are not MRSA and
Skin/soft tissue infection ARO culture results are negative and
or cellulitis Antibiotics given for 24 hours or more and
Clinical improvement observed
Responding to antibiotics given for 24 hours or more
OR
5 days since start of symptoms when a viral infection is
suspected (labs, physical findings)
New or worsening cough AND
Culture of sputum or blood is negative for MRSA
AND
Droplet Negative viral swab for influenza
Precautions* Suspected MRSA Negative ARO cultures OR
with cough Cough is resolved but must continue with Contact Precautions
Known MRSA with cough Cough is resolved but must continue with Contact Precautions
Fever with rash NYD, Antibiotics given for 24 hours or more and
suspect Meningitis Clinical improvement observed
Diarrhea NYD
No diarrhea or vomiting x 48 hours
with vomiting
Suspected pulmonary TB Concentrated AFB smears negative x 3
Diagnosed pulmonary TB ONLY when authorized by Infection Prevention & Control
Airborne
Precautions* Chickenpox All skin lesions crusted
Widespread Varicella
Until lesions can be covered with dressings or are crusted over
Zoster (Shingles)
* Immediately have the room “discharge” cleaned following VIHA Guidelines, Facility specific, even if the patient is
not being discharged from the Unit/Facility
However, your Practitioner, in consultation with the Infection Prevention & Control Physician,
may determine that precautions can be removed earlier for some situations (e.g. C.difficile).
PART 4: HOUSEKEEPING
1. Clean Environment
[NOTE: This includes direction relating to current housekeeping service levels only.]
PRINCIPLES:
As a guiding principle, all healthcare workers share the role of maintaining a clean
environment.
GUIDELINES:
Patient rooms, equipment used in the assessment and care of patients/residents/clients,
diagnostic treatment and service delivery areas are to be cleaned according to the
infection prevention and control standards described in this document.
Housekeeping Services within VIHA are to establish and maintain a clean, sanitary, and
aesthetically pleasing environment for patients/residents/clients, staff and visitors.
QUALITY AUDITING:
In addition to audits done by Housekeeping Services and Environmental Support
Services, the IPC team may conduct independent audits of the environment, to determine
adherence to quality standards.
A. CLEANING
Please Note: Routine practices are used at all times when handling soiled items. This
includes the wearing of PPE and hand hygiene which must be performed upon
completion of the task
1. Nursing/Housekeeping Responsibilities
Cleaning of Isolation carts
It is the responsibility of the nursing staff to empty the isolation cart following the
patient/resident/client being removed from additional precautions.
Unused gloves/masks/gowns, alcohol based hand rub and Percept wipe containers will
remain on the isolation cart and be cleaned
Partially used patient designated items such as wound care products shall be either
sent home with the patient or discarded as garbage.
It is the responsibility of the housekeeping staff to clean/decontaminate the isolation carts

following the patient/resident/client being removed from additional precautions. This will be
done the time of the patient/resident/client‘s room being terminally cleaned.
At sites with Infection Prevention and Control Aides, the aides will compliment the
cleaning/decontamination already in place.
2. Nursing Responsibilities:
When automated washer/disinfectors are installed in care areas bedpans, urinals and
commode pots are emptied and decontaminated in these following each use, items placed in
these are cleaned using cycle number 5. Once bed pans and urinals have been processed
through the bed pan washer/disinfector at the appropriate cycle, they can be used by any
patient on the unit (they do not need to be sent to central processing for further
decontamination).
Please refer to: DEKO or Meiko loading and usage instructions. The items removed from the
machine can be used for any patient following processing through completed recommended
cycle.
Process
Wash basins should be dedicated to the patient. Wash basins are
wiped/decontaminated using an Accelerated Hydrogen Peroxide wipe (e.g. Percept
wipe) between uses by the same patient. Upon patient discharge, the patient
dedicated wash basin will be sent to central processing for appropriate
decontamination prior to use on another patient.
o In Residential Care facilities, if automated washer disinfector is not installed, the

receptacles are to be emptied and washed. Receptacles will then be sent to
central processing after use for cleaning/disinfection prior to further use
o In Residential Care facilities, Peri cloths/Depends will be disposed of by nursing

staff within appropriate bins provided
Non disposable receptacles containing body fluids (e.g. glass suction canisters), are to
be emptied and rinsed with cold water prior to transport to CPS for terminal cleaning
and disinfection. Ensure items are transported in a suitable lidded container.
Following use, equipment in direct contact with patient skin will be disinfected
according to the manufacturer‘s instructions and suggested products e.g. O2 sat finger
clip
Encourage patients/residents/clients to keep personal belongings on over bed

table/bedside lockers to a minimum to allow thorough cleaning of all surfaces
Discontinuation of Additional Precautions:

When plans are being made to discontinue additional IPC precautions, nurses should arrange
for as many items of the patients personal belongings are taken home by the patients family
(where possible). Nurses to remove and bag all remaining patient belongings. Open patient
wound care products, etc. are to be discarded in the garbage.
Items such as used suction bottles and bed pans/urinals will be removed from room prior to
housekeeping commencing clean.
Ensure:
Patient/resident is helped into a clean gown/pajamas and housecoat
Hand hygiene is performed by the patient/resident/client and the patient/resident
brought out of room
The bed space/room is cleaned according to current VIHA Guidelines
If possible, the patient/resident is showered/bathed and bathroom subsequently
cleaned according to current VIHA Guidelines
The patient/resident/client may return to the room once the cleaning is complete and
housekeeping has removed the additional precaution sign
3. Housekeeping Responsibilities:
Table 13: Cleaning Solutions Used in Various Types of Cleaning
TYPE OF
SOLUTIONS AREAS
CLEANING
Main Operating rooms
 Including PAR & Surgical Day Care
Labour and delivery rooms
Quaternary Endoscopy
Ammonium based Any area where there is a risk of large volumes of blood or
detergent (e.g. Virex body fluid contamination of the environment or invasive
or A456) surgical procedures are being performed (i.e. cardiac
catheter lab).
Routine Clean If unsure please discuss individual units with the Infection
Control Practitioner
All healthcare units

 Including medical & surgical units
Neutral Detergent
 Emergency departments
(e.g. Stride or 310)
 Renal Units
 Intensive care units (both general ICU & cardiac ICU)
Accelerated Hydrogen For all rooms/bed spaces where patients/residents/clients

Precaution
Peroxide (e.g. Virox or are on additional precautions (Contact, Droplet, Airborne)
Clean Percept) This clean will follow the Housekeeping Checklist form
Used during an outbreak or increased incidence of

infection
This clean involves a precaution clean and is followed
later in the shift with a clean of the high touch areas
At the request of an ICP when additional cleaning is
Accelerated Hydrogen required in order to prevent an outbreak occurring (or over
Precaution Plus
Peroxide (e.g. Virox or census capacity for a number of days)
Clean Percept)  Second step of cleaning will be performed for high
touch areas and bathrooms etc.
This clean will follow the Housekeeping Checklist form
and includes a curtain change on patient/client/resident
discharge, discontinuation of precautions or when visibly
soiled
The cleaning that occurs when a patient/resident/client is
on precautions and:
 Precautions are discontinued or
Accelerated Hydrogen
 The patient/resident/client is discharged or transferred
Terminal Clean Peroxide (e.g. Virox or
to another unit, bed or facility
Percept)
This clean will follow the Housekeeping Checklist form
using Accelerated Hydrogen Peroxide and includes a
curtain change
Quaternary
Ammonium based
Discharge Clean The cleaning that occurs when a patient/resident/client is
detergent (e.g. Virex
–(refer to same or A456) discharged and has not been on any additional
areas as in precautions
Routine Clean) Neutral Detergent This clean will follow the Housekeeping Checklist form
(e.g. Stride or 310)
Please Note: Gloves that meet WorkSafe BC standards for the task are to be used for
all work requiring chemicals, cleaners, and disinfectants
Please Note: Non-disposable household utility gloves are only acceptable for cleaning
in non-patient care areas, with the exception of public washrooms. Housekeeping
services are responsible for developing and maintaining written protocols on their use,
in accordance with PIDAC guidelines, and ensuring that employees are aware of, and
comply with these protocols
All housekeeping staff will adhere to VIHA‘s Policy 15.1 – Hand Hygiene
Disposable gloves will be changed between bed spaces. If integrity is

compromised prior to moving to a new bed space, gloves will be changed
immediately
Floor bucket with appropriate solution is freshly prepared and frequently changed at
a minimum after
o two large rooms (4-bed rooms),
o three small rooms (2-bed or single bed rooms), or
o when cleaning water is visibly dirty
Cleaning will be performed commencing with the ‗least soiled‘ areas to the ‗most
soiled‘ areas
The mop bucket and double bucket are to be washed and rinsed before refilling
All cleaning equipment is disinfected at the end of each cleaning period
Microfibre cloths are to be dipped into solution only once. After usage, they will be
laundered
Dry dusting is to be avoided in clinical patient care areas due to the risk of
dispensing dust and microorganisms into the environment
ALL soap, paper towel dispensers and alcohol based hand rub dispensers, wall-
mounted and floor model kiosks, will be monitored/cleaned daily. Clean the outside
and inside of dispensers when refilling
Cleaning of patient/resident/client rooms and equipment will be performed in accordance
to the Housekeeping Checklist. The following environmental surfaces and
equipment/furniture will be cleaned and disinfected daily. Examples of items have been
identified, but this is not an all-inclusive list:
Table 14: Some Equipment/Environmental Surfaces to be Cleaned Daily
Central and POD Nursing Horizontal and contact surfaces, telephones and receivers, hand hygiene
Stations sinks including taps and faucets, ABHR dispensers/ kiosks
Bed pan washer / Soiled and clean service rooms, sinks in a similar fashion to patient
disinfectors toilets. The bedpan washer will be cleaned daily as follows:
The inside seal of the bedpan washer is cleaned with accelerated
hydrogen peroxide (e.g. Virox or Percept)
Check drain area for any blockage
Clean the exterior sides, front and handle areas with an
accelerated hydrogen peroxide wipe
Check detergents. If replacement is necessary, replace with full
bottle then run machine through full cycle
Report any maintenance issues to Unit Clerk and Maintenance
Garbage Cans Emptied when full - minimum once daily. Cleaned/ disinfected inside and
out at a minimum of once per week and when visibly soiled
Laundry Receptacles Cleaned/disinfected inside and out daily following removal of the bag
liner/ removal of laundry bags
SCHEDULED AND CYCLED CLEANING & DISINFECTION:

Cleaning and disinfection of the following items not captured during routine daily or discharge
cleaning will be managed on a cyclic basis and following additional written policies.
Care & Assessment Equipment:
In some areas, an arrangement has been made with Central Processing and
Sterilization departments to clean pumps such as gastric, IVAC, nutrition
administration, continuous pumps; crash cart and defibrillator, emergency cart, and
continuous renal replacement therapy (CRRT) machines
Clean and soiled equipment will be stored/held within separate designated areas on all units.
Areas will be identified using clear signage, for example:
Clean commodes only (return all other equipment to designated area)
Clean equipment only
Soiled equipment only
Please Note: Clean and soiled areas should be at least 1 metre (3 feet) apart
Once a piece of equipment has been cleaned using the appropriate method, a pink ―Clean‖
tag will be attached. The tag will be removed prior to use of the equipment. The tag will be
cleaned appropriately prior to it being stored ready for further use.
These are examples of equipment needing to be tagged following cleaning:

Commode chairs
Intravenous poles
Intravenous pumps
Wheelchairs
Walkers
Patient chairs
This list is not exhaustive and relates to all equipment.
Once a piece of medical equipment is no longer needed by the patient, or a patient is

discharged/ discontinuation of precautions, the piece of medical equipment will remain within
the patient room/bed space and be removed following the appropriate cleaning process or, if
necessary, removed for cleaning in the Dirty Utility Room. If the equipment was in a room
where patients/residents were on precautions, it must remain there until appropriately
cleaned. The equipment will be tagged ‗clean‘ and stored in the appropriate designated
‗Clean‘ area.
SOILED LINEN
According to the principles of routine practices, soiled or used linens generated from all
sources are considered to be contaminated and must be contained prior to transportation.
Clean linen that has been dropped on the floor is considered soiled.
When handling linen:

Wear non-sterile gloves and disposable gown or apron
Position hamper/tote/laundry bag in room (i.e. locate centrally in room and open lid) or
as close to the room entrance as possible
Ensure that linen is free of biomedical waste (e.g. needles and syringes, soiled wound
dressings), instruments and patient‘s personal belongings
Roll linen carefully into itself, avoid shaking or fluffing
Dispose of immediately into linen tote/hamper
Soiled linen hamper/tote/laundry will be closed when ⅔ full and not over-filled
Remove PPE and perform appropriate hand hygiene
Please Note: Dirty linen is not to be placed on bedside tables, chairs, floors or in the
sink
Please Note: Linen that is heavily soiled, saturated or dripping should be placed in a
leak proof clear plastic bag and then placed inside the regular hamper/ tote/ laundry
bag
LAUNDERING ON THE UNITS

Laundering on units is not advocated in acute care setting. Items such as transfer belts,
mattress covers, patient slings, etc. will be sent to either the site laundry or an industrial
laundry facility. However, in some areas such as residential care settings it may be necessary
to launder residents/clients belongings. In these cases, the following is recommended:
Washers and dryers of an industrial standard must be used

The outside of the machines (i.e. washer and dryer) should be cleaned daily with
disinfectant
Wash items with detergent on HOT WASH >160ºF (>71ºC) cycle for 25 minutes or
more
If HOT WASH is not available, items MUST be cycled through dryer on a hot setting for
25 minutes or more (not air dried)
The laundry area should be in a dedicated space and must not be located in the same
area as a dishwasher or fridge (used for food)
Ensure that laundry areas have hand washing facilities and products and appropriate
PPE available for workers
Adhering to routine practices when handling laundry is effective in reducing the risk of
disease transmission to patients and staff.
References:
MMWR (2003) Guidelines for Environmental Infection Control in Health-Care Facilities,
Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)
nd
NHS Estates (2002), Infection Control in the Built Environment – Design and Planning (2 edition),
Norwich, UK: Wiseman, Sue
CLEAN LINEN
Please Note: Perform hand hygiene prior to removing clean linen from central supply
area or from carts
The dedicated linen room should have a door that is kept closed. If this is not possible,
dedicated linen cart will have covers that should remain closed when not being
accessed
o Regular schedule for laundering of cover will be established
Clean linen must be stored at least 1metre (3feet) away from any ―soiled area/items‖ or
fire equipment
Linen which is removed from the clean supply area/cart is not to be returned to that
cart
Please Note: Linen will NOT be removed from large linen carts and placed onto small
carts stored in hallways. If small carts are used during a shift to distribute linen,
remaining linen will be placed in laundry tote at the end of the shift and cart cleaned
HANDLING SOILED LINEN CONTAMINATED WITH HAZARDOUS MATERIALS

When hazardous materials are used, stored or disposed of, written safe work procedures
must be developed and implemented for preparation, administration and waste handling.
Departments intending to return soiled linens that are contaminated with hazardous materials
must ensure that there is no potential risk to staff or patients/residents.
Hazardous materials include, but are not limited to:

Chemicals that are a risk due to being toxic, poisonous, carcinogenic, noxious,
flammable, combustible, corrosive or reactive with other chemicals.
Radioactive substances that are present on soiled linen will be decontaminated at the
site at which the patient resides. Linen contaminated by radioactive substances will
not be sent to the Laundry until it is decontaminated by removing the radioactive
nuclide contaminants or setting it aside for the appropriate time (i.e. ten half lives).
Chemotherapy drugs (i.e. Antineoplastics).
Any contaminated linen identified by the user site as not able to be safely laundered will be
safely disposed of by the user and the Regional Laundry informed of the disposal.
Reference: Fraser Health Authority, Acute Care Infection Prevention and Control Manual, 2008
Please Note: Items of linen from patients/residents/clients with unusual infections (e.g.
Anthrax, Lassa Fever) should not be disposed of without consulting either the Medical
Microbiologist in the first instance or the Infection Control Practitioner.
B. EVALUATING PRODUCTS
Prior to purchasing new patient care/medical equipment, written guidelines will be obtained
from the manufacturer prior to the IPC team reviewing the product in order that a thorough
assessment may be completed. IPC team will consider how easily the product may be
cleaned/disinfected. Responsibility for cleaning must be established prior to purchase and
installation.
Evaluation of new products will be done in cooperation and consultation with

Environmental Support Services, Infection Prevention and Control and
Purchasing.
2. Bed Bug Infestation
If a bed bug infestation is suspected, contact the Housekeeping Supervisor

through the call centre.
Review Beg Bug information on Environmental Support Services web page
A. Pests and Infestations in Home and Community Care

If pest infestation is suspected or confirmed, inform the Home and Community Care leader.
Although pests are not generally associated with transmission of disease, health care workers
will need to avoid becoming a vehicle for their transfer to other homes. If an infestation is
suspected/confirmed, clinician bags will remain in the vehicle.
If the infested home is in an apartment building, inform Environmental Health (through Public
Health Unit) as other apartments may also become infested.
PART 5: ANTIBIOTIC RESISTANT ORGANISMS

1. Introduction
Antibiotic resistant organisms (AROs), also known as multi-drug resistant organisms
(MDROs), are defined as microorganisms that are resistant to one or more classes of
antimicrobial agents. Although the names of certain AROs describe resistance to only one
agent these pathogens are frequently resistant to a number of antimicrobial agents.
Examples of resistant bacteria are:

Methicillin Resistant Staphylococcus aureus (MRSA)
Vancomycin Resistant Enterococci (VRE)
Bacteria containing Extended Spectrum Beta-Lactamase (ESBL)
Or any bacteria resistant to usual antibiotic therapy, such as Burkholderia cepacia.
2. Definitions
Colonization
Colonization is the presence, growth and multiplication of the organism in one or more body
sites without observable clinical symptoms.
Infection
Infection occurs when microorganisms invade a body site, multiplying in tissue and causing
clinical manifestations of local or systemic inflammation e.g. fever, redness, heat, swelling,
pain.
3. Acute Care Screening Protocol

All patients/residents admitted to acute care hospitals will be screened using the ARO
Screening Questionnaire. Persons identified as having risk factors for MRSA acquisition will
be swabbed for MRSA.
Based on your assessment, perform actions as required — collect cultures and implement
additional precautions where appropriate.
Note: Notify Infection Prevention and Control of all patients/residents placed on additional
precautions.
Check the Patient Record disease alert field. This will be blank unless the patient has
previously been positive for an ARO.
If an ARO alert is present, the type of resistant organism will be identified according to the
following codes:
As soon as initial nursing risk assessment is complete, nursing staff can place
patients/residents on appropriate precautions (no need to wait for physician’s
directive).
Table 15: List of Organisms with Corresponding Precautions and Other Considerations
Precautions and Other
ARO Alert Name of Organism
Considerations in acute care10
MRSA Methicillin Resistant Staphylococcus
aureus
VRE Vancomycin Resistant Enterococcus
ESBL Extended Spectrum Beta Lactamase

Contact or Droplet Precautions
KPC Klebsiella pneumoniae carbapenemases dependent on location of organism
MRAB Multi Drug Resistant Acinetobacter Precaution Cleaning
baumannii
MRPA Multi Drug Resistant Pseudomonas
aeruginosa
VRSA Vancomycin Resistant Staphylococcus
aureus
BCEP Burkholderia cepacia Cystic fibrosis patients/residents/clients
are placed on Contact Precautions, in a
Private Room, do not cohort with another
diagnosed cystic fibrosis patient
Precaution Cleaning
MRSP Multi Drug Resistant Pneumococcus Droplet Precautions
Preferably Private Room
Precaution Cleaning
MRTB Multi Drug Resistant Tuberculosis Airborne Precautions
Negative Pressure Room
Routine Cleaning
Other – ARO New organism not listed above Discuss with IPC practitioner
Multiple AROs Unusual combination of AROs listed Dependent on Organisms involved

above
10
Precautions are based on the acute care setting. In other settings, routine practices are generally sufficient,
unless identified differently by the IPC Practitioner.
4. ARO Screening and Collecting Swabs

Table 16: Screening and Specimen Collection
Screening ARO
Encounter Question- Screening MRSA VRE ESBL CRGNB
naire Cultures
Admission YES If positive Nares NO Urine, Rectum Urine (if catheterized or
to acute response to Groin Wound, sign/symptom of UTI),
care screening Wound Sputum if Rectum, Wound
questionnaire Sputum if productive Sputum if productive
productive cough, stoma, cough if directed by ARO
cough device Screening Questionnaire
Admission NO If known No – only if NO NO NO
to MRSA known
Residential positive, swab MRSA as per
Care as per VIHA‘s VIHA‘s Policy
Policy 15.4 15.4
Management Management
of Residents of Residents
with MRSA with MRSA
(Residential (Residential
Care) Care)
Admission, NO All admissions, Nares NO NO Yes – only if direct
discharge discharges or Groin admission from a
to/from transfers from Wound hospital within a high risk
NICU, another VIHA Sputum if area. Please refer to
PICU, CCU, or external productive VIHA‘s Policy 15.5
CVU, ICU hospital cough Management of Patients
with New Carbapenem
Resistant Gram
Negative Bacillus
(CRGNB)
In-Patient NO All admissions, Nares Rectum NO Yes – only if direct
Renal discharges or Groin and admission from a
transfers from Wound wounds hospital within a high risk
another VIHA Sputum if if present area. Please refer to
or external productive VIHA‘s Policy 15.5
hospital cough Management of Patients
with New Carbapenem
Resistant Gram
Negative Bacillus
(CRGNB)
Transfer NO All admissions Nares NO NO All admissions who have
between who have Groin been transferred from
VIHA been Wound another hospital within a
hospitals or transferred Sputum if high risk area. Please
other from another productive refer to VIHA‘s Policy
hospitals hospital (within cough 15.5 Management of
or external to Patients with New
VIHA) Carbapenem Resistant
Gram
Negative Bacillus
(CRGNB)
5. Overview of Antibiotic Resistant Organisms

In most instances, infections due to AROs have clinical manifestations that are similar or the
same as infections caused by susceptible pathogens. However, options for treating
patients/residents with these infections are often extremely limited due to their multiple
resistances to antibiotics. The result is that infections due to AROs often cause increased
morbidity and mortality, as well as increased length of hospital stay and costs.
The following factors contribute to emergence of resistance in this setting:

intensive, prolonged use of broad spectrum antibiotics
high intensity of medical care provided in the close physical confines of a hospital
a more vulnerable population, especially patients/residents suffering chronic illness,
those critically ill, those with invasive devices in place, those requiring intensive
medical or surgical care
A. Methicillin-Resistant Staphylococcus aureus (MRSA)

Staphylococcus aureus (S. aureus) is a common cause of infection in hospital and the
community, causing a spectrum of problems from minor skin and wound infections, to serious
deep infections such as osteomyelitis and blood stream infection, which may be associated
with significant morbidity and mortality.
Staphylococcus aureus can survive on the skin, particularly the anterior nares, skin folds,
hairline, perineum and umbilicus, without causing infection. This is known as colonization.
Methicillin-Resistant Staphylococcus aureus (MRSA) are strains of S. aureus that are

resistant to antibiotics such as cloxacillin and cephalosporins. Cloxacillin is considered to be
identical to Methicillin (the drug used by the laboratory to detect resistance). MRSA are
cross-resistant to all cephalosporins, imipenem, meropenem, aminoglycosides, erythromycin
and quinolones, and they may also be resistant to many other antibiotics.
Certain strains of community-acquired MRSA can cause much more serious infections (eg.
Necrotizing pneumonia) than typical MSSA, in part due to a number of toxins of virulence
factors, including Panton Valentine Leukocidin (PVL) toxin.
In community settings the prevalence is unknown; however the following represent high-risk
groups:
injection drug users
dialysis or chemotherapy patients/residents
individuals living in Residential Care Facility
persons living on the street or using shelters
individuals in correctional facilities
individuals taking frequent and/or prolonged courses of broad spectrum antibiotics
chronically ill
persons will a skin infection that was difficult to treat
individuals discharged from healthcare facilities that were in hospital for a period longer
than 48 hours
individuals who have had a medical procedure in a medical clinic or who have been
hospitalized anywhere outside of Canada
B. Vancomycin-Resistant Enterococci (VRE)

Enterococci are part of the normal flora of the gastrointestinal tract. They are organisms of
low virulence but can cause infections such as urinary tract infection, bacteraemia and
endocarditis, particularly in debilitated patients/residents. Acquired resistance to Vancomycin
has emerged in enterococci.
Most enterococcal infections arise from the patient‘s endogenous flora, but cross infection
between hospital patients/residents does occur.
Contact transmission, either directly from person to person or indirectly via contaminated
inanimate objects such as commodes or bedpans, plays an important role in mode of
transmission.
C. Extended Spectrum Beta-Lactamase (ESBL)

Organisms
Extended Spectrum Beta-Lactamase is a bacterial enzyme with the ability to break down
(inactivate) a wide variety of antibiotics, including penicillins and all first, second and third-
generation cephalosporins. When present, this enzyme results in the bacteria being resistant
to antibiotic therapy.
ESBL enzymes are most commonly found in two bacteria – Escherichia coli (otherwise known
as E. coli) and Klebsiella pneumoniae, but can also be found in bacteria such as Salmonella,
Proteus, Morganella, Enterobacter, Citrobacter, Serratia, and Pseudomonas.
In many cases, ESBL bacteria can colonize the gut and other body sites without producing
disease. Significant infections include urinary tract infections and surgical wound infections.
Patients/residents whose gastrointestinal flora has been altered by previous antibiotic
treatment are predisposed to acquiring these pathogens.
6. ARO Room Placement

Figure 6: ARO Room Placement
Room Placement for a Patient Positive for an Antibiotic

Resistant Organism
Colonized Patient Infected Patient
Single Room Single Room

*YES *YES
Available? Available?
NO NO
Place in Single Room Place in Single Room
Double Room Double Room

YES YES
Available? Available?
Place in Double Room. Place in Double Room.

NO
Prepare to manage Prepare to manage
personal space. personal space.
Place in multi-bed room.

Prepare to manage NO
personal space.
Consult with Infection

Prevention & Control
Place in multi-bed room. Confine

patient to bed space with curtains
drawn. Consult with Infection
Prevention & Control when available
*If more than one patient with same ARO on ward, it may be preferable to cohort in a semi-private or multi-bed room as appropriate
Due to the limited number of single rooms available, where patients/residents must be placed
in a double or multi-bedded room, priority for the single room assignment should be as follows
(in priority order):
1. Clostridium difficile infection

2. Diarrhea cause not yet diagnosed
3. MRSA infection
4. Patient colonized with multiple AROs
5. MRSA Colonization
6. Infection from other source
Special Considerations in Bed Placement for VRE

In some instances, VRE infected or colonized patients/residents will need VRE management
(i.e. patients/residents in a designated renal unit, an adult Intensive Care Units or pediatric or
neonatal Intensive Care Unit). In these instances, please refer to VIHA‘s Policy 15.3
Management of Patients with VRE (Acute and Residential) for bed placement procedures.
7. Key Management Issues

Table 17: Key Management Issues for MRSA and ESBL
MRSA – Methicillin Resistant Staphylococcus aureus
Presentation Infection or colonization of any site on the body; most often skin and wound infections
A patient is colonized with MRSA when the culture report is positive for Staphylococcus aureus resistant to Cloxacillin with no
clinical signs/symptoms or infection.
ARO Status
Notice of previous colonization within a VIHA facility will be recorded in:
 The Health Record encounters and/or Powerchart
 The Admission Record which shows “ALERT” for ARO status
Contaminated environmental surfaces (high touch areas: over bed tables, blood pressure machine, wheelchairs, etc.) may also
Reservoirs serve as a reservoir. Therefore, routine cleaning of the environmental surfaces is necessary to reduce the potential bacterial
load.
Direct and indirect contact (see Part 2: Transmission)
The primary mode of transmission is from one patient to another are hands that have become transiently colonized by either:
 after direct contact with colonized or infected patients/residents/clients while performing care
Mode of
 when removing gloves
Transmission
 when touching contaminated surfaces
Droplet transmission is possible with patients/residents/clients that have a productive cough and are MRSA colonized within
their nares/respiratory system.
The likelihood of transmission increases in patients/residents/clients with:
 Draining wounds or open skin lesions
 Poor respiratory hygiene and coughing
 Fecal or urinary incontinence, diarrhea, ileostomy or colostomy, poor hygiene
Likelihood of  Invasive devices in place
Transmission  Requiring intensive contact care, i.e. post CVA, dementia, post major surgery, Intensive Care treatment
 Requiring mobility assistance, i.e. paraplegic, amputee
 Infection due to greater number of organisms present
As these patients/residents/clients are more likely to disperse large numbers of organisms into the environment
Routine practices are to be applied at all times and all staff must adhere to VIHA’s Hand Hygiene Policy.
 In acute and residential care, contact precautions must be put in place including donning a gown/apron and gloves for
all contact with the patient and their physical environment. Ensure Contact Precautions sign is posted
 Droplet precautions should be put in place if the patient has a cough with or without productive sputum
 All patients/residents/clients admitted to acute care will be screened using the ARO Screening Questionnaire. All
patients/residents/clients identified ‘At Risk’ will be swabbed
 Swab sites will include
o Nares
o Groin (creases at junction of torso with the legs, on either side of pubic area)
o Open wound(s)
o Urine (if catheter present)
 All patients/residents/clients admitted to an intensive care unit or designated in-patient renal unit will be swabbed at
specific time frames – please refer to page 2 of VIHA’s Policy 15.2 Management of Patients with MRSA (Acute Care)
 Screening/swabbing is not required for residents being admitted to or transferred from acute care to Residential care
 Residents – previously identified as MRSA positive – will be swabbed one month after admission/transfer Policy 15.4
Management of Patients with MRSA (Residential Care)
Precautions  The infection prevention and control measures to prevent the spread of MRSA are the same, whether the patient is
Needed for colonized or infected
Patients  Unit staff will initiate and maintain nursing orders for Additional Precautions
 Ensure ongoing communication of the patient’s status with other relevant healthcare workers (e.g. diagnostics,
housekeeping, etc)
 Place the patient in an appropriate room (see patient placement)
 Provide the patient with dedicated toilet/commode facilities
 Encourage the patient with meticulous hand hygiene, particularly on leaving the room and after toilet, etc
Staff Must:
 Complete a point of care risk assessment
 Wear gloves and gown/apron for contact with the patient/resident/client and/or their environment. A surgical grade
mask (120 mmHg) with visor may be required
Visitors Must:
Visitors must speak with the patient’s/resident’s/client’s primary nurse before visiting patient so that proper Additional
Precautions and procedures can be discussed, including the importance of hand hygiene
Visitors are required to adhere to contact precautions and wear protective clothing only when providing close personal care.
Patients/Residents/Clients Must:
 Wear clean dressing gown/clothing when exiting the room
 Wear shoes or slippers; no bare feet
 Have a clean dry dressing covering any skin/soft tissue infections
Acute Care Patients:

 The patient may be out of their room for tests, mobilization or rehabilitation
 Patient must perform hand hygiene on exiting and re-entering their room
 They must not visit public areas within the facility (unit kitchen, cafeteria, shops/kiosks in main entrance, etc)
 Are encouraged not to visit any other patients’ rooms
Residential Care Patients

 The resident/client can leave their room for all activities, but is to be excluded from food preparation activities
All patients/resident/client found to be MRSA positive will be considered for topical decolonization treatment, in an attempt to
eradicate MRSA and reduce the risk of subsequent infection.
Decolonization
Please refer to VIHA’s Policy 15.2 - Management of Patients with MRSA (Acute Care) for acute care and VIHA’s Policy 15.4 -
Management of Residents with MRSA (Residential Care) for residential care
For infected patients/residents/clients, treatment is determined by the Most Responsible Physician (MRP). Please refer to the
Treatment
Antimicrobial Prescribing Guide for Adult Patients: System Wide Initiative (SWI) booklet for more detail
For colonized patients/residents/clients, wait 7 days post completion of any antibiotic treatment (topical, oral or injectable) or
following decolonization.
 Separate swabs from nares, groin and any other sites previously found to be positive
 Two negative sets of swabs 7 days apart (the first swabs must be negative before doing the second set). Please refer to
Discontinuing VIHA’s Policy 15.2 - Management of Patients with MRSA (Acute Care) and Policy 15.4 - Management of Residents with
Additional MRSA (Residential Care) for further information
Precautions  If first swab is positive, consider decolonization if not already done so, wait 7 days before doing another swab
 Notify the Infection Control Practitioner if the swabs have been done and are negative
For infected patients/residents/clients, wait 30 days post completion of any antibiotic treatment (topical, oral or injectible)
prior to initial set of swabs being taken. Then follow the above steps
Discharge or  The MRP may discharge the patient/resident/client as soon as their physical condition permits
Transfer  The receiving facility or home care must be notified prior to transfer for patients/residents/clients colonized or infected
with MRSA. The Most Responsible Nurse must record status on the Home Care Transfer Form
 If cultures remain positive on discharge, decolonization may be continued following consultation with MRP
Laundry
Waste
Cleaning
Environment
Patient Care Equipment – once patient/resident/client has been discharged or precautions have been discontinued, precaution
signage will remain in place and all patient equipment will remain in the room. Equipment will be removed by housekeeping
only after appropriate disinfection.
ESBL – Extended Spectrum Beta Lactamase

A variety of gram negative bacteria, most commonly Escherichia coli and Klebsiella species, have acquired antibiotic resistance
Presentation and are classed as Extended Spectrum Beta Lactamase (ESBL). Usually found in lower gastrointestinal tract and/or in urine and
moist wounds.
A patient is colonized with ESBL when a culture report is positive for Extended Spectrum Beta Lactamase with no clinical
symptoms or infection
ARO Status
Notice of previous colonization within a VIHA facility will be recorded in:
 The Health Record encounters and/or Powerchart
 The Admission Record which shows “ALERT” for ARO status
Contaminated environmental surfaces (high touch areas: over bed tables, blood pressure machine, wheelchairs, etc.) may also
Reservoirs serve as a reservoir. Therefore, routine cleaning of the environmental surfaces is necessary to reduce the potential bacterial
load.
Direct and indirect contact (see Part 2: Transmission)
ESBL producing bacteria can be spread by direct contact with feces and secretions (i.e. wound drainage, sputum and urine)
from an infected person.
Mode of
Transmission
The primary mode of transmission is from one patient to another are hands that have become transiently colonized by either:
 after direct contact with colonized or infected patients/residents/clients while performing care
 when removing gloves
 when touching contaminated surfaces
Likelihood of The likelihood of transmission increases in patients/residents/clients with:
Transmission  Draining wounds or open skin lesions
 Fecal or urinary incontinence, diarrhea, ileostomy or colostomy, poor hygiene

 Invasive devices in place
 Requiring intensive contact care, i.e. post CVA, dementia, post major surgery, Intensive Care treatment
 Requiring mobility assistance, i.e. paraplegic, amputee
 Infection due to greater number of organisms present
As these patients/residents/clients are more likely to disperse large numbers of organisms into the environment
Routine practices are to be applied at all times and all staff must adhere to VIHA’s Hand Hygiene Policy.
Once colonization is confirmed:

 In acute and residential care, contact precautions must be put in place including donning a gown/apron and gloves for
all contact with the patient and their physical environment. Ensure Contact Precautions sign is posted
 Measures to prevent the spread of ESBL are the same, whether the patient is colonized or infected
 In residential care, apply contact precautions for all close personal care
 Notify the Infection Control Practitioner
 Ensure ongoing communication of the patient’s status with other relevant healthcare workers (e.g. diagnostics,
housekeeping, etc)
 Place the patient in an appropriate room (see patient placement)
 Provide the patient with dedicated toilet/commode facilities
Precautions  Encourage the patient with meticulous hand hygiene, particularly on leaving the room and after toileting, etc
Needed for
Patients Staff Must:
 Complete a point of care risk assessment
 Wear gloves and gown/apron for contact with the patient/resident/client and/or their environment
Visitors Must:
Provided that visitors of patients/residents/client with ESBL are healthy, there is no restriction on visiting, and it carries no risk.
Visitors must speak with the patient’s/resident’s/client’s primary nurse before visiting so that proper Additional Precautions
and procedures can be discussed, including the importance of hand hygiene upon entering and exiting the
patient’s/resident’s/client’s room.
Visitors are required to adhere to contact precautions and wear protective clothing only when providing close personal care.
Patients/Residents/Clients Must:
 Wear clean dressing gown/clothing when exiting the room
 Wear shoes or slippers; no bare feet
 Have a clean dry dressing covering any skin/soft tissue infections
Acute Care Patients:

 The patient may be out of their room for tests, mobilization or rehabilitation
 Patient must perform hand hygiene on exiting and re-entering their room
 They must not visit public areas within the facility (unit kitchen, cafeteria, shops/kiosks in main entrance, etc)
 Are encouraged not to visit any other patients’ rooms
Decolonization There is no decolonization therapy for ESBL.
For patients/residents/clients infected with ESBL, treatment and repeat cultures should be ordered by the Most Responsible
Treatment
Physician (MRP) in consultation with the Medical Microbiologist.
Wait 7 days post completion of any antibiotic treatment (topical, oral or injectable).
 Separate swabs from rectum and any other sites previously found to be positive
 Mid-stream or catheter specimen of urine, specifying an ESBL screen
Discontinuing
 Two negative sets of results 7 days apart (the first swabs/specimens must be negative before doing the second set)
Additional
 If first swab/ specimen is positive, wait 7 days before doing another swab/specimen
Precautions
 Notify the Infection Control Practitioner if the swabs/specimens have been done and are negative
For infected patients/residents/clients, wait 30 days post completion of any antibiotic treatment (topical, oral or injectible)
prior to initial set of swabs being taken. Then follow the above steps
 The MRP may discharge the patient/resident/client as soon as their physical condition permits
Discharge or
 The receiving facility or home care must be notified prior to transfer for patients/residents/clients colonized or
Transfer
infected. The Most Responsible Nurse must record status on the Home Care Transfer Form
Laundry
Waste
Cleaning
Environment
Patient Care Equipment – once patient/resident/client has been discharged or precautions have been discontinued, precaution
signage will remain in place and all patient equipment will remain in the room. Equipment will be removed by housekeeping
only after appropriate disinfection.
PART 6: OUTBREAK MANAGEMENT

VIHA’s Infection Prevention and Control Program would like to thank Capital Health Region in Alberta, Canada
for generously sharing their Outbreak Prevention, Control and Management in Acute Care Facilities
document with us. The shared materials greatly assisted us in our development of this section of our manual.
1. Introduction
Early recognition of unusual clusters of illness and swift actions in response to these episodes
are essential for effective management of outbreaks. It is vital that all healthcare workers
collaborate to facilitate prompt identification, reporting, specimen collection, and
implementation of appropriate infection prevention and control measures to help minimize the
impact of an outbreak.
Early recognition of suspected outbreaks is important. Patients/residents and staff should be

assessed on an ongoing basis for signs/symptoms of an infectious disease (see algorithm).
An outbreak may be declared anytime that the number of individuals presenting with similar
signs/symptoms exceeds the normal expected number of cases. Contact your Outbreak Lead
any time you are suspicious that an outbreak may be occurring within your unit.
The majority of outbreaks that occur are either respiratory or gastrointestinal. The following
case definitions were developed to assist in the early identification of ―unusual clusters‖ of
influenza-like (ILI) or gastrointestinal (GI) illness and/or outbreaks.
The purpose of this section of the manual is to provide current best practice/evidence-based
guidelines to assist staff with outbreak prevention, control, and management of outbreaks.
The information is divided into four sections:
Section A – General guidelines for management of any suspected outbreak activity.

Subsequently, these basic recommendations may be enhanced or modified depending on
identification of the causative agent.
Section B – Specific recommendations for the prevention, control, and management of

influenza outbreaks.
Section C – Specific recommendations for the prevention, control, and management of

outbreaks of gastrointestinal illness.
Section D – Specific recommendations for the prevention, control and management of

Clostridium difficile (CDI) and Scabies outbreaks.
2. General Guidelines for Outbreak Management
A. Reporting a Suspected Outbreak

Prompt reporting permits early identification and interventions to interrupt transmission,
reducing morbidity and mortality. Report any suspicion of an outbreak to the necessary
authority as soon as possible. The table below identifies whom to contact for your area.
Table 18: Contact List

Infection Prevention and
Type of Facility Medical Physician Contact
Control Contact
VIHA Acute Care VIHA Infection Prevention and VIHA Infection Prevention and Control
Control Physician
VIHA Amalgamated LTCF VIHA Infection Prevention and VIHA Infection Prevention and
(Owned/Operated) Control Control Physician
VIHA Affiliated LTCF, Private Public Health: CD Nurses (ILI); Public Health Medical Health
LTCF, and Community CD Environmental Health Officers (MHO)
Officers (NLI)
After hours contact
Medical Microbiologist on-call – covers all medical microbiology calls and any URGENT
infection prevention and control issues that cannot wait until the IPC practitioner is available.
(Paged through the RJH switchboard (250-370-8000).
Weekends/Stat Holidays – IPCP On-Call from 0930-1730 hours, for all acute care hospitals,
St. Joseph‘s Acute and Residential, and all VIHA-owned residential facilities. Contact via
your manager-on-call who has the number for the IPCP on-call.
Medical Health Officer on-call – Covers all questions from affiliated continuing care
facilities. (MHO Numbers)
1. Initial Infection Prevention and Control Precautions

Routine practices are to be used at all times with all patients/residents.
In addition, based on the type of outbreak, appropriate Additional Precautions will need to be
implemented as soon as possible.
It is essential to NOT wait until the causative agent is identified before implementing
Additional Precautions. Initiate appropriate additional precautions as soon as a patient
presents with symptoms.
The appropriate type of precautions (e.g. contact and/or droplet) must be determined by the
presenting symptoms and the procedure being undertaken (e.g. mask with visor for any
cough inducing procedure for suspected ILI). Precaution signs should be posted on the
entrance to each affected room and elsewhere as directed by your Outbreak Lead.
The Suspected Respiratory Infection or Gastroenteritis Outbreak algorithm provides guidance

as to what initial infection prevention and control precautions are required in the event of any
ILI/GI outbreak.
Figure 7: Suspected Respiratory Infection or Gastroenteritis Outbreak Algorithm
2. Confirming an Outbreak
The Infection Control Practitioner, in consultation with the Infection Prevention and Control
Physician and/or the Infection Prevention and Control Manager, will review the data and
confirm that an outbreak is occurring.
The IPCP will notify other areas of the organization that the unit/facility is on Outbreak Status
(i.e. sending out a memo and/or in the case of Residential Facilities, posting on Healthspace).
3. Outbreak Management
In the event of an outbreak in a VIHA facility, Infection Prevention and Control will work
collaboratively with the outbreak team to investigate, identify, and plan the management of
the outbreak.
4. Compiling a Post-Outbreak Investigation Summary

Within VIHA facilities, the Infection Prevention and Control Team will lead the preparation of
an outbreak summary once the outbreak is declared over. The Clinical Coordinator, Manager,
Team Leader and the Occupational Health & Safety representative are expected to be key
contributors to the summary. Once a summary is complete it is reviewed by the Infection
Prevention and Control Team and key issues/concerns and/or successes are escalated to the
Infection Prevention and Control Quality Committee for its review.
B. Influenza-Like Illness (ILI) Outbreaks

1. Introduction
Outbreaks of influenza generally occur in Canada between fall and early spring. Influenza
viruses cause disease among all age groups. Rates of serious illness and death are highest
among persons aged 65 years or older and in persons of any age who have medical
conditions that place them at increased risk from complications of influenza. In most local
outbreaks, complications and/or deaths related to influenza A occur in the elderly,
immunocompromised and pediatric patients/residents.
It is recommended that each facility have a process in place to ensure eligible inpatients
receive influenza immunization each year.
Annual influenza immunization is the primary tool for preventing influenza and its severe
complications. According to the Canadian National Advisory Committee on Immunization
(NACI) statement on influenza vaccination, all healthcare workers have a duty to promote,
implement, and comply with influenza immunization recommendations to decrease the risk of
infection and complications in vulnerable populations for which they provide care.
NACI considers the provision of influenza immunization for healthcare workers to be an

essential component of the standard of care. To prevent transmitting influenza to those at
high risk of influenza related complications, all healthcare providers should receive annual
influenza immunization, unless contraindicated.
Outbreaks of influenza can be propagated when staff immunization rates are low even though
immunization rates in patients/residents may be high. The optimal time for delivering
organized immunization campaigns for both patients/residents and staff is in the autumn.
Effectiveness of the influenza vaccine is dependent on the age and immunocompetence of

the person receiving the vaccine and the similarity of the virus strains in the vaccine and
those in circulation during the influenza season. Although elderly persons and those with
chronic diseases may have a lower immune response to the vaccine than healthy young
adults, the vaccine is still very effective in preventing lower respiratory tract infections such as
pneumonia and other secondary complications, thereby reducing the risk for hospitalization
and death.
The influenza virus changes from year to year so the vaccine is adjusted to match with the
viruses expected to be circulating during the current influenza season. Each spring the World
Health Organization, CDC Atlanta, and the Public Health Canada Agency decide on the three
components of the vaccine.
For the current influenza vaccine information see the National Advisory Committee on
Immunization (NACI) and for FAQs the BC Healthfiles
2. Confirming an ILI Outbreak

The following two tables help to differentiate between signs and symptoms of influenza and
other respiratory organisms.
Table 19: Common Differences between Influenza and Common Cold Symptoms
Symptoms/Description Influenza Common Cold
Fever Usually high Sometimes
Chills, aches, pain Frequent Slight
Loss of appetite Sometimes Sometimes
Cough Usual Sometimes
Sore throat Sometimes Sometimes
Sniffles or Sneezes Sometimes Common
Involves whole body Often Never
Symptoms appear quickly Always More gradual
Extreme Tiredness Common Rare
Complications Pneumonia - can be life Sinus infection
threatening Ear infection
Table 20: Respiratory Infections

ORGANISM SYMPTOMS MODE OF INCUBATION PERIOD OF RESTRICTIONS
TRANSMISSION PERIOD COMMUNICABILITY
INFLUENZA Sudden onset of Person to person by 1 to 4 days Adults: Usually 24 Precautions:
TYPE A or B respiratory illness droplets or direct hours prior to Droplet
with fever and cough contact with articles symptoms and up to 4
and with one or more recently days after clinical Cases should
of the following: sore contaminated with onset remain on
throat, athralgia respiratory precautions until
(painful joints), secretions. Pediatric & they are over the
myalgia (muscle Immunocompro- acute illness and
pain), runny nose, mised: Usually 24 have been afebrile
headache, prostration hours prior to for 48 hours
symptoms and up to 7 (minimum of 5 days
Note: Fever may not days after clinical from onset of acute
be prominent in those onset illness).
>65 years or in
paediatric populations Unit restrictions for
or those who are an influenza
immunocompromised outbreak remain in
In children under 5, place for 6 days
gastrointestinal after onset of
symptoms may also symptoms in the last
be present case.
RESPIRATORY Similar to common Person to person 2 to 8 days, Period of viral Precautions:
SYNCYTIAL cold symptoms; usually by direct or average 4 to 6 shedding is usually
VIRUS (RSV) usually mild but can close contact with days from 3 to 8 days but Adults: Droplet
be moderate to contaminated may be longer in precautions
severe. secretions which pediatric and those
may involve droplets who are Pediatrics:
Severe lower or fomites. immunocompromised. Droplet
respiratory tract precautions while
disease can occur in Virus may live on symptomatic
the elderly. environmental In pediatric settings,
surfaces for many unit restrictions may
hours and for a half- be recommended by
hour or more on Infection Prevention
hands. and Control.
Cases should
remain on
precautions until
they are over the
acute illness.
PARAINFLUENZA Similar to common Person to person 2 to 6 days Varies with different Adults: Droplet
Type 1, 2, 3, 4 cold symptoms. Can through direct types. precautions
also cause serious contact with infected
lower respiratory tract persons or exposure Pediatrics:
disease with repeat to respiratory Droplet and
infection (e.g. secretions on contact
pneumonia, contaminated precautions while
bronchitis, and surfaces or objects. symptomatic
bronchiolitis) in the In pediatric settings,
elderly. unit restrictions may
It is the most be recommended by
common etiologic Infection Prevention
agent of croup and and Control.
viral bronchitis in
young children. Cases should
remain on
precautions until
they are over the
acute illness.
ORGANISM SYMPTOMS MODE OF INCUBATION PERIOD OF RESTRICTIONS

TRANSMISSION PERIOD COMMUNICABILITY
ADENOVIRUS Similar to common Person to person 2 to 14 days While symptomatic. Adults: Droplet
cold symptoms; through direct precautions
usually mild but can contact with infected
be moderate to persons or exposure Pediatrics:
severe. to respiratory Droplet
secretions on precautions while
contaminated symptomatic
surfaces or objects. In pediatric settings,
unit restrictions may
be recommended by
Infection Prevention
and Control.
Cases should
remain on
precautions until
they are over the
acute illness.
HUMAN META- Similar to common Person to person 2 to 8 days While symptomatic Adults: Droplet
PNEUMOVIRUS cold symptoms; through direct precautions
usually mild but can contact with infected
be moderate to persons or exposure Pediatrics:
severe. to respiratory Droplet and
secretions on Contact
Note: unlike contaminated Precautions while
influenza, surfaces or objects. symptomatic
patients/residents In pediatric settings,
usually maintain a unit restrictions may
normal appetite. be recommended by
Infection Prevention
and Control.
Cases should
remain on
precautions until
they are over the
acute illness, for a
minimum of 5 days.
Reference: John Hopkins University, Infection Prevention Guidelines for Healthcare Facilities with Limited Resources.
Table 21: Case Definition for ILI and an ILI Outbreak

Influenza-like Illness (ILI) Case Definition ILI Outbreak Suspected
Patient/resident/client on your shift with new or If you discover ≥2 patients/residents/clients and/or
worsening cough with fever (>38C) or a temperature staff with ILI symptoms occurring within 7 days which
that is abnormal for that individual AND one or more are epidemiologically linked (e.g. room / floor /
of the following: common area / staff), then case definition has been
 Sore throat met and an outbreak can be declared.
 Athralgia (painful joints)
 Myalgia (muscle pain)
 Nasal discharge Note: Symptomatic staff cases must have worked
 Headache within the outbreak facility or area during the 4 days
 Prostration prior to onset of symptoms (i.e. during their incubation
period). Please refer to the Influenza Outbreak
Temp > 38 may not always be present in infected Declared algorithm for further instructions for staff.
elderly persons. Subjective report of fever may be
sufficient in some cases.
3. ILI Outbreak Management

All ILI illness is to be treated as if it is Influenza A or B until proven otherwise. Once influenza
is ruled out it is quite possible that Infection Prevention and Control will require all the
following restrictions to remain in place save for those that are described for unvaccinated
staff. Always consult with Infection Prevention and Control to determine what precautions or
restrictions are required.
Practices and Precautions

Routine practices are used for the care of all patients/residents at ALL times.
Influenza can be spread by contact and droplet routes,

consequently, droplet precautions are required.
Droplet precautions include:

Thorough hand washing before and after any patient contact
Wearing of a gown and gloves
Surgical grade mask with attached visor or face shield
Appropriate hand washing while removing protective attire. This is important as
contamination from used attire may occur during removal
Room/Unit Closures
The Infection Prevention and Control Team in collaboration with the Clinical
Coordinator/Manager of Patient Care and members of the Outbreak Management Team will
determine room and unit closures.
Patient Line Listings

Infection Prevention and Control requires a daily completion of line listings.
It is the responsibility of the Clinical Coordinator/Manager of Patient Care (or designate) to

ensure that the line listings are filled out completely at the beginning of each day, and
submitted to the Infection Control Practitioner by 1000 hrs, by either fax or email as agreed.
Information required includes:

Identification of the unit
Date of completion
Contact person and details
Patient information
Name
Date of birth
Room number
Symptoms, and onset date
Specimens sent
Influenza immunization information
Line listing paperwork should be kept up to date and be available within the affected area,
and faxed/emailed daily to identify any new cases, and current symptom status of all
patients/residents affected. The reporting period is 0700 hrs the previous day to 0700 hrs of
day of faxing/emailing. If there are no new cases within a 24 hour period, this should be
stated on the line listing.
Discontinue daily faxing/emailing of line listings only when instructed by the Infection Control
Practitioner.
Staff Line Listings

Occupational Health & Safety requires daily completion of staff line listings. It is the
responsibility of the Clinical Coordinator/Manager of Patient Care (or designate) to ensure the
following information is completed each day, and forwarded to Occupational Health & Safety:

Date of completion
Staff details
Full name
Telephone number
Date last worked
Symptoms and onset date
Number of shifts missed
Specimen information
Influenza immunization information.
Discontinue daily faxing/emailing of line listings only when instructed by Occupational Health
& Safety.
Lost Bed Days

ensure that the bed days lost is recorded at the beginning of each period (0700-0700).
Restrictions on Patient Activities

Patients/residents symptomatic with a respiratory illness should be restricted to their room, on
droplet precautions for a minimum of five (5) days after the start of the illness, or until the
symptoms are no longer present, whichever time period is longer.
All group activities will be cancelled during the course of the outbreak.
Patients/residents may be transferred to other healthcare facilities for a higher level of care
(e.g. Emergency), should their condition require and with communication with that unit/facility.
The transport company and receiving facility must be notified of the precautions required.
The patient must wear a mask for transport. The Infection Prevention and Control Team
should also be informed of the transfer.
Any offsite appointments are discouraged, unless absolutely necessary. Where necessary,
the receiving department or facility is to be notified beforehand. The patient must wear a
mask, and the transport company and receiving facility must be notified of precautions
required.
Working Restrictions for Asymptomatic Healthcare Workers

Working Restrictions for Asymptomatic Staff, immediately following the identification of the
outbreak:
Working on the Outbreak Unit

(VIHA policy No. 5.8.6PR, Influenza Prevention Program Procedure)
Unvaccinated staff are subject to exclusion from work within the outbreak facility or
reassignment until the outbreak is declared over. An exception to exclusion of unvaccinated
staff may be made if the unvaccinated staff take antiviral medication as prescribed and the
antiviral medication is continued until the outbreak is declared over. These workers must be
alert to the signs and symptoms of influenza, particularly in the first two (2) days after starting
antiviral prophylaxis, and should be excluded from the patient care environment should they
develop symptoms11.
During an outbreak of laboratory confirmed influenza12, unvaccinated healthcare workers or

those vaccinated within two (2) weeks of the onset of outbreak13 must obtain antiviral
medication, if they are to work on the outbreak unit.
Working on a Non-Outbreak Unit
Asymptomatic healthcare workers, who are not vaccinated for influenza and have worked on
an outbreak unit within three (3) days of the outbreak declaration, will be unable to work on
another unit/facility for three (3) days after the last shift they worked on that unit. This is to
ensure that they remain free from infection following their last exposure. Once the three days
has lapsed, and if they remain without symptoms, they may work on a non-outbreak unit or
facility. This includes casual staff who work in several areas.
Working Restrictions for Symptomatic Healthcare Workers

All symptomatic staff (including students and physicians) must remain off work for a minimum
of five (5) days after onset of illness or until asymptomatic, whichever is the longer time
period.
Students
Students on healthcare worker programs14 will be permitted to attend outbreak units, if they
have previously received instruction on Infection Prevention and Control principles. The
students and Educational Facility Instructor must abide by the same requirements for vaccine
and/or antiviral medication, and the same work restrictions as those of all other healthcare
workers. The Educational Facility Instructor is responsible to provide completed student
vaccination lists to Occupational Health & Safety and to ensure student compliance with
healthcare worker restrictions.
11
Unvaccinated staff can use the form letter ―Family Physicians ordering Health Care Worker Anti-viral
Medication‖ to obtain prophylactic medication. Note: the cost of antiviral medication is not covered by the
employer.
12
If the presentation meets the outbreak definition for ILI then one should assume it is influenza, until proven
otherwise by the MHO or IPCT
13
Those considered not protected at the time the outbreak commences. Vaccinated staff should discuss with
Occupational Health & Safety about when they can discontinue taking prophylactic medication.
14
This includes all professions of caregivers, including medical students
Visitors/ Volunteers
Visitation to an outbreak unit should be restricted to 2 visitors per patient at any one time
during scheduled visitation hours. Patients/residents should be reviewed and
visitors/volunteers determined on an individual basis, considering the needs and medical
condition of the patient. Staff must be consistent with their approach to facility visitation
throughout the outbreak.
Visitors/volunteers choosing to enter the facility must be free of symptoms of illness, and
encouraged to be vaccinated. However, it must be noted that maximum protection takes at
least 2 weeks from vaccination. Visitor/volunteers must be educated in the correct procedure
for hand hygiene and on the correct use of PPE if required. Visitors/volunteers will not visit
other patients/residents/patient rooms, must not visit public areas within the facility (unit
kitchen, cafeteria, shops/kiosks in main entrance etc.) and SHALL NOT use the
patient/resident bathroom.
It is important to consider the needs of the patients/residents and possible staffing shortages,
and weigh these against the concern about community spread of the disease.
Meals
Symptomatic patients/residents should dine in their room with tray service and be restricted
from the dining room and communal activities involving food preparation.
The trays are managed according to direction for individuals on droplet precautions.
Pets
No pets are allowed on affected units.
Housekeeping
For ILI, routine cleaning is required. Attention to detail must be given, especially with
horizontal surfaces and bedside curtains (which must be changed on discharge of the patient
or discontinuation of precautions). Other housekeeping requirements may also be requested.
See also the Housekeeping Cleaning table.
Linen
No special handling/cleaning of linen is required.
Collection and Transportation of Nasopharyngeal Swabs

Specimen results directly impact outbreak management strategies for outbreaks of ILI.
Take samples from residents who are newly symptomatic (within 72 hours) or as directed.
Before performing any nasopharyngeal swab, ensure there are no contraindications (e.g.
facial surgery or trauma).
Collect a nasopharyngeal swab from newly symptomatic patients/residents, preferably within

24–72 hours of onset of symptoms (see directions below).
Specimens must be transported directly to the laboratory as soon as possible. Using

established methods for transporting STAT laboratory specimens (i.e. with a cold pack).
Return samples to the laboratory, either by courier during regular business hours or by taxi
after hours and on weekends. The laboratory covers cost of transportation of specimens back
to a VIHA laboratory. They will provide instruction on the process at the time.
Purpose: This procedure describes how to collect a nasopharyngeal swab for influenza
testing.
Collect specimens from patient presenting with Influenza like illness within 72 hours of
onset of symptoms
Routine diagnostic swabs in transport media are NOT acceptable
Calcium alginate swabs used for Bordetella pertussis are NOT acceptable. Residues
present in the swabs may inhibit PCR assays
Nasopharyngeal swabs are available from the Microbiology Laboratory at RJH, NRGH,
CRH, and from the Laboratory at CDH, VGH, SPH, LMH, WCGH, and SJGH
Supplies
Obtain an ‗Influenza Outbreak kit‘ from the Laboratory
Flocked viral swab with Viral transport media (COPAN Red Top)
VIHA inpatient Microbiology requisition
If not available, use Herpes viral swab with viral transport media (Blue Top)
Procedure
1 Explain procedure to the patient.
2 Protect yourself (fluid resistant mask with visor, gloves and disposable gown).
3 If the patient has a lot of mucous, ask them to use a tissue to gently blow their nose
prior to specimen collection.
· Influenza is found in the cells that line the nasopharynx, not in the mucous
4 With head supported, push the tip of

the nose upwards. Insert the swab
backwards and downwards to a depth
of 2-4 cm into one nostril. Rotate the
swab gently for 5-10seconds.
5 Place the swab into the virus transport media, snap off the top of swab, tighten cap
securely.
6 Label container with sample type and a minimum of two patient identifiers: First/Last
Name, DOB, PHN, or use patient label with bar graph demographics label.
7 Instruct the patient to use a tissue to contain cough and mucous.

· Provide hand hygiene for the patient after the procedure
References:
1. BCCDC H1N1 Specimen Collection Guidelines.
2. Vancouver Coastal Health, Influenza-like Illness Outbreak – Specimen Collection.
Staff will obtain an ‗Influenza outbreak kit‘ from the laboratory which will include appropriate
swabs and requisition forms.
Please ensure that you include the facility and relevant outbreak unit on the requisition.
This will ensure the test is done promptly and correctly reported.
Continue collecting specimens from newly symptomatic patients/residents until the laboratory
confirms the organism or you are instructed to stop by the Infection Prevention and Control
Team, Public Health, Medical Health Officer, Microbiologist or Infectious Disease/Control
Physician.
Prophylaxis for Laboratory Confirmed Influenza

Prophylaxis is the prevention of a disease (in this case influenza) through the use of
medication. As the type of anti-viral medication used varies based on the strain of influenza
and patterns of organism resistance, it is important that the prophylaxis used is the one
recommended by the Medical Health Officer during the current influenza season. Check the
protocol to ensure that it contains this year‘s date. Also, as patients/residents‘ kidney function
may change, it is important that both the Physician‘s prepared order form and the patient‘s
creatinine levels are updated annually.
C. Gastrointestinal Illness (GI) Outbreaks

1. Introduction
Infectious gastrointestinal (GI) illness or gastroenteritis (―gastro‖) can be associated with a
high incidence of morbidity and mortality. Many of these infections are attributable to
Norovirus (previously known as Norwalk-like virus). Norovirus is extremely communicable
and outbreaks are common. Outbreaks can present in sporadic episodes, or as intensely
concentrated events occurring all at once. Attack rates can be quite high (> 50%) in both staff
and patients/residents.
Symptoms of Gastroenteritis include any combination of nausea, vomiting, diarrhea, and/or

abdominal pain, which may be accompanied by myalgia, headache, low-grade fever, and
malaise. Although most gastroenteritis cases are mild and self-limiting, serious dehydration
and/or aspiration pneumonia secondary to emesis can occur in debilitated individuals.
Transmission usually occurs via the fecal/oral or vomitus/oral route, but can also include
fomite (objects or environmental surfaces) or droplet spread.
2. Confirming a GI Outbreak
Outbreaks of diarrhea in hospitals, nursing homes and NICUs have been associated with a
wide variety of organisms including salmonella, shigella, Clostridium difficile, vibrio (cholera),
Staphylococcus aureus, cryptosporidium, rotavirus and other enteroviruses. Some of the
most common bacterial and viral agents causing infectious diarrhea, their incubation period
and most prominent clinical characteristics are listed in the Table below — Common Bacterial
and Viral Causes of Gastroenteritis.
Table 22: Common Bacterial and Viral Causes of Gastroenteritis

Organism name Description
Salmonella Produces fever, nausea and vomiting followed by diarrhea that frequently contains
(salmonellosis) mucus (whitish and stringy), but rarely blood, in stools. The incubation period is
less than 72 hours (3 days) when large doses of organisms are eaten in
contaminated food or drinks. Outbreaks among children, however, are commonly
the results of contact transmission, and about 50% of exposed infants will develop
illness once a case is introduced in a nursery. Adults, on the other hand, usually
get salmonellosis from contaminated food, drinks or inadequately cleaned and
disinfected medical instruments such as endoscopes. Once several
patients/residents or staff are infected, transmission by contact to new susceptibles
may be very rapid. Salmonellosis is a common cause of infectious diarrhea,
accounting for more than 50% of all diarrhea outbreaks in nursing homes in which
the causative agent was identified (Levine et al 1991). Control of outbreaks may be
difficult; some nurseries or units have had to restrict new admissions. Safe food
handling is essential for prevention, especially raw (uncooked) eggs or egg
products (e.g.homemade mayonnaise or tartar sauce). Antibiotic treatment
prolongs the time the infected person may carry the organism in her/his GI system,
but antibiotic treatment may be necessary for septic or severely ill
patients/residents.
Shigella (shigellosis) Produces rapid onset of diarrhea, with stools containing mucus and often blood.
Infected persons are often more sick than is typical for other infecting agents. The
incubation period is 1–6 days, and the usual source is fecal/oral transmission from
acutely infected patients/residents. Outbreaks are less common than with
salmonella or viral agents, and patients/residents shed the organisms only for a
short period after becoming symptomatic.
Clostridium difficile Has increasingly become an important cause of diarrhea. It may be the cause of
(formerly called nearly half of all cases of nosocomial diarrhea in adult hospitalized
antibiotic-resistant patients/residents. The diarrhea ranges from mild and self-limiting to severe
diarrhea or pseudomembranous colitis, which can be fatal. Because C. difficile is present in
pseudomembranous the stools of infants and preschool children, colonization without clinical disease
colitis) apparently occurs. Its presence in the GI tract gradually decreases with age. In
addition, C. difficile may become endemic in the nursery and other high-risk units.
No nosocomial outbreaks have been associated with food borne transmission,
suggesting that contact transmission from contaminated articles or the hands of
staff is responsible. For example, one report noted that when culture-negative
patients/residents were placed in a hospital room currently or previously occupied
by a person with C.difficile diarrhea, they were more likely to develop this type of
diarrhea than patients/residents placed in rooms where no patient had had C.
difficile diarrhea. This suggests the organism can persist on inanimate articles (e.g.
lamps, door handles or bed rails) for some time unless rooms are thoroughly
cleaned between patients/residents.
Escherichia coli Strains that cause acute diarrhea have not been reported to be nosocomially
transmitted. Toxic strains have been transmitted in restaurants from contaminated
meat that was not cooked sufficiently to kill the organisms and could be a problem
in healthcare facilities that prepare their own meals from raw meat.
Vibrio cholerae Subgroups produce acute, severe diarrheal disease characterized by local
outbreaks, widespread epidemics and occasional individual outbreaks. Cholera is
usually associated with contaminated water sources.
Organism name Description

Rotavirus Cause sudden onset of vomiting and diarrhea within 48–72 hours
(2–3 days) after exposure. Fever and upper respiratory symptoms are present in
about half the cases. In addition the virus may be present in the sputum or
secretions for several days. This may account for the extremely rapid transmission
and seasonal peak in infections during winter. Symptoms subside in a few days,
but the stool may contain virus for up to 2 weeks. Rotaviruses are the most
common cause of diarrhea in children under five. Because it is highly infectious,
during nursery outbreaks nearly all infants will become infected. Like C. difficile,
the virus survives well on inanimate surfaces and may become endemic in
hospitals.
Reference: John Hopkins University, Infection Prevention Guidelines for Healthcare Facilities with Limited
Resources
Table 23: Gastrointestinal Illness Case Definition

Gastrointestinal Illness (GI) Case Definition GI Outbreak Suspected if:
Norovirus Like Illness: An outbreak should be suspected if the following
17
occurs on a designated geographical unit :
A resident or healthcare worker experiencing sudden The onset among patients/residents and/or staff
unexplained vomiting or diarrhea in the absence of of 3 or more symptomatic cases of gastroenteritis
a functional cause. Diarrhea is considered two or within a 4 day period.
more stools greater than the number normally 18
Cases must be confirmed with the Infection
experienced in a day, and in the absence of laxatives Prevention and Control Team. Once they are
15
or other bowel stimulating products . Diarrhea confirmed and the number of cases within the
should be liquid enough to take the shape of the correct time period validated, an outbreak will be
container. declared and restrictions imposed.
Note: To be defined as a case, the person must
have been present in the facility during the period
of time it takes to incubate the disease. If a staff
member has not been in the facility within the past 3
days, even if they have gastro symptoms, they do
not qualify as a Norovirus case for the purposes of
16
facility tracking . They may have Norovirus, but it
would be considered a ―community‖, not ―workplace‖,
associated case.
3. GI Outbreak Management
All GI illness is to be treated as if it is Norovirus until proven otherwise. Once Norovirus is
ruled out it is quite possible that Infection Prevention and Control may modify some of the
15
Although antibiotics can cause diarrhea also, gastroenteritis should be suspected, especially once antibiotic associated diarrhea is
excluded.
16
This person may be the index case or initiator of an outbreak and their information should be communicated to the Infection Prevention
and Control/ Public Health Lead and Employee Occupational Health & Safety or staffing person.
17
Outbreak Unit designation varies based on the design and layout of the physical structure. The boundaries of the Outbreak Unit will be
established by the Outbreak Lead/Medical Lead in collaboration with the Responsible Physician and the facility administrator.
18
Cases must meet the case definition and then the number of cases must be adequate to meet the outbreak definition.
restrictions/precautions in place. Always consult with the Infection Prevention and Control
Team to determine what actions are required.

Routine practices are used for the care of all patients/residents at all times.
Norovirus can be spread by contact and droplet routes, consequently

Droplet Precautions are required for vomiting and handling body fluids only.
Droplet precautions include:

Thorough hand washing before and after any patient contact
Wearing of a gown and gloves
Surgical grade mask with attached visor or face shield
Appropriate hand washing while removing protective attire. This is important as
contamination from used attire may occur during removal
Where there is explosive diarrhea and vomit, the

wearing of a fluid repellent gown is required
Room/Unit Closures
The Infection Prevention and Control Team in collaboration with the Clinical
Coordinator/Manager of Patient Care and members of the Outbreak Management Team will
determine room and unit closures.
Patient Line Listings

Infection Prevention and Control requires a daily completion of line listings

ensure that the line listings are filled out completely at the beginning of each day, and
submitted to the Infection Control Practitioner by 1000hrs, by either fax or email as agreed.
Information required includes:

Date of completion
Patient information
Name
Date of birth
Room number
Symptoms, and onset date
Specimens sent
Line listing paperwork should be kept up to date and be available within the affected area,
and faxed/emailed daily to identify any new cases, and current symptom status of all
patients/residents affected. The reporting period is 0700 hrs the previous day to 0700 hrs of
day of faxing/ emailing. If there are no new cases within a 24 hour period, this should be
stated on the line listing.
Discontinue daily faxing/emailing of line listings only when instructed by the Infection Control
Practitioner.
Staff Line Listings

Occupational Health & Safety requires daily completion of staff line listings. It is the
responsibility of the Clinical Coordinator/Manager of Patient Care (or designate) to ensure the
following information is completed each day, and forwarded to Occupational Health & Safety:

Date of completion
Staff details
Full name
Telephone number
Date last worked
Symptoms and onset date
Number of shifts missed
Specimen information
Discontinue daily faxing/emailing of line listings only when instructed by Occupational Health
& Safety.
Lost Bed Days

ensure that the bed days lost is recorded at the beginning of each period (0700-0700).
Restrictions on Patient Activities

Patients/residents symptomatic for a GI illness should remain in their room on droplet
precautions for a minimum of 2 days (48 hours) after symptoms have ended, unless going
off the unit for tests which are in the interests of the patient‘s well being (however, if the test
or treatment can be provided in the room this should be the first consideration).
These patients/residents should dine in their room with tray service and not attend communal
activities/dining room. If the person shares a room with someone who is not yet symptomatic,
a commode or alternate unshared toilet facility should be provided to prevent further cross-
contamination. Patients/residents should be reminded about, and assisted with hand
washing if necessary.
Note: Norovirus can appear to ―relapse‖ frequently, i.e. experience onset of gastroenteritis
symptoms after being asymptomatic for 24 – 48 hours. This relapse is likely due to
malabsorption following infection, rather than a recurrence or reinfection of Norovirus. These
patients/residents should be isolated again until they are symptom free for 48 hours, as cross
infection may still occur. The recurrence of symptoms should be noted on the line listing.
All group activities will be cancelled during the course of the outbreak.
Patients/residents may be transferred to other healthcare facilities for a higher level of care
(e.g. Emergency), should their condition require and with communication with that unit/facility.
The transport company and receiving facility must be notified of the precautions required.
The Infection Prevention and Control Team should also be informed of the transfer.
Offsite appointments are discouraged, unless absolutely necessary. Where necessary, the
receiving department or facility is to be notified beforehand. The transport company and
receiving facility must be notified of precautions required.
Working Restrictions for Staff

Working Restrictions for Staff, please review the GI/Norovirus Algorithm for Staff on the
Infection Prevention and Control internal web site. This algorithm covers information on:
Working on the Outbreak Unit
Working on a Non-Outbreak Unit
Symptomatic Healthcare Workers
Students
Students of healthcare worker programs19 will be permitted to attend outbreak units, if they
have previously received instruction on Infection Prevention and Control practices. The
students and Educational Facility Instructor must abide by the same work restrictions as
those of all other healthcare workers set out in the GI/Norovirus Algorithm for Staff. The
19
This includes all professions of caregivers, including medical students
Educational Facility Instructor is responsible for ensuring student compliance with healthcare
worker restrictions.
Visitors/ Volunteers
Visitation to an outbreak unit should be restricted to 2 visitors per patient at any one time,
during scheduled visitation hours. Patients/residents should be reviewed and
visitors/volunteers determined on an individual basis, considering the needs and medical
condition of the patient. Staff must be consistent with their approach to facility visitation
throughout the outbreak.
Visitors/volunteers choosing to enter the facility must be symptom free of any communicable
illness (respiratory illness, diarrhea/vomiting, rash, etc). Visitor/volunteers must be educated
in the correct procedure for hand hygiene and on the correct use of PPE if required.
Visitors/volunteers will not visit other patients/residents/patient rooms, must not visit public
areas within the facility (unit kitchen, cafeteria, shops/kiosks in main entrance etc.) and
SHALL NOT use the patient/resident bathroom.
It is important to consider the needs of the patients/residents and possible staffing shortages,
and weigh these against the concern about community spread of the disease.
Meals
Symptomatic patients/residents should dine in their room with tray service and be restricted
from the dining room and communal activities involving food preparation.
The trays are managed according to direction for individuals on droplet precautions.
Pets
No pets are allowed on affected units.
Housekeeping
During a GI outbreak, units must be cleaned using a precaution plus clean. Attention during
cleaning must be given to frequent-touch areas, specifically horizontal surfaces and
bathrooms. See Housekeeping Cleaning table.
A thorough clean of the unit following a GI outbreak should not begin until 4 days (96 hours)
following the cessation of symptoms.
Linen
No special handling/cleaning of linen is required.
Collection and Transportation of Stool Specimens

Management strategies for outbreaks of gastrointestinal illness are not dependent on
laboratory confirmation. However, it is valuable to collect stool specimens from cases during
outbreaks to try to identify the etiology, if possible.
As directed by Outbreak Lead/Medical Lead, collect stool specimens from patients/residents

that are acutely ill with GI symptoms, preferably within 24-48 hours of onset of symptoms.
Collect one stool specimen from up to 6 symptomatic patients/residents. This number of

specimens is usually sufficient to determine the etiology of the outbreak.
Specimens must be transported to the laboratory as soon as possible using established

methods for transporting STAT laboratory specimens.
Obtaining An Outbreak Number

A unique outbreak identifier number is assigned to each specific GI outbreak. Contact the
Infection Prevention and Control Team to get your number.
How To Collect A Stool Specimen

Gather supplies including a dry specimen container and a clean tongue depressor or
plastic spoon
Pre-label specimen container accurately including patient information and date of
collection
Ensure Outbreak Number is on the requisition
Perform hand hygiene and don appropriate PPE
Scoop the specimen into the container with a disposable tongue depressor or plastic
spoon
Fill the container with stool up to one third or approximately one-tablespoon full
Keep the outside of the container clean, screw the lid tightly onto the plastic container
If possible, have a second person waiting outside the room holding open a biohazard bag
to drop the specimen container into. Have the second person seal the bag
Remove PPE appropriately and perform hand hygiene
Send the specimen and the requisition to the laboratory in a biohazard bag marked
―STAT‖
Note: only stool specimens will be tested. Emesis is no longer acceptable as a suitable
specimen for confirmation of GI.
Figure 8: Requisition Form for GI Testing
Under examination required, check  Other, and write ―Norovirus PCR‖
One BCCDC virus isolation requisition must be completed for each specimen.
Also include:
Facility
From Outbreak Unit_________(state Unit)
Patient identifiers
Facility contact person
This will ensure the test is done promptly and correctly reported.
Continue collecting specimens from newly symptomatic patients/residents until the laboratory
confirms the organism or you are instructed to stop by the Infection Prevention and Control
Team/Public Health, Medical Health Officer, Microbiologist or Infectious Disease/Control
Physician.
D. Outbreaks Caused by Other Organisms

1. Clostridium Difficile Outbreak
Clostridium difficile illness (CDI) should be considered when a patient experiences sudden
unexplained diarrhea in the absence of a functional cause.
The case definition for CDI is:
Acute onset of diarrhea (3 or more loose stools within a 24 hr period) without another
etiology (diarrhea should be liquid enough to take the shape of the container).
And one or more of the following
Laboratory confirmation (positive toxin), or

Diagnosis of typical pseudo-membranes on sigmoidoscopy or colonoscopy or
histological/pathological diagnosis of CDI, or
Diagnosis of toxic megacolon.
It is assumed that any stool sent to the laboratory for CDI testing is from a patient that has
had at least 3 episodes of loose stools in a 24 hour period. It is accepted that the
surveillance protocol may overestimate the number of cases as some patients/residents
may have had only one or two loose stools prior to a specimen being collected.
Confirming a CDI Outbreak

The outbreak definition for CDI is:
3 or more cases who meet the above case definition within a defined geographical
area and are found to be hospital acquired on the same unit (i.e. does not include
community acquired cases or those readmitted or transferred from a different unit).
The Infection Prevention and Control Team will review and validate that an outbreak exists.
Laboratory samples
Stool that is liquid enough to assume the shape of the container is the acceptable specimen
and must be specifically requisitioned for CDI testing.
If the results of the test are ―Antigen Positive‖ and ―Toxin Negative‖ and symptoms persist,
another specimen should be sent for CDI testing.
Send repeat samples only on patients/residents that meet the definition of relapse or
reinfection (based on a symptom-free interval). Relapse or reinfection is defined as a
reoccurrence of symptoms within 30 days of a previous diagnosed cases of CDI.
Testing for cure is not required.
2. Work Restrictions
There are no staff work restrictions associated with a CDI outbreak.

Contact precautions in private room or cohorting with other confirmed cases
Emphasize the importance of hand washing for patients/residents, staff and visitors.
ABHRs are less effective for killing C. difficile spores; hand washing must be
encouraged using a neutral soap and water
Precaution Plus cleans are required in any rooms with affected patients/residents.
Attention is required especially to frequent touch areas and bathrooms/toilet facilities
3. Scabies
Definitions
Clinical features of infestation
skin penetration visible as papules or vesicles
burrows formed by mites under the skin are visible as linear tracts
lesions are seen most frequently in inter-digital spaces, anterior surfaces of wrists and
ankles, axillae, folds of skin, breasts, genitalia, belt-line and abdomen. Infants may
have lesions of the head, neck, palms and soles of the feet
itching does not always occur with a primary infestation, but when it does it is most
intense at night
itching may continue for approximately 6 weeks after treatment. This does not mean
treatment was not successful
Suspected case
Patient has the above clinical features of scabies infestation
Clinically diagnosed case

Patient has the above clinical features of scabies but skin scraping does not positively
confirm the presence of scabies
Confirmed case
Patient with skin scraping showing mites, eggs or fecal pellets, or a written opinion by
a dermatologist based on signs and symptoms
Close contact
Unprotected, prolonged, direct contact with skin, clothing or linens of a person with
untreated scabies
Crusted (Norwegian) scabies

Is usually seen in immunocompromised people, this form of scabies is characterized
by widespread, extensive crusting and scaling of the skin. Rash may be present and
on any area of the body and thousands of mites may be present
This form of scabies is highly contagious
An outbreak is considered when:

Two or more patients/residents diagnosed with scabies on one unit within a 2-week
period
or
One patient plus one or more staff members on one unit are diagnosed with
scabies within a 2-week period
Specific Interventions
Validation
The Infection Prevention and Control Team will validate an outbreak and its extent. This
may involve consultation with a dermatologist to attempt to confirm the diagnosis by
obtaining skin scrapings
Assessment of all current patients/residents, staff, volunteers and students on the unit for
symptoms must be carried out prior to administration of treatment or prophylaxis of cases
or contacts. All patients/residents cared for on the unit and staff assigned on the unit in
the previous 6 weeks will be tracked and contacted
Administration will be informed of a suspected outbreak by the Infection Prevention and
Control team
Laboratory Samples
Skin scrapings are obtained by a person trained in collection of the specimen using a kit
requested from the Microbiology Laboratory
Control Measures
Upon validation of an outbreak, the unit will be closed to admissions and transfers.
Discharged patients/residents should be assessed for symptoms and advised of the need
for treatment or prophylaxis
Only patients/residents who have symptoms or have positive skin scrapings need to be
placed on contact precautions until 24 hours after initiation of treatment.
Patients/residents with Crusted Scabies remain on precautions until symptoms have

abated
Treatment of symptomatic cases and prophylaxis of all contacts (including asymptomatic
patients/residents, healthcare workers, volunteers and visitors) must take place within the
same 24-hour period
Symptomatic Patients/Residents – Treatment

Staff, using contact precautions and working in teams, will bathe and dry
patients/residents, clip the patients/residents‘ fingernails, and clean under their nails.
Examine the scalp for crusted lesions in confirmed cases. Apply medication as ordered
and according to the drug information insert. Simultaneously the patient bed must be
stripped, cleaned and remade and clothing is bagged
In accordance with contact precautions, staff must wear long sleeved gowns and gloves,
which are changed between patients/residents
Follow-up baths to remove medication are done at either 8 or 12 hours after treatment,
dependent on the treatment used. Bed is again stripped and remade
Asymptomatic Patients/Residents – Prophylaxis

Prophylaxis of asymptomatic patients/residents is limited to the involved unit. These
patients/residents receive one application of medication and follow-up bath. Linens and
clothing are changed per routine
Symptomatic Staff – Treatment

Every employee case must be reported to Occupational Health & Safety, who can
facilitate dermatology consultation and staff case management. Staff and students who
have worked on this unit over the previous 6 weeks must be contacted and assessed
Staff diagnosed with scabies are relieved of direct patient contact until 24 hours after
initiation of treatment
Household, sexual and other close contacts (skin to skin contact or sharing clothes or bed
linens) of a staff case should receive treatment (if symptomatic) or prophylaxis during the
same 24-hour period as the staff treatment
Pet prophylaxis is not needed, as animal scabies is a different species
Environment
All linen, towels and clothing used in the previous 4 days should be washed in hot water
(60ºC) and heat dried. Items that cannot be washed in hot water should be stored in a
plastic bag for at least 7 days before washing and reusing
There is no need for special treatment of furniture, mattresses or rugs. General cleaning
and thorough vacuuming is recommended
Asymptomatic Staff, Volunteers and Physicians – Prophylaxis

For staff – apply the medication, and then bath or shower at either 8 or 12 hours,
dependent on the treatment used later as per the medication package information insert
For volunteers/physicians, need for prophylaxis treatment is determined on the amount of
direct contact that the person has with the patient and environment
No special handling of clothing or linens is needed
Family members of asymptomatic staff do not require prophylaxis
Note: If pregnant, or for children under 2 years of age, consult physician prior to treatment
Environmental Cleaning
Special attention should be paid to the items with which infested patients/residents have had
direct skin contact in the previous four days. These include clothing, wheelchair cushions,
shoes, slippers, coats, lap blankets, etc. Items that cannot be washed in hot water (60ºC) or
sent to laundry are placed in a sealed plastic bag for 7 days or dry-cleaned. General cleaning
and thorough vacuuming of furniture is recommended.
Scabies Outbreak Conclusion

The unit may be reopened to admissions and transfers when all patients/residents involved
have received treatment or prophylaxis and follow-up baths. Symptomatic patients/residents
may still be cared for in isolation.
Monitoring continues for at least 6 weeks following last exposure for development of new
cases.
Reference: Scabies Control Guidelines circular #2005: 02, BC Centre for Disease Control February 2005.
PART 7: DEPARTMENTAL GUIDELINES

1. Inpatient Mother and Baby
A. Routine Practices
Routine practices are to be used with all patients/residents at all times.

microorganisms before any interaction with the patient. The elements of routine practices
are:
Risk Assessment
Risk Reduction
Education
Hand hygiene is the single most effective method of reducing cross infection. The healthcare
setting provides an ideal opportunity to educate parents on the importance, methods and
situations for hand hygiene.
B. Additional Precautions
Additional precautions are required when routine practices are not sufficient to prevent the
transmission of certain microorganisms.
It may be necessary to isolate both mother and baby into a single room. Where this is not
possible, additional precautions can be implemented in a multi-patient room. However, in this
situation it is important to limit the movement of the mother around the room/unit.
Table 24: Common Conditions and Precautions Needed

Note: This list is not exhaustive, but includes conditions of particular importance to this
area (see also Appendix A)
CONDITION PRECAUTIONS / PRACTICES COMMENTS

Ophthalmia neonatorum Contact Precautions Until 24 hours of effective
antibiotic therapy
Pustules/cellulitis Routine Practices
Toxoplasma, Rubella, Droplet Precautions No precautions necessary by the
Cytomegalovirus and Herpes parents
Virus (TORCH) Syndrome
20
Varicella Airborne Precautions Between 10–21 days
Herpes (Non-Genital and Genital) See algorithm below
20
Neonates born to mothers with active Varicella should be placed on airborne precautions until 21 days of age (or 28 days if
VZIG is given). If a mother develops chicken pox from 5 days before to 3 days after delivery, consult the physician regarding
the possible administration of VZIG to the neonate. Neonates (up to 2 months of age) of antibody positive mothers, who are
exposed to varicella do not require isolation.
C. Herpes
Figure 9: Precautions Required When Caring for Mother with Non-Genital Herpes
Mother with
Non-Genital Herpes
Lesions Lesions
dry / crusted open / weeping
Good personal
ROUTINE PRACTICES NO
hygiene?
YES
CONTACT PRECAUTIONS
 Single room isolation Can lesions be covered with
NO
 Instruction regarding dressing or mask?
hygiene measures
YES
ROUTINE PRACTICES
 Reinforce need to cover
lesions
Figure 10: Precautions Required When Caring for Mother with Genital Herpes
Mother with
Genital Herpes
No open lesions; Lesions present; or

No recent positive culture recent positive for HSV
ROUTINE PRACTICES CONTACT PRECAUTIONS

 Single room isolation
1. Staff Precautions
Staff must be free from any transmissible infection. This includes dermatitis, which can be
colonized with microorganisms, and skin cells are readily shed.
Staff with herpes lesions must not work while they are in the early stages of disease (wet
blistered lesions). Lesions must be dry and scabbed, and preferably covered with a dressing
prior to returning to work.
Information relating to staff immunization can be obtained from Occupational Health & Safety.
Any further advice should be sought from Occupational Health & Safety.
D. Antibiotic Resistant Organisms

AROs are defined as microorganisms that are resistant to one or more classes of
antimicrobial agents.
a. Methicillin Resistant Staphylococcus aureus (MRSA)

b. Vancomycin Resistant Enterococci (VRE)
c. Bacteria containing Extended Spectrum Beta Lactamase (ESBL)
All admissions to the maternity unit must be screened for AROs by completing the ARO
Screening Questionnaire. It is the responsibility of the nurse/midwife completing this
questionnaire to collect the swabs as required. If swabs are required from the mother, a
vaginal swab for MRSA is also required. The vagina is a significant site as a source of
transmission to the newborn.
In the instance that a parent or family member living in the home is identified as having an
ARO, there is a significant risk that the baby will become colonized during their
hospitalization. For this reason, the baby should also be treated as if positive, and
appropriate additional precautions put in place.
E. Outbreaks
The Infection Prevention and Control Team will investigate all outbreaks in close liaison with
the Clinical coordinator/Clinical Nurse Leader/Unit Manager (Outbreak Team). In order to
bring control, and reduce/prevent further cross infection, it is essential to alert the Infection
Prevention and Control Team as soon as there is any suspicion there could be an outbreak.
An outbreak is defined as the occurrence of two or more related cases of the same infection,
or where the number of infections is greater than would normally be expected.
2. Neonatal Intensive Care and Special Care Baby Units

Due to the vulnerability and increased invasive procedures required, the neonate is at great
risk from acquiring an infection. Routine practices are to be used with all patients/residents at
all times

microorganisms before any interaction with the patient. The elements of routine practices
are:
Risk Assessment
Risk Reduction
Education
Hand hygiene is the single most effective method of reducing cross infection. Parents must
be taught and encouraged to perform hand hygiene before any contact with their baby.
B. Visitors
Parents, visitors or staff believed to be incubating or infectious with a communicable
illness must be restricted from visiting the nursery. Staff should contact Occupational
Health & Safety for further information and advice
Parents, visitors or staff with open skin lesions should be assessed and counseled prior to
having contact with the neonate. Staff should contact Occupational Health & Safety for
further information and advice
Mothers believed to be incubating or infectious with a communicable illness should be
assessed by the physician to confirm prior exposure and advice on where visitation may
occur
All visitors must be discouraged from visiting other parents at their baby‘s cot or incubator
at any time
C. Additional Precautions
It may be necessary to isolate the neonate into a single room. Where this is not possible,
additional precautions can be implemented in a multi-patient room with the use of an
incubator.
It is usually not necessary for parents to wear gloves for contact with their baby, but hand
hygiene must precede and follow any contact with the baby. A long sleeved gown should be
worn when additional precautions are required, to prevent contamination of their clothing and
therefore transmission to the environment.
1. Contact Precautions
Contact precautions are implemented for pathogenic organisms, which are principally spread
through direct (hands) or indirect (equipment, environmental) contact.
Label the cot, incubator or room with the yellow precautions sign
Gloves and gown are worn for all contact with the neonate and their physical
environment
Ensure the isolation cart is positioned appropriately for easy access to protective
clothing and other equipment, but not in a position where it will become contaminated
Dedicate equipment to the neonate. Where equipment cannot be dedicated, it must be
thoroughly decontaminated after use
Notify housekeeping as special cleaning will be required. See Housekeeping Cleaning
table
2. Droplet Precautions
Droplet precautions are implemented for pathogenic organisms, which are transmitted by
aerosol of respiratory secretions, emesis or diarrhea, through forceful expulsion of these body
fluids.
Label the cot, incubator or room with the green precautions sign
Gloves and gown are worn for all contact with the neonate and their physical
environment. A mask with visor may be necessary, particularly if the neonate is not in
an incubator
Dedicate equipment to the neonate. Where equipment cannot be dedicated, it must be
table
3. Airborne Precautions
Airborne precautions are implemented for pathogenic organisms, which are transmitted by
way of the respiratory tract.
The neonate is cared for in an isolation room with negative pressure ventilation. The
Infection Prevention and Control Team should be consulted, and will advise where a
negative pressure room is unavailable
Label the room with the blue precautions sign

All staff are directed to wear an appropriate mask if susceptible to the confirmed or
suspected infection
Doors to the room must remain closed
Table 25: Common Conditions and Precautions Needed
Note: This list is not exhaustive, but includes conditions of particular importance to this
area (see Appendix A)
CONDITION PRECAUTIONS/ PRACTICES COMMENTS

Ophthalmia neonatorum Contact Precautions Until 24 hours of effective
antibiotic therapy
Pustules/cellulitis Routine Practices
TORCH Syndrome Droplet Precautions No precautions necessary by the
parents
Varicella Airborne precautions Between 10-21 days21

antimicrobial agents
Examples of Antibiotic Resistant Organisms include:

Bacteria containing Extended Spectrum Beta Lactamase (ESBL)
All admissions to the Neonatal/Special Care Baby Unit must be screened for AROs by
completing the Neonatal ARO Screening Questionnaire. It is the responsibility of the
nurse/midwife completing this questionnaire to collect the swabs as required.
ESBL is very rare in neonates and therefore screening swabs for these organisms are not
required from the neonate.
In the instance that a parent or family member living in the home are identified as having an
ARO, there is a significant risk that the baby will become colonized during hospitalization. For
this reason, the baby should also be treated as if positive and appropriate additional
precautions put in place.
21
Neonates born to mothers with active Varicella should be placed on airborne precautions until 21 days of age (or 28 if VZIG is given). If a
mother develops chicken pox from 5 days before to 3 days after deliver, consult the physician regarding the possible administration of VZIG
to the neonate. Neonates (up to 2 months of age) of antibody positive mothers, who are exposed to varicella do not require isolation.
The parents of the baby being isolated for TORCH syndrome or hepatitis are not required to
wear protective clothing for handling their child, as they have already been exposed and are
therefore either immune or infected. It is still important for parents to wash their hands
following contact to reduce the risk of further contamination of the environment through
contact.
E. Outbreaks
The Infection Prevention and Control Team will investigate all outbreaks in close liaison with
the Clinical coordinator/Clinical Nurse Leader/Unit Manager (Outbreak Team). In order to
bring control, and reduce/prevent further cross infection, it is essential to alert the Infection
Prevention and Control Team as soon as there is any suspicion there could be an outbreak.
3. Pediatrics
Due to the vulnerability and increased invasive procedures required, children are at great risk
from acquiring an infection. Routine practices are to be used with all patients/residents at all
times.

microorganisms before any interaction with the patient. The elements of Routine Practices
are:
Risk Assessment
Risk Reduction
Education
Hand hygiene is the single most effective method of reducing cross infection. The healthcare
setting provides an ideal opportunity to educate children and their parents/visitors on the
importance, methods and situations for hand hygiene.
B. Additional Precautions
The implementation of additional precautions into pediatric units and departments presents
some unique challenges. Unfortunately, it is very difficult to set specific rules as precautions
taken often depend upon the age and developmental stage of the child.
Young children have a limited understanding of infection prevention and control, because it is
difficult for them to comprehend cause and effect relationships between germs and illness.
These children require greater restrictions on their activities, as they cannot be relied upon to
practice routine infection prevention and control practices, such as cough etiquette or hand
hygiene after using the bathroom. It is essential to communicate honestly and openly with
parents, to harness their cooperation and support in limiting the child‘s activities.
Older children understand causality better, and can be provided with factual information.
However, compliance with infection prevention and control principles can still be problematic,
and often requires great skill to encourage the child.
Communication and education of family members and visitors is essential to ensure

compliance with routine practices and any additional precautions implemented. Decisions to
isolate and add precautions must be fully explained to the family, with the underlying rationale
for doing so.
1. Contact Precautions
Contact precautions are implemented for pathogenic organisms, which are principally spread
through direct (hands) or indirect (equipment, environmental) contact.
Where possible isolate the child in a single room, or cohort with other children with the same
infectious illness. Where this is not possible:
Precautions should be put in place in a multi-bedded room and the Infection Control
Practitioner informed
Label the room with the yellow precautions sign
Gloves and gown are worn for all contact with the child and their physical environment
Dedicate equipment to the child. Where equipment cannot be dedicated, it must be
table
2. Droplet Precautions
Droplet precautions are implemented for pathogenic organisms, which are transmitted by
aerosol of respiratory secretions, emesis or diarrhea, through forceful expulsion of these body
fluids.
Where possible isolate the child in a single room, or cohort with other children with the
same infectious illness. Where this is not possible, precautions should be put in place
in a multi-bedded room and the Infection Control Practitioner informed
Label the room with the green precautions sign
A mask with visor may be necessary
Dedicate equipment to the child. Where equipment cannot be dedicated, it must be
table
3. Airborne Precautions
Airborne precautions are implemented for pathogenic organisms, which are transmitted by
way of the respiratory tract.
The child is cared for in an isolation room with negative pressure ventilation. The
Infection Prevention and Control Team should be consulted, and will advise where a
negative pressure room is unavailable
Label the room with the blue precautions sign
All staff are directed to wear an appropriate mask if susceptible to the confirmed or
suspected infection
Doors to the room must remain closed
C. Communicability Periods
Note: this list is not exhaustive, but includes conditions of particular importance to this area
(See Appendix A)
From – To – (days after last definitive
Susceptible Contacts of
(days after first contact) contact)
Chickenpox 10 days 21 days (28 days if VZIG given)
Diphtheria 2 days 14 days if no culture or until bacteriology
confirms absence of carrage
Mumps 12 days 25 days
Polio 0 days When stools negative
Streptococcal Pharyngitis 1 day 1 day (treated)
3 days (untreated)
Rubella (German Measles) 14 days 23 days
Rubeola (Measles) 7 days 18 days
Tuberculosis (pulmonary) 4 weeks Until bacteriology confirms absence of
infection
Pertussis (Whooping Cough) 5 days 14 days after last exposure or until cases
and contacts have received a minimum of
14 days course of appropriate antibiotics
Precautions are not required before and after the above established incubation periods.
During the presumed infectious period, elective admission should be avoided.
Patients/residents admitted during these times shall be treated with appropriate precautions.

antimicrobial agents.
Examples of Antibiotic Resistant Organisms include:

Bacteria containing Extended Spectrum Beta Lactamase (ESBL)
All admissions to the Paediatric unit must be screened for AROs by completing the ARO
screening questionnaire. It is the responsibility of the nurse completing this questionnaire to
collect the swabs as required.
In the instance that a parent or family member living in the home are identified as having an
ARO, there is a significant risk that the baby will become colonized during hospitalization. For
this reason, the child should also be treated as if positive and appropriate additional
In the instance that a parent (mother, father or mother‘s partner) is identified as having an
ARO, there is a significant risk that the child will become colonized during hospitalization. For
this reason, the child should also be treated as if positive and appropriate additional
E. Outbreaks
The Infection Prevention and Control Team will coordinate all outbreaks in close liaison with
the Clinical coordinator/Clinical Nurse Leader/Unit Manager. In order to bring control, and
reduce/prevent further cross infection, it is essential to alert the Infection Prevention and
Control Team as soon as there is any suspicion there could be an outbreak.
4. Infection Prevention and Control Practices for Surgical

Service Areas
A. Rationale
Surgical procedures are associated with risk of introducing infection to the patient as a result
of disruption of normal host barriers. Hence, use of appropriate sterile technique by all
personnel is necessary to reduce the risk of introducing infection to the patient.
However, given the invasive nature of operative procedures, there is also significant risk of
exposure and contamination of healthcare staff and the environment in surgical care areas by
blood, body fluids and tissue (including airborne skin and other epithelial cells colonized with
microbes) from patients/residents undergoing surgery. Consequently, strict adherence to
infection prevention and control practices is necessary to protect staff and other
patients/residents. This includes following strict aseptic technique, the appropriate use of
PPE, as well as thorough cleaning and disinfection of the surgical environment (from pre-
anaesthetic to operative to post-anaesthetic areas) between patients/residents.
The basic standard of infection prevention and control and housekeeping practices should be
sufficient in most cases to prevent the transmission of infection. This is particularly relevant
for antibiotic resistant organisms (AROs), since a patient‘s colonization status may not be
known at the time of their surgical procedure. Patients/residents who require additional
precautions in the operating room are those who have clinical signs and symptoms consistent
with infection with a communicable pathogen, whether directly related to the nature of the
surgical procedure or not (e.g. a patient with diarrhea undergoing pacemaker implantation), or
who are known to be colonized with a pathogen that represents an increased risk of
transmission (e.g. AROs).
B. Principles
Routine practices are exercised by all staff at all times.
Additional precautions will be dictated by prior knowledge of ARO colonization status and
patient assessment of risk for transmission of communicable disease (evidence of infection,
whether directly related to the surgical procedure or not).
Only anaesthetic/OR equipment and supplies needed for the surgical procedure are to be
brought into the operating suite. Equipment that cannot be removed should be located as far
from the procedure table as possible. If within a one metre distance, they should be draped
to protect them from splashes. The drape is removed and replaced during post-case
cleaning.
Personal items (e.g. computers, brief cases, backpacks, etc.) are not to be brought into the
operating suite.
Use of appropriate barrier precautions by staff at all times is essential to protect staff and
reduce risk of communicable disease transmission.
Patient isolation is generally unnecessary and potentially detrimental to patient care.
Cleaning and disinfection must be performed for all cases sufficient to eradicate most
pathogens (including AROs) from the surgical environment and must be performed between
each case. Accelerated hydrogen peroxide (1:16) is the agent advocated for cleaning of all
surgical care areas. This will likely have significant potential impact on flow through the
operating rooms.
Precaution cleaning (for VRE or diarrheal illnesses) using accelerated hydrogen peroxide
may be necessary in particular instances for patients/residents requiring Additional
Precautions, on the recommendation of Infection Prevention and Control. See
Housekeeping Cleaning table
Where feasible, cases involving patients/residents who require additional precautions should
be booked at the end of the slate. If the case cannot be delayed, thorough cleaning and
disinfection of the surgical care areas must be assured between cases.
Figure 11: Surgical Booking Procedure
Booking Request
Contact
Precautions
- Gloves - casual
contact
Airborne - Gowns - close
No Infection contact
No Infection Infection Infection Airborne AND
ARO- or - Hand hygiene
ARO+ ARO+ or ARO- Only other infection
unknown after any contact
ARO+ or ARO-
Droplet
Book Negative Book Negative Precautions
Book for Book for Book for Routine
Pressure Room & Pressure Room & - Gloves & gown
Routine Discharge Routine Discharge Discharge
Routine Discharge Routine Discharge for all contact
Cleaning Cleaning Cleaning + Walls
Cleaning Cleaning + Walls - Mask with shield
if within 3 feet
- Hand hygiene
after any contact
Patient Reassessment for Communicable Disease (Infection) Risk

(Pre-admit Clinic, Anesthesiologist, Surgeon, Admitting Nurse) Airborne
Precautions
- N95 Mask
- Negative
pressure room
*TB/Chickenpox *TB/Chickenpox &

No Infection No Infection Infection
ARO+ or ARO- other infection
Airborne AND
Contact /
Droplet
Precautions:
Airborne Precautions
Airborne AND - N95 Mask
Routine Contact Contact / Droplet plus Contact
Contact / Droplet - Negative air
Practices Precautions Precautions Precautions
Precautions room
(if required)
- Gloves & gown
for all contact
- Shield or
protective eye
Routine Routine Routine Routine Routine wear within 3 feet
Discharge Discharge Discharge Discharge Discharge - Hand hygiene
Cleaning Cleaning Cleaning + Walls Cleaning Cleaning + Walls after any contact
*Most common airborne organisms. Schedule case at end of day or allow an extra 10 minutes for cleaning.
When a surgical booking is made, increased risk of communicable disease transmission

should be identified by the booking surgeon (i.e. infection, see the following Table:
Assessment for Increased Risk of Communicable Disease Transmission).
Table 26: Assessment for Increased Risk of Communicable Disease Transmission
Determine from the booking surgeon (at time of booking) and patient and/or unit staff
(hospitalized patient) if the patient has:
TB or Chicken Pox • Airborne Precautions

Fever & Cough • Droplet Precautions
Skin Infection, open wound, boil or
abscess • Contact Precautions
Diarrhea in the past 2 days • Contact Precautions
No risk factors for communicable
disease transmission • Routine Practices
If on contact precautions, determine from the patient and/or unit staff if the patient has:
C.difficile VRE
Note: If there is a Norovirus outbreak in the facility/unit from which the patient is coming, check with
Unit Manager/Infection Control Practitioner.
Cases where there is NO known colonization with an ARO and no identified increased risk of
communicable disease transmission (i.e. infection, see Table 21: Assessment for Increased
Risk of Communicable Disease Transmission) may be booked at ANY TIME with direction for
Routine Discharge Cleaning. See Housekeeping Cleaning table
Cases where there is known colonization with an ARO but no identified increased risk of
communicable disease transmission (i.e. infection, see Table 21: Assessment for Increased
Risk of Communicable Disease Transmission) may be booked at any time with direction for
Routine Discharge cleaning. See Housekeeping Cleaning table. OR/PAR staff to use Contact
Precautions.
If there is identified increased risk of communicable disease transmission (i.e. infection, see
Table 21: Assessment for Increased Risk of Communicable Disease Transmission),
determine if the infection is known or thought due to tuberculosis (TB) or chickenpox. If so,
book as an Airborne case at any time in a negative pressure OR suite, with direction for
Routine Discharge Cleaning. See Housekeeping Cleaning table.
If there is an infection other than TB or chickenpox, the case may be booked as a contact or
droplet case at any time with direction for Routine Discharge Cleaning with the addition of
wall surfaces. Additional time for such cleaning to be done (add an approximate additional 10
minutes) should be added. Cases with infections where precaution cleaning is required (i.e.
Norovirus, clostridium difficile, etc.), should be booked at the end of the slate if possible.
Where feasible, it should be recommended that ALL patients/residents have a preoperative

bath or shower with antiseptic soap the night before and the morning of surgery. This is
mandatory for elective cases, but not anticipated to be feasible for non-elective cases.
Chlorhexidine (4%) is the antiseptic agent recommended.
C. Procedure Pre-Operatively
See also Assessment for Increased Risk of Communicable Disease Transmission
1. Cases Without Identified Need for Additional Precautions

The patient should have a preoperative bath or shower with antiseptic soap the night before
and the morning of surgery. This is mandatory for elective cases, but not anticipated to be
feasible for non-elective cases. Chlorhexidine (4%) is the antiseptic agent recommended.
All slated Same Day Admit or Daycare patients check in and are prepared in the normal
fashion, including hand hygiene on arrival.
They should be instructed on admission on hand hygiene and instructed to clean toilet
surfaces after personal use with accelerated hydrogen peroxide wipes. For non-elective
cases, if possible, the patient should be instructed to wash hands or use ABHR on arrival to
the preoperative area.
Patients/residents should be assessed for presence of increased risk of communicable

disease transmission (i.e. infection; see Assessment for Increased Risk of Communicable
Disease Transmission). If present, follow the appropriate algorithm (see Surgery Booking
Request) The need for additional precautions must be clearly communicated to other staff in
the surgical care areas (OR and post-anaesthetic area).
Routine practices are to be used by all personnel unless otherwise indicated.
Cleaning/disinfection of environmental surfaces in all pre-operative care areas contaminated

or potentially contaminated by the patient should be performed prior to next patient use.
2. Cases Known to be Colonized with an ARO Without Evidence of

Infection
See Assessment for Increased Risk of Communicable Disease Transmission.
and the morning of surgery. This is mandatory for elective cases, but not anticipated for non-
elective cases. Chlorhexidine (4%) is the antiseptic agent recommended.
All slated Same Day Admit or Daycare patients check in and are prepared in the normal
fashion, including hand hygiene on arrival.
They should be instructed on admission on hand hygiene and instructed to clean toilet
surfaces after personal use with accelerated hydrogen peroxide wipes. For non-elective
cases, if possible, the patient should be instructed to wash hands or use ABHR on arrival to
the preoperative area.
Patients/residents should be treated with contact precautions when close personal care is
being provided (from pre-anaesthetic to operative to post-anaesthetic areas. The need for
contact precautions must be clearly communicated to other staff in the surgical care areas
(OR and post-anaesthetic area).
The patient chart will be transported in a pillowcase. When removed from the pillowcase, the
chart should be placed on a clean surface away from patient contact surfaces (such as the
bed and any over bed table, etc.). Hand hygiene should be performed before and after
handling the chart. The chart may be returned to the same pillowcase used for transport, as
long as the inside of the pillowcase has not been contaminated.

disease transmission (i.e. infection; see Assessment for Increased Risk of Communicable
Disease Transmission). If present, follow the appropriate algorithm (see Surgery Booking
Request); this may require additional precautions. The need for additional precautions must
be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic
area).
Cleaning/disinfection of environmental surfaces in all pre-operative care areas contaminated

or potentially contaminated by the patient should be performed prior to next patient use.
3. Cases Where Patient has Evidence of Infection: Contact or

Droplet Precautions
and the morning of surgery. This is mandatory for elective cases, but not anticipated to be
feasible for non-elective cases. Chlorhexidine (4%) is the antiseptic agent recommended.
Patients/residents known to have an infection or who are already under additional precautions
should be transferred under contact or droplet precautions directly into the OR or to the OR
holding area (not the pre-operative area) on their bed or stretcher. Cleaning of that
environment may be necessary if there is obvious contamination. If the patient is in the
Emergency Department (ED) and transfer on the ED stretcher is not feasible, if possible, the
patient should be transported on a stretcher from the post-anaesthetic area, brought from the
post-anaesthetic area to ED by the porter.
The patient chart will be transported in a pillowcase. When removed from the pillowcase, the
chart should be placed on a clean surface away from patient contact surfaces (such as the
bed and any over bed table, etc.). Hand hygiene should be performed before and after
handling the chart. The chart may be returned to the same pillowcase used for transport, as
long as the inside of the pillowcase has not been contaminated.
Patients/residents should continue to be treated with contact or droplet precautions when

close personal care is being provided (from pre-anaesthetic to operative to post-anaesthetic
areas). The need for and type of contact or droplet precautions must be clearly
communicated to other staff in the surgical care areas (OR and post-anaesthetic area).

disease transmission (i.e. infection) other than that already identified prior to admission to the
surgical care area; see Assessment for Increased Risk of Communicable Disease
Transmission. If present, follow the appropriate algorithm (see Surgery Booking Request).
The need for additional precautions must be clearly communicated to other staff in the
surgical care areas (OR and post-anaesthetic area).
Cleaning of environmental surfaces in all pre-operative care areas contaminated or potentially

contaminated by the patient should be performed prior to next patient use. Where additional
precautions are required, precaution cleaning using accelerated hydrogen peroxide may be
necessary in particular instances for patients/residents requiring Additional Precautions, on
the recommendation of Infection Prevention and Control (see the Surgical Housekeeping
algorithm and Housekeeping Cleaning table.)
Figure 12: Surgical Housekeeping Algorithm
No Infection Cases requiring Infection Requiring Cases requiring

ARO+ or ARO- Airborne Precautions Contact Precautions Droplet Precautions
Routine Discharge Cleaning Routine Discharge Cleaning

with *H2O2 1:16 with *H2O2 1:16
or or
QAC QAC
All horizontal and contact surfaces (both All horizontal and contact surfaces (both
sides) in pre-anesthetic area, OR & sides) in pre-anesthetic area, OR &
postoperative area postoperative area
Cleaning of walls if visibly soiled (OR) Cleaning of walls (OR)
Cleaning of head space walls and Cleaning of head space walls and
Change bedside drapes when visibly Change bedside drapes after patient
soiled (PAR) (PAR)
Two-Step Cleaning for

- C.difficile
- Norovirus
- Diarrhea
*H2O2=Acclerated Hydrogen Peroxide - Preferred cleaning solution and must be used for VRE.
QAC=Quaternary Ammonium Compound
D. Procedure in the Operating Room

1. Routine Practices
Routine practices are to be used by all personnel.
All personnel entering and remaining in the OR are to perform hand hygiene (at a minimum)
prior to entering the suite. Hand hygiene must be used before and after contact with the
patients/residents or their environment. Hand hygiene product should be available at point-

of-use for this purpose.
All personnel in the OR must wear a fluid-resistant mask within one metre of any potential
splash/splatter risk. A mask with face shield must be worn when there is risk of splash with
blood or body substances, contaminating mucous membranes, during surgery, placement of
venous lines and intubation.
Gloves must also be worn at all times where there is risk of contact with blood or body
substances (e.g. during intubation). Disposable gloves must be available at point-of-use for
this purpose.
Shoe covers or footwear dedicated to the surgical care area must be worn at all times and
removed prior to leaving the surgical care area followed immediately by hand hygiene.
Only anaesthetic/OR equipment and supplies needed for the surgical procedure are to be
brought into the operating suite. Equipment that cannot be removed should be located as far
from the procedure table as possible. If within a one metre distance, they should be draped
to protect them from splashes. The drape is removed and replaced during post-case
cleaning.
Personal items (i.e. computers, brief cases, backpacks, etc.) are not to be brought into the
operating suite.
Hand hygiene must be performed before removal of any supply from a drawer or cupboard
during surgery. Any supply removed from a drawer or cupboard during surgery is considered
contaminated following the surgical procedure. Such unused supplies must be discarded.
The patient chart should be placed on a clean surface away from patient contact surfaces
(such as the bed). Hand hygiene should be performed before and after handling the chart.
Where possible, program the telephone for auto-answer to permit hands-free handling of
incoming calls. Gloves should always be removed and hand hygiene performed prior to
handling the phone.
Remove patient set pans and return them to the Sterile Core (or equivalent) prior to patient
arrival.
The scrub nurse will contain all instruments, suction bottles and used anaesthetic equipment
in the case cart, where case carts are used. The case cart door will remain open until
housekeeping closes it prior to its removal for decontamination. Alternatively, where case
carts are not available, one or (preferably) two tables well removed from the operative site will
be designated for holding and keeping separate sterile and contaminated instruments
respectively; these will be covered with a drape at the end of the case. At the end of the
case, the cleaners/nurse will remove the cart or table(s) to be delivered to CSD for
cleaning/disinfection and the cleaners will perform cleaning of the room.
All equipment brought into the room during a case, such as the C-arm, must remain in the
room until cleaned/disinfected by the cleaners.
Additional needed supplies should be passed directly to OR staff by Sterile Core (or
equivalent) personnel from the Sterile Core.
Where required, radiology aprons should be worn by scrubbed personnel under sterile gowns
for the entire case. Radiology aprons must be handled following hand hygiene.
All doors to the OR must be kept closed throughout surgeries. Entry to the OR suite during
surgery is strongly discouraged. Appropriate signage on the door (―No Entry‖) should support
this. OR staff should not generally enter the Sterile Core. Where necessary OR staff should
enter the Sterile Core directly from the OR, not from the outside corridor.
All unused sterile equipment must be returned to the Sterile Core or CSD.
surgical care areas since it meets this standard.
Precaution cleaning using accelerated hydrogen peroxide may be necessary in particular

instances for patients/residents requiring Additional Precautions, on the recommendation of
Infection Prevention and Control (see the Surgical Housekeeping Algorithm and the
Housekeeping Cleaning table.)
Routine discharge cleaning practices will include cleaning of all horizontal (both sides) and
contact surfaces within the room that have been touched by the patient, surgeon, assistants,
and anesthetist, and includes the anesthetic cart, monitors and leads, dust covers on
keyboards and on equipment, as well as operating lights and switches. In addition, the floor
must be wet mopped. The walls are wiped when visibly soiled. Cleaning of the walls is done
daily, preferably at the end of the slate.
For any patient with increased risk of communicable disease transmission (i.e. infection, see
Assessment for Increased Risk of Communicable Disease Transmission and the Surgical
Housekeeping Algorithm), cleaning of the walls is done in conjunction with the Routine
Discharge Cleaning. See Housekeeping Cleaning table.
The room may be used again as soon as the indicated type of cleaning is complete.
2. Patient Known to be Colonized with an ARO Without Evidence of

Infection
being provided (from pre-anaesthetic to operative to post-anaesthetic areas. The need for
Contact Precautions must be clearly communicated to other staff in the surgical care areas
Appropriate signage should be placed on all doors to the OR.
In addition to routine dress code outlined above (see Page 138), the anaesthetist and
circulating nurse must wear shoe covers dedicated for the particular case. Other personal
barrier equipment/ clothing should be used as outlined under contact precautions.
The patient chart may be brought into the room and placed on a designated clean surface
away from patient contact surfaces (such as the bed and any over bed table, etc.). Hand
hygiene should be performed before and after handling the chart. Both the circulating nurse
and anesthetist may do charting on this surface, as long as gloves that have touched the
patient are removed before doing so and after hand hygiene. The chart may be returned to
the same pillowcase used for transport, as long as the inside of the pillowcase has not been
contaminated.
Gloves are always to be removed after activities where patient contact has occurred (e.g. IV
starts, intubations) before contact with clean items/areas. Hand hygiene must be performed
before and after glove use.
The patient bed or stretcher is to be taken out of the room and covered with a sheet. The
appropriate Additional Precautions sign is to be placed on top of the bed. At the end of the
case, the sheet should be removed from the bed and placed in the OR linen hamper. If the
bed or stretcher needs to be exchanged, housekeeping staff should be notified accordingly
and the bed should be stripped in the hall and cleaned (precaution cleaning) before being put
back into circulation. See Housekeeping Cleaning table.
Following the surgical procedure, the circulating nurse and/or anaesthetist and/or porter will
remove or exchange shoe covers and contaminated gloves and discard them before leaving
the OR. Hand hygiene with ABHR is to be done immediately following removal of
contaminated barrier clothing. Clean gloves must be worn for transport of the patient.
Pressing elevator buttons while wearing gloves for patient transport is acceptable, as there is
very low likelihood of contamination of the elevator button.
Garbage and linen may be collected as routine, unless alternative methods are requested by
Infection Prevention and Control. However, there should be no recycling performed.
The OR may be used for the next patient once Routine cleaning is completed.
3. Cases with Infection – Contact and Droplet Precautions

Patients/residents should be treated with appropriate contact or droplet precautions as

warranted at all times while in the surgical care areas (from pre-anaesthetic to operative to
post-anaesthetic areas). The need for contact or droplet precautions must be clearly
communicated to other staff in the surgical care areas (OR and post-anaesthetic area).
Appropriate signage should be placed on all doors to the OR.
In addition to routine dress code outlined above (see Page 138), the anaesthetist and
circulating nurse must wear shoe covers dedicated for the particular case. Other personal
barrier equipment/clothing should be used according to contact/droplet precautions.
The patient chart may be brought into the room and placed on a designated clean surface
away from patient contact surfaces (such as the bed and any over bed table, etc.). Hand
hygiene should be performed before and after handling the chart. Charting may be done on
this surface by both the circulating nurse and anaesthetist, as long as gloves that have
touched the patient are removed before doing so and after hand hygiene. The chart may be
returned to the same pillowcase used for transport, as long as the inside of the pillowcase has
not been contaminated.
Gloves are always to be removed after activities where patient contact has occurred (e.g. IV
starts, intubations) before contact with clean items/areas. Hand hygiene must be performed
before and after glove use.
The patient bed or stretcher is to be taken out of the room and covered with a sheet. The
appropriate additional precautions sign is to be placed on top of the bed. At the end of the
case, the sheet should be removed from the bed and placed in the OR linen hamper. If the
bed or stretcher needs to be exchanged, housekeeping staff should be notified accordingly
and the bed should be stripped in the hall and cleaned (precaution cleaning – see
Housekeeping Cleaning table) before being put back into circulation.
Following the surgical procedure, the circulating nurse and/or anaesthetist and/or porter will
remove or exchange shoe covers and contaminated gloves and discard them before leaving
the OR. Hand washing or hand hygiene with ABHR is to be done immediately following
removal of contaminated barrier clothing. Clean gloves must be donned for transport of the
patient. Pressing elevator buttons, while wearing gloves for patient transport is acceptable,
as there is very low likelihood of contamination of the elevator button.
Garbage and linen may be collected as per routine, unless alternative methods are requested
by Infection Prevention and Control. However, there should be no recycling performed.
The OR may be used for the next patient once Routine Discharge Cleaning including the
walls is completed. This will include ―Routine Discharge Cleaning‖ as outlined above, as well
as cleaning of the walls. Precaution cleaning using accelerated hydrogen peroxide may be
necessary in particular instances for patients/residents requiring additional precautions, on
the recommendation of Infection Prevention and Control. (See the Surgical Housekeeping
Algorithm and Housekeeping Cleaning table.)
4. Cases with Infection – Airborne Precautions

Procedures for patients/residents requiring airborne precautions should only be performed if

negative air pressure can be assured within the OR relative to the hallway and adjacent
rooms.
Appropriate signage should be placed on the OR door.
In addition to routine dress code outlined above (see Page 138), all personnel in the OR must
wear an N95 mask (for which staff have been fit tested) at all times; see airborne precautions.
Additional precautions are necessary only if warranted.
Routine practices (including housekeeping) should be followed otherwise; see the Surgery
Booking Request Algorithm and the Surgical Housekeeping Algorithm.
E. Procedure in the Post-Anaesthetic Area

1. Routine Practices
Routine practices are to be used by all personnel at all times.
A minimal amount of supplies should be stored in the patient stretcher area.
surgical care areas since it meets this standard.
Routine discharge cleaning practices after discharge of patient from PAR will include cleaning
of all horizontal and contact surfaces within the stretcher area that may have been touched by
the patient and staff, and includes counters, stretcher, monitors, IV poles, keyboard, etc. In
addition, the floor must be wet mopped. Headspace wall is wiped and bedside curtains
changed when visibly soiled; see the Surgical Housekeeping algorithm. Cleaning of the
headspace wall is done at minimum daily, preferably at the end of the slate.
Cleaning of the stretcher area for patients/residents on additional precautions will include the
above.
Routine discharge cleaning as well as the headspace wall, see the Surgical Housekeeping
algorithm.
The stretcher area may be used again as soon as the appropriate type of cleaning is
complete.
2. Patient Known to be Colonized with an ARO Without Evidence of

Infection
being provided (from pre-anesthetic to operative to post-anesthetic areas). The need for
contact precautions must be clearly communicated to other staff in the surgical care areas
Patients/residents requiring additional precautions generally do not require placement in an

isolation room in the post-anesthetic area, but can be managed within the general post-
anesthetic area, as long as dedicated toileting facility is provided (e.g. dedicated commode)
and there is acceptable physical separation from adjacent stretchers (at least two metres/6
feet).
Patients/residents on contact precautions requiring nebulized therapy, non-invasive

ventilation or who have had a tracheostomy performed (not ventilated) are placed on droplet
precautions with a curtain around the stretcher; see Assessment for Increased Risk of
Communicable Disease Transmission.
Appropriate signage should be placed at the foot of the bed or on the curtain around the
stretcher.
Appropriate infection prevention and control barriers must be used for direct patient care; see
Assessment for Increased Risk of Communicable Disease Transmission.
The post-anaesthetic bay may be used for the next patient once routine discharge cleaning is
completed; see Surgical Housekeeping algorithm. Bedside curtains are changed if visibly
soiled.

instances for patients/residents requiring additional precautions, on the recommendation of
Infection Prevention and Control. (See Surgical Housekeeping algorithm and Housekeeping
Cleaning table.
3. Cases with Infection – Contact and Droplet Precautions

Patients/residents requiring additional precautions generally do not require placement in an

isolation room in the post-anesthetic area, but can be managed within the general post-
anesthetic area, as long as dedicated toileting facility is provided (e.g. dedicated commode)
and there is acceptable physical separation from adjacent stretchers (at least two metres/6
feet).
Patients/residents on droplet precautions should be managed with additional physical barrier

of drawn curtains between patient bays.
Patients/residents on contact/droplet precautions requiring nebulized therapy, non-invasive

ventilation or who have had a tracheostomy performed (not ventilated) must be placed under
droplet precautions with the bedside curtain drawn around the stretcher.
Appropriate signage should be placed at the foot of the bed or on the bedside curtain.
Appropriate infection prevention and control barriers must be used for direct patient care; see
contact/droplet precautions.
The post-anesthetic bay may be used for the next patient once routine discharge cleaning,
including head space walls is completed; see Surgical Housekeeping algorithm. Where
patients/residents have been on droplet precautions, curtains should be changed between
patients/residents; see Surgical Housekeeping algorithm.

instances for patients/residents additional precautions, on the recommendation of Infection
Prevention and Control. (See Surgical Housekeeping algorithm and Housekeeping Cleaning
table.)
4. Cases with Infection – Airborne Precautions

Patients/residents requiring airborne precautions should be transferred to the post-

anaesthetic area wearing a surgical grade mask.
Patients/residents requiring airborne precautions should be recovered ONLY in a private

room in which negative air pressure can be assured within the room relative to the general
post-anesthetic area and adjacent rooms.
Appropriate signage should be placed on the isolation room door.
Any person entering the isolation room must wear an N95 mask (which staff must be fit tested
for) at all times. Additional precautions are necessary only if warranted; see airborne
precautions.
The post-anaesthetic bay may be used for the next patient once routine cleaning is
completed; see the Surgical Housekeeping algorithm.
5. Burn Unit Recommendations

Infection prevention and control begins at the time the patient is admitted to the hospital and
continues until the patient‘s graft sites have healed. Because of the nature of the burn
wound (loss of preventive covering of the skin) the burned patient is more susceptible to
invasive bacterial infection. The patient is ―autocontaminated‖ prior to arrival at the hospital
by the bacteria that survive in the hair follicles and sweat glands beneath the burned tissues,
and by the dirt from the burned clothing or accident environment. In addition, the burn
wound provides the media necessary for bacterial growth; food, warmth and moisture.
Eliminating reservoirs of infection begins with the patient and we must rely on aseptic
technique as a factor in controlling the infection inherent in the patient.
All patients/residents in the Burn Unit, Intensive and Intermediate, will be isolated.
Unit Isolation
Unit doors must be kept closed to maintain positive pressure when there are
patients/residents within the unit being treated for burns.
All disciplines (including medical staff and hospital services) must ensure they perform
thorough hand hygiene upon entering and exiting this unit. It is acceptable to use ABHR
or soap and water.
Nursing must ensure a clean, freshly laundered uniform is worn at the start of each shift.
Patient Room
Each patient‘s room is a separate isolation unit. Before entering:
Appropriate and thorough hand hygiene must be carried out before entering and upon
leaving room. Hand hygiene stations are provided for this purpose directly outside each
individual room.
PPE will be donned prior to entry of the patient‘s room. This includes isolation gowns,
caps, gloves and all other appropriate protective attire that may be necessary (masks,
face shield etc).
Upon exiting the patient‘s room, all PPE must be discarded in the appropriate receptacles
contained within the room and new attire donned if re-entering.
Housekeeping, food service employees and all other auxiliary staff must check with
nursing staff for direction prior to entering the patient‘s room.
Isolation Protocols
Isolation protocols must be instituted for all patients/residents treated for burns:
Private room must be used
Doors must be kept closed
Individual gown technique is imperative for all persons entering room
Surgical masks must be worn by all persons entering patient rooms
Hands must be washed as per policy by all personnel before entering, after leaving and as
otherwise indicated during patient care
Gloves – must be put on routinely by all personnel before entering and kept on until
discarded in a receptacle before leaving the room
Attire must be discarded in appropriate receptacle, then hands must be washed upon
leaving room
Visitors
Visitors entering the Unit:
Cap to be worn over hair
Clean, disposable protective gowns to be worn
Surgical mask to be worn
When leaving Unit, visitors will be instructed to discard all attire in laundry/garbage
hampers provided in the patient‘s room and wash hands
Visitors will be restricted to two persons per patient at a time
Visitors will be restricted to immediate family only (any deviation from this must be
approved by the person in charge)
Visitors will NOT be allowed to visit during treatment hours
If children are to visit, parents must be informed of all necessary precautions required and
ensure adherence to unit policy for both patient and visitor safety
Personal items such as bedding, clothing or any items made of fabric that cannot be
decontaminated appropriately are not permitted in the acute private rooms. Advice may
be obtained from Infection Prevention and Control for any questions
Real plants or flower arrangements are not permitted on the unit
Visitors must be instructed not to sit on patient‘s bed
Pets are not permitted on the unit at any time
Note: All Visitors must be made aware of the implications of visiting a patient treated for
burns and the importance of basic precautions and hand hygiene, especially when it is a new
burn and when not covered with a dressing.
Equipment and PPE

Other aspects of isolation within unit:
Sterile gloves are worn for contact with the burn wound
Protective gowns must be worn during wound care and hydrotherapy
All outside equipment will be cleaned with a disinfecting solution prior to being brought into
the unit. If the equipment is to be used for more than one patient, it must be disinfected
after each patient use
Items from Pharmacy, Central Sterilizing/Processing, Stores and Linen will be considered
clean and may be taken directly into unit
6. Renal Dialysis Department

A. Introduction
There is a high risk of infection from blood borne viruses and transmission of infectious
organisms in the dialysis setting from contaminated environmental surfaces and equipment,
inappropriate healthcare worker technique and person-to-person transmission. Stringent
infection prevention and control principles and procedures must be followed to decrease
these risks and ensure a safe level of care.
B. Policy
Basic infection prevention and control principles must be met at all times to prevent
transmission of infectious disease and to ensure protection of patients/residents and staff in
the dialysis environment.
1. Guidelines for Patient Care

Ensure all staff are knowledgeable and well-trained and will adhere to the principles of
infection prevention and control, including implementation of routine practices
Use routine practices for all patients/residents
Maintain strict aseptic technique during all dialysis procedures
Implement routine monitoring and follow-up for signs and symptoms of any adverse
reaction, including local and systemic infection from vascular access or contamination
during dialysis
Advise patients/residents and visitors to complete hand hygiene prior to entering the
dialysis treatment station and on exit from the unit once dialysis is complete; ensure
pamphlets and adequate hand hygiene education are provided
Ensure appropriate signage with step by step instructions for hand hygiene are visible and
ABHR is available on entry and throughout the unit
Healthcare workers must follow established guidelines for hand hygiene techniques
and procedures
Meticulous aseptic technique is critical to prevent vascular access site
contamination
Hand hygiene must be performed before and after palpating a vascular access site,
before and after inserting, replacing, accessing, repairing, or dressing an
intravascular catheter. Palpation of the insertion site should not be performed after
the application of antiseptic, unless aseptic technique is maintained.
Medication Administration
Common medication carts must not be used for medication. If trays are used to pass
medications, they must be cleaned in between patients/residents
Multiple dose medication vials must not be used between patients/residents. When they
are used, prepare individual patient doses in a clean area away from dialysis stations and
deliver separately to each patient
Medications should be mixed and stored in a designated, separate area, separate from
any contaminated/used supplies or equipment
IV medication or dilution vials labeled for single use should not be punctured more than
once. Once a needle has entered this type of vial, the sterility of the product can no longer
be guaranteed. Do not pool residual medication from multiple vials
Environment and Supplies

Cleaning and disinfection procedures must meet hospital requirements, including the use
of hospital approved disinfectants and cleaning solutions. Refer to the cleaning section of
the infection prevention and control manual for approved disinfectants
Blood spills must be managed appropriately following established VIHA Renal guidelines
Clean non-sterile gloves and waste containers should be placed near each dialysis station
Sufficient number of sinks with warm water and soap, and ABHR for when hands are not
visibly soiled must be available
Supply carts should not contain both clean supplies and blood-contaminated items and
should not be moved from within one patient space to another or stored in patient care
areas
Supplies and equipment labeled ‗single use only‘ must be dedicated for single patient use.
In instances where equipment is intended for multiple use, disinfection of items must be
performed between patients/residents
There must be a separate storage area for patient‘s articles
Patient Food and Snacks

Snacks supplied by the dialysis unit should be pre-wrapped only
Dialysis chairs should be draped for patients/residents given foods that may spill on the
chair/bed. Drapes must be changed in between each patient. If a drape is not available,
thorough cleaning of the chair must be performed to remove all remnants of food prior to
the next patient‘s use
Patients/residents should be instructed to perform hand hygiene prior to eating
Waste
Discard all fluids and disinfect all surfaces and containers associated with prime waste
Waste generated from a hemodialysis facility should be considered potentially infectious
and handled according to local and provincial regulations governing medical waste
disposal
All disposable items containing fluids or biohazardous material should be placed in thick,
leak resistant bags and stored in appropriately constructed and labeled receptacles
Equipment
Non-disposable items that cannot be cleaned and disinfected (e.g. adhesive tape, cloth
covered BP cuffs etc), must be dedicated whenever possible for use on a single patient
only. If common use equipment cannot be dedicated, ensure adequate cleaning and
disinfection between patients/residents
There must be strict adherence to policy and procedures for the use, disinfection and
maintenance of hemodialysis machines and all dialysis related equipment
Manufacturer‘s recommendations must be followed
Refer to VIHA Reprocessing policy for decontamination of critical, semi-critical and
non critical equipment.
Items taken into a dialysis station, including those placed on top of dialysis machines, should
either be disposed of, dedicated for single patient use only, or cleaned and disinfected before
the next patient use or returning to storage.
Education
Regular updated education must be provided to patients/residents and their families,
clarifying their role in health maintenance and the prevention of dialysis-related
complications and infections.
2. Guidelines for Care of Vascular Access

Follow Established Guidelines Provided by the National Kidney Foundation–Kidney Dialysis
Outcomes Quality Initiative (NKF - KDOQI) for Selection and Maintenance of Vascular Access
for Hemodialysis.
Aseptic Procedure
Gloves must be changed between patients/residents and hand hygiene performed
Care to be taken to avoid touching surfaces with gloved hands that will later be touched
with ungloved hands
Staff must wear gowns, full face shields, or masks with eye protection to protect
themselves and their clothing when performing procedures in which blood or body fluid
splatter may occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers
and centrifugation of blood)
Discard protective equipment in provided waste receptacles and linen hampers nearest
the dialysis station
Skin Antisepsis – Fistulas, Grafts and Catheters

Disinfect clean skin with an approved antiseptic before needle insertion and during
dressing changes
Approved antiseptics for cleansing fistula, graft, arterial catheters and central venous
catheter (CVC) insertion sites include a 2% chlorhexidine gluconate preparation as a first
choice
10% Povidone-Iodine solution or 70% alcohol may be used in the case of skin reaction to
chlorhexidine. If iodine is used, it must be allowed to dry for at least 2 minutes prior to
skin puncture
Sodium Hypochlorite solutions may be used as an alternate antiseptic at the discretion of
the Infection Prevention and Control Team
Any other solution to be used for vascular access site care must be first approved by
Infection Prevention and Control Team
Catheter Site Dressing Regime

A new sterile dressing should be applied with each dialysis treatment
A topical antibiotic ointment should be applied at the catheter exit sites whenever possible
to help reduce the risk of infection
A dry gauze dressing is the recommended choice, and should be applied with each
dialysis treatment and replaced when site inspection is required or the dressing becomes
loosened or soiled
Patients/residents should be instructed to keep the CVC dressing clean and dry, to
replace the dressing if it becomes damp, soiled or loosened and to report to their
healthcare provider any changes in their catheter site or any new discomfort at the site
Occlusive transparent dressings:
If a transparent dressing is used, chose a product with a high-moisture vapor
transmission rate to prevent increased moisture accumulation under the dressing
(some types of these dressings are associated with an increase in microbial growth
under the dressing and thus an increase risk of infection)
Follow established BC Renal Agency guidelines for transparent dressing care
policy
Occlusive dressings are less compatible with the use of antimicrobial ointment at
catheter exit sites
3. Surveillance
Surveillance of important blood borne viruses and AROs will be performed on a routine basis
for monitoring and infection prevention and control purposes.
ARO Screening for Renal Dialysis Patients/Residents

Prevalence Screening
Prevalence screening for AROs are organized by Infection Prevention and Control at
regularly scheduled time frames
Frequency of screening and information collected is reviewed annually and in consultation
with the renal dialysis group to establish if there are indications for further surveillance
Prevalence screening may be performed more frequently at the direction of Infection
Prevention and Control during times of increased incidence, outbreaks and heightened
surveillance, etc.
MRSA screening includes:

Swabs to be collected prior to commencement of dialysis and then annually on the
patient‘s birthday
Swab sites include both nares (one swab), rectal swab (one swab), large (draining)
wounds.
VRE screening Includes:

Swabs to be collected prior to commencement of dialysis and then annually on the
patient‘s birthday
VRE point prevalence (collecting swabs from all patients/residents at a set point in time)
will be performed twice yearly
VRE swab sites include a rectal swab, ostomy swab (swab should be stool stained; collect
both ostomy and rectal swab only if patient continues to pass fluid/stool through rectum)
and any large draining wounds.
Screening Requirements for Patients/Residents Not Known to be ARO Positive

Screening for MRSA/VRE is to be completed:
On initial admission to any hemodialysis or peritoneal dialysis facility
Upon returning from travel (within or outside BC, for any period of time)
Upon return from admission to an acute care hospital or residential care facility (unless
already collected within the last 48 hours)
When peritoneal dialysis patients/residents require temporary hemodialysis unless
swabbed within the previous 48 hours
Incoming Visiting Patients/Residents (Travelers)

The patient‘s current ARO status should be received within 2-4 weeks prior to the patient‘s
arrival to the dialysis unit. A risk assessment should be made on arrival to the dialysis unit
Visiting dialysis patients/residents should be screened for MRSA and VRE upon their
initial arrival to the dialysis unit
Patients/residents returning from travel outside Canada should be screened with a risk
assessment completed to determine if additional precautions are necessary until negative
results are available.
Outgoing Traveling Patients/Residents

For patients/residents traveling outside BC: If requested, current ARO culture results
should be provided to the receiving dialysis unit along with the patient‘s clinical information
Monitoring ARO Status for Patients/Residents Known to be MRSA or VRE Positive

Patients/residents noted to be ARO positive are not routinely screened for the known ARO.
However, upon patient or Infection Prevention and Control‘s request, requirements for alert
removal and discontinuation of precautions include:
all ARO positive patients/residents must have stopped all antibiotics (topical and oral,
including decolonization protocol if MRSA positive) at least one week (or one month if
infected) prior to collecting swabs
MRSA
Collect two sets of swabs, at least one week apart
Wait at least one week after the last positive culture if the patient was colonized
Wait one month from the last positive culture if the patient had an ARO infection
If both sets of results are negative and the patient has not been on oral/topical antibiotics
contact Infection Prevention and Control for further guidance
MRSA decolonization is not routinely performed (clinical indications such as large draining
wounds require further assessment), but may be an option for some patients/residents.
VRE
Collect two sets of swabs, at least one month apart
Wait at least one month after the last positive culture
If both sets of results are negative and the patient has not been on topical/oral
antibiotics contact Infection Prevention and Control for further guidance
Consult with Infection Prevention and Control

Consult with the Infection Prevention and Control prior to discontinuing precautions for
final approval
Contact Infection Prevention and Control prior to discontinuing precautions on
patients/residents with multi-ARO (e.g. VRE and MRSA)
Consult with Infection Prevention and Control for follow up of ESBL
4. Acute Care Patients Receiving Dialysis

Patients admitted to acute care hospitals who meet the admission screening questionnaire
criteria should have swabs collected
Patients admitted to acute care must have a discharge swab collected
5. Residential Care Residents Receiving Dialysis

Residents admitted to acute care from a residential care facility and meet the admission
screening questionnaire criteria should have swabs collected
Note: In instances where Infection Prevention and Control has approved for a patient to
personally collect an ARO swab, the patient must be given the appropriate pamphlet with
accurate instructions to guide their technique and to ensure VIHA has access to results.
Consult with Infection Prevention and Control first.
6. Routine Surveillance, Evaluation and Management of

Communicable Diseases
Refer to CDC Recommendations: Guidelines for Vaccinating Kidney Dialysis
Patients/Residents and Patients/Residents with Chronic Kidney Disease (Recommendations
of the Advisory Committee on Immunization Practices –ACIP) for further recommended
guidelines for surveillance and patient vaccinations
7. Guidelines for Patients/Residents Requiring Additional

Precautions
Patients/residents who exhibit the following require additional precautions while receiving
treatment at a renal dialysis unit:
Known to have a confirmed ARO (MRSA, VRE or ESBL)
Confirmed C.difficile
Undiagnosed diarrhea
Large open draining wounds
Productive cough
Patient Placement for Dialysis

Patients/residents known to be positive with an ARO should be cared for in a private room if
available, but may also be cohorted with patients/residents of the same ARO in a shared
room or area (complete a risk assessment for signs and symptoms of infection prior to
cohorting). The cohorted area is a defined geographical area in the hemodialysis unit with
physical separation from other dialysis stations
Note: for patients/residents known to be ARO positive, whether or not cohorting is possible,
the patient‘s dialysis station must be thoroughly cleaned prior to the next patient‘s treatment
Visitors
In order to maintain a safe patient environment:
Visitors will perform hand hygiene on entry and exit to the dialysis unit. Education and
pamphlets must be provided to ensure appropriate technique
Visitors should don gowns and gloves when providing direct patient care. Information will
be given to visitors on the importance of hand hygiene while in the renal dialysis
environment
Visitors should not enter other patient‘s dialysis stations and should not be present during
times when vascular access is occurring
8. Guidelines for Outbreak Management

Patients/residents receiving dialysis who are transferred from an outbreak unit must be
placed on the appropriate precautions with the appropriate cleaning provided when the
patient has left the station. Patients/residents should be dialyzed in an area separate from
others whenever possible.
9. Guidelines for Cleaning and Disinfection

The following cleaning practices must be met performed between all patients/residents:
Clean and disinfect dialysis station (chairs, beds, tables, machines) between each patient
with a recommended disinfectant
Special attention to be paid to cleaning control panels on the dialysis machines and other
surfaces that are frequently touched and potentially contaminated with patients/residents
blood
Discard all fluids, clean and disinfect all surfaces, tubing and containers associated with
the prime waste (including buckets attached to the machines if applicable)
Dialysis machines:
o Surface must be cleaned between each patient; interior to be cleaned by technician or
designated personnel daily or immediately if contaminated, according to the
Association for the Advancement of Medical Instrumentation (AAMI), the Canadian
Standards Association (CSA) and manufacturer‘s recommendations
Curtains should be changed when visibly soiled and routinely on a monthly basis. In
areas where patients/residents known to be ARO positive are cohorted change curtains
weekly
Telephones, keyboards and general office surfaces must be cleaned daily. All keyboards
should be covered. Use alcohol swabs or hydrogen peroxide wipes for covered
keyboards. Nursing staff/Unit clerks to provide additional cleans throughout the day
following use
For patients/residents with undiagnosed diarrhea or symptoms of diagnosed Norovirus or
C.difficile, a precaution clean is necessary (see Housekeeping Cleaning table.)
For patients/residents known to be VRE positive, precaution cleaning is implemented
between patients/residents (see Housekeeping Cleaning table).
Table 27: Disinfection Procedures Recommended for Commonly Used Items or Surfaces in
Hemodialysis Units
Item or Surface Low level Disinfection Intermediate level
disinfection 22
Gross blood spills or items
X
contaminated with visible blood
Hemodialyzer port caps X
Water treatment and distribution
X X 23
system
Scissors, hemostats, clamps,
blood pressure cuffs, X X 24
stethoscopes
22
Careful mechanical cleaning to remove debris should always be done before disinfection. If item is visibly
contaminated with blood, use a tuberculocidal disinfectant.
23
Water treatment and distribution systems of dialysis fluid concentrates require more extensive disinfection if
significant biofilm is present within the system.
24
If item is visibly contaminated with blood, use a tuberculocidal disinfectant.
Environmental surfaces, including

exterior surfaces of hemodialysis X
machines
Adapted from: CDC MMWR Vol 50/No.RR-5, 2001
Care and Maintenance of the Dialysis System

AAMI and CSA standards must be followed
Manufacturer‘s recommendations must be followed
Water Treatment for Dialysis

Dialysis units must meet or exceed AAMI and CSA standards for hemodialysis water
purity, quality and monitoring
Water samples should be collected at the point where water enters the dialysate
concentrate proportioning unit
Dialysis fluid samples should be taken from the entry or exit point of the dialyzer during or
at termination of dialysis
If acceptable levels are exceeded, disinfection of the water system must occur and repeat
samples taken prior to use
Written procedures must be available, outlining all testing policy and procedures, actions
performed if contamination levels are exceeded and how documentation and records are
maintained
10. Guidelines for Peritoneal Dialysis

Infection prevention and control Considerations:
Strict use of aseptic technique and sterile dressings are required for the operative wound
and exit sites until well healed
Perform aseptic manipulation of the sterile disposable lines that deliver dialysis fluid into
the peritoneal cavity for peritoneal dialysis and aseptic connection of the tubing to the
patients/residents‘ catheter
Wear gloves whenever there is any potential contact with dialysis effluent, during exit-site
care, and when drawing blood or taking dialysate samples. Wear gloves, gown and face
shield when disposing of the effluent
Peritoneal effluent should be considered potentially infectious for bloodborne pathogens
PD drains must be used for draining peritoneal/dialysate only
Patients/residents must be instructed on proper use of these sinks and shown
where sinks designated for personal care and hand washing are located.
Peritoneal Dialysis sinks: On a weekly basis, peritoneal dialysis sinks will be disinfected using
a bleach solution of 100 mL of 5% household bleach diluted in 900 mL of water (for a 1:9 ratio
of 1 part bleach to 9 parts water out of a total of 10 parts). Pour the solution down the sink
drain, let it sit for 5–10 minutes, and follow with a water flush. Notify maintenance
immediately if there is any residue or clogs noted in the drain.
Sources:
American Institute of Architects. (2006). Renal Dialysis unit (acute and chronic) Guidelines for design and
construction of healthcare facilities. (pp.93-96). Washington, DC: American Institute of Architects.
Association for Advancement of Medical Instrumentation. (2003). AAMI standards and recommended
practices, dialysis. Arlington, VA: American National Standards Institute
Association for Professionals in Infection Control and Epidemiology. (2004). Infection control in ambulatory
care. (pp.98-107). Washington, DC: Association for Professionals in Infection Control and Epidemiology.
Association for Professionals in Infection Control and Epidemiology. (2005). Dialysis. APIC text of infection
nd
control and epidemiology 2 edition. (pp.1-15). Washington, DC: Association for Professionals in Infection
Control and Epidemiology.
Bender, F., Bernardini, J., & Piraino, B. (2006) Prevention of infectious complications in peritoneal dialysis:
Best demonstrated practices. Kidney International, 70, 44-54.
Bianchi, P,. Buoncristiani, E., Buoncristiani, U. (2007). Disinfection by sodium hypochlorite: Dialysis
applications. Contributions to Nephrology. 154, 1-6.
BC Renal Agency. (2008). Prevention, treatment and monitoring of vascular access related infection in
hemodialysis patients: Vascular access guideline
Brunch, M. (2007. Toxicity and safety of topical sodium hypochlorite. Contributions to Nephrology, 154, 24-38.
Center for Disease Control. (2001). Recommendations for preventing transmission of infections among chronic
hemodialysis patients. Morbidity and Mortality Weekly Report. 50 (RR-5), 1-43.
Center for Disease Control. (2002). Guidelines for prevention of intravascular catheter related infections,
Morbidity and Mortality Weekly Report. 51(RR-10), 1-26.
Center for Disease Control. (2003). Guideline for environmental infection control in health care facilities.
Center for Disease Control. (2006). Guidelines for vaccinating kidney dialysis patients and patients with chronic
kidney disease (summarized from recommendations of the advisory committee on immunization practices).
Department of Health. (2002). Good practice guidelines for renal dialysis/transplantation units: Prevention and
control of blood borne virus infection.
De Vos, J., Elseviers, M., Harrington, M., Zampieron, A., Vlaminck, H., Ormandy, P., et al. (2006). Infection
control practice across Europe: Results of the European practice database project. EDTNA/ERCA Journal, 32
(1), 38-41.
Health Canada. (1999). Infection control guidelines: Routine practices and additional precautions for
preventing the transmission of infection in health care. Canada Communicable Disease Report. Vol. 25S4.
Lam, L. D., Newman, A., & CHICA Dialysis Interest Group. (2005). A survey of infection control practices in
hemodiaysis units in Canada. Canadian Journal of Infection Control, 20(3), 118-136.
Mendoza-Guevara, L., Castro-Vazquez, F., Aquilar-Kitsu, A., Morales-Nava, A., Rodriguez-Leyva, F. Sanchez-
Barbosa, J.L. (2007). Amuchina 10% solution, safe antiseptic for preventing infections of exit-site of Techkhoff
catheters, in the pediatric population of a dialysis program. Contributions to Nephrology. 154, 139-144.
National Center for Infectious Diseases. (1999). National surveillance of dialysis-associated diseases in the
united states. Atlanta, Georgia: Public Health Service, Department of Health and Human Services.
National Kidney Foundation. (2006). Clinical practice guidelines for peritoneal dialysis adequacy: Update 2006.
National Kidney Foundation. (2006). Kidney dialysis outcomes quality initiative, clinical practice guidelines for
vascular access: Update 2006.
Peleman, R., Vogelaers, D., & Verschraegen, G. (2000). Changing patterns of antibiotic resistance-update on
antibiotic management of the infected vascular access. European Renal Association –European Dialysis and
Transplant Association, 15, 1281-1284.
Taal, M,. Fluck, R., & McIntyre, W. (2006). Preventing catheter related infections in hemodialysis patients.
Current Opinion in Nephrology and Hypertension. 15, 599-602.
Vancouver Coastal Hospital Infection Prevention and Control Manual. (2006). Vancouver coastal infection
control guidelines for hemodialysis patients with antibiotic resistant organisms (revised December 2005 and
January 2006).
Zuckerman, M. (2002). Surveillance and control of blood-borne virus infections in haemodialysis units. Journal
of Hospital Infection, 50, 1-5.
7. Respiratory Department Guidelines

A. Introduction
Prevention and control of hospital-acquired infections associated with respiratory therapy is
dependent upon adequate procedures for maintenance and operation, including the use of
strict aseptic technique, routine practices and appropriate reprocessing methods.
B. Equipment
Microorganisms found in respiratory equipment often come from the patient during
breathing or coughing into the system. It is essential that this contamination be destroyed
or removed from all reusable apparatus
Routine practices must be used for handling all used equipment. All contaminated
equipment must be cleaned and decontaminated before attempting sterilization
Follow the manufacturers‘ recommendations for disassembling equipment and for
cleaning and decontamination
The outside surfaces of large pieces of equipment should be cleaned and disinfected after
use (e.g. nebulizers, oxygen tents, humidifiers, incubators, compressors etc.). Clean
thoroughly using a hospital approved detergent and/or disinfectant that is consistent with
manufacturer‘s recommendations
Cover and protect all equipment when not in use
For guidelines regarding the appropriate care and use of specific respiratory equipment,
solutions and products, refer to established VIHA Respiratory Therapy policy and
procedure
If an outbreak is suspected, notify Infection Prevention and Control. The Infection Control
Practitioner will coordinate all swabs collected from equipment for laboratory analysis
C. Disposable Equipment
A wide variety of disposable equipment is available and should be used whenever
possible, especially in the care of patients/residents where there is a risk of contact with
potentially infectious body fluids, excretions and secretions
Single use items must not be reprocessed, according to VIHA Reprocessing Manual.
D. Respiratory Patients/Residents Requiring Additional

Precautions
A risk assessment must be completed prior to initiating any respiratory procedure to
determine which additional precautions are necessary.
For all respiratory procedures, such as sputum induction, nasal-pharyngeal

washes/specimen collection, use of nebulizers etc, refer to established VIHA Respiratory
Therapy policy and procedure.
1. Guidelines for Ventilator Associated Pneumonia (VAP)

Definition
Ventilator associated pneumonia is defined by CDC as a condition in patients/residents on
mechanical ventilation for > 48hrs, who present with fever, cough and new onset of purulent
sputum, combined with:
Radiologic evidence of a new or progressive pulmonary infiltrate
Leukocytosis
A suggestive Gram's stain
Growth of bacteria in cultures of sputum, tracheal aspirate, pleural fluid, or blood.
Reference: CDC Guidelines for Preventing Health-care associated Pneumonia, 2003
VAP Prevention Strategies

Surveillance
Infection Prevention and Control conducts ongoing surveillance for all new cases of
pneumonia, including patients/residents at high risk for healthcare related pneumonia
such as those admitted to ICU, mechanically ventilated patients/residents or high risk
surgical patients/residents
Goals of surveillance:
Identify outbreaks early
Ensure the appropriate precautions and education are put into place
Determine trends and help identify practices that require closer review and
education.
Cross Contamination
Routine Practices must be adhered to at all times, including:
Use of gloves before handling respiratory secretions or contaminated objects
Appropriate hand hygiene (soap and water or ABHR) before and after any contact with the
patient or equipment in the patient‘s environment; before and after contact with mucous
membranes or any respiratory secretions
Use of gown (impermeable) when contact with respiratory secretions are anticipated
Use of mask when contact with respiratory secretions are anticipated and when
performing procedures that induce coughing or create aerosol
Airway Management
Perform orotracheal rather than nasotracheal intubation, unless contraindicated
Ensure secretions are removed from above the cuff prior to deflating the cuff of an ET
tube when repositioning or removing
Gastric Reflux Prevention

Maintain elevation of the head of the bed between 30 – 45 degrees unless contraindicated
Ensure routine verification of placement of feeding tube
Equipment
For maintenance care, ensure there is periodic draining and discarding of any condensate
collected in the tubing
Ensure condensate is not able to drain toward the patient
Oral Care
Ensure standard practice for thorough oral care/decontamination is available and utilized
Sources:
Centre for Disease Control. (2003), Guidelines for environmental infection control in health care facilities.
Morbidity and mortality weekly report, 52(RR10), 1-42.
Chulay, M. (2005). VAP prevention: The latest guidelines. RN, 68(3), 53-56.
Evans, E. (2005). Best-practice protocols: VAP prevention. Nursing Management, 36(12), 10-16.
Favero, M.S., Bond, W.W. (1991). Sterilization, disinfection and antisepsis in the hospital manual of clinical
microbiology. Washington, DC: American Society for Microbiology.
Ohana, S., Denys, P., Guillemot, D., Lortat-jacob, S., Ronco, E., Rottman, M., et al. (2006). Control of an ACC-
1-producing Klebsiella pneumonia outbreak in a physical medicine and rehabilitation unit. Journal of Hospital
Infection, 63, 34-38.
O‘Keefe-McCarthy, S. (2006). Evidence-based nursing strategies to prevent ventilator-acquired pneumonia.

Canadian Association of Critical Care Nurses, 17(1), 8-11.
Powers, J. (2006). Managing VAP effectively to optimize outcomes and costs. Nursing Management Supp, 37,
48b-48f.
Vancouver Island Health Authority. (2008). Respiratory therapy policy and procedure.
PART 8: Specific Procedural Recommendations

1. Asepsis
Aseptic technique can be defined as all the measures we take to purposefully reduce the
number of microorganisms to an irreducible number for the purpose of preventing
transmission of infection. The strictness (or level) of aseptic technique increases as you
perform more invasive procedures. For example, taking a blood pressure requires only clean
technique, while procedures that enter a sterile body cavity require sterile technique.
Microorganisms Live In and On Our Bodies

Transient microorganisms are easily picked up on hands, clothing, inanimate objects, etc.,
and are easily removed by hand washing and cleaning (physical removal of "germs"),
antisepsis and disinfection. Antisepsis (or hand washing and pre-op skin preparation) is the
removal of transient microorganisms from the skin with a reduction in the resident flora.
Resident or Normal Flora are those microorganisms that are constantly present on our
bodies; no amount of scrubbing will totally remove them (the skin cannot be made sterile).
These organisms cause "trouble" when introduced into normally sterile areas (like the bladder
or bloodstream).
Pathogens: Microorganisms that nearly always produce disease. For example: Salmonella
and Shigella cause diarrheal illness upon ingestion of enough organisms. Normal flora can
become pathogenic when introduced into areas where they don't belong, for example,
through insertion of a catheter or through surgery. S. epidermidis, normal flora of the skin,
causes most central line infections and hip implant infections.
The Seven Keys of Asepsis

Know what is clean
Know what is contaminated
Know what is sterile
Keep clean, contaminated and sterile items separated
Keep sterile sites sterile
Resolve contamination immediately
Train yourself to realize when you have broken technique
Know what is clean

Clean techniques are any procedures that involve contact with intact skin or mucous
membranes only. For example, when you are taking blood pressure or temperature, these
articles need to be clean only.
Know what is contaminated

Certain procedures like dressing changes produce contaminated materials. These
contaminated materials must be disposed of properly by incineration or autoclave. Touching
non-intact skin is a contaminated procedure; wear clean gloves unless a sterile procedure
(like a dressing change) is being done.
Know what is sterile

During certain procedures (for example, the insertion of an IV or urinary catheter), sterile
technique must be used. The level of sterile procedures increases with the level of
invasiveness. For example, surgical procedures require stricter aseptic technique than
starting an IV. Sterile gloves are required for sterile procedures.
Keep clean, contaminated and sterile items separated

Keep contaminated articles from touching clean or sterile items. Store clean and sterile items
separately from contaminated areas or items. Keep sterile items from touching anything but a
sterile field or another sterile item.
Keep sterile sites sterile

Once a tube has been inserted into the body, care must be given to mitigate the travel of
microorganisms up the catheter or tube. Give dressing changes or catheter care and replace
catheters per your facility's policy and procedure.
Resolve contamination immediately

If sterile technique cannot be used or is broken (e.g. during an emergency), resolve
contamination when it occurs. For example, if an IV is inserted during an emergency, replace
the IV as soon as possible after the code is completed.
Train yourself to realize when you have broken technique

If a technique is broken, remedy the problem if possible. For example, if during the insertion
of an IV the catheter is contaminated by touching a non-sterile surface, replace the catheter
before insertion. If contamination cannot be resolved, report it to the proper person. For
example, if the bowel is nicked during surgery, the case classification will change from clean
or clean-contaminated to contaminated and extra care should be given to prevent infection.
For details on approved disinfectants and antiseptics for different procedures see the Table
below – Approved Antiseptic Agents and Procedures.
Reference: Rhodes, M. (2003) The ABCs of Infection Control. Infection control Today Magazine
Table 28: Approved Antiseptic Agents and Procedures

PURPOSE OF SKIN
AGENT(S) CONTACT TIME COMMENTS
PREPARATION
Patient’s personal Neutral soap 10-15 seconds Hand hygiene to be promoted
hygiene after toileting and before
meals
Alcohol antisepsis 15 seconds Hand hygiene to be promoted
after toileting and before
meals
Staff hygiene
Social hand wash Neutral soap 10-15 seconds Attention to nails. Remove
rings and watches. Perform
when hands visibly soiled and
when managing C.difficile
patients/residents.
Hand antisepsis - Approved alcohol based 15 seconds Use as first line or routine
Alcohol based hand hand rub approach to hand hygiene.
rub *Do not use if hands visibly
soiled or when managing
C.difficile.
Aseptic hand scrub or CHG 2% detergent 3-5 minutes To be performed prior to
rub Povidone Iodine 10% 3-5 minutes aseptic procedures. If alcohol
Approved alcohol based 2-3 minutes based hand rub used, 2-3
hand rub liberal applications rubbed all
surfaces-hands, wrists,
forearms
Preparation of skin for 70% Isopropyl alcohol Until dry Care not to retouch prepared
intramuscular or skin surface
subcutaneous
injections
Preparation of skin for CHG 2% with 70% Until dry For neonates or if allergic to
peripheral venous isopropyl (preferred) Povidone Iodine: 2% CHG
access or 70% Isopropyl with 70% Isopropyl alcohol
alcohol
Preparation of skin for: Povidone Iodine 10%, Until dry (at least 2
Withdrawal of blood for followed by 70% minutes)
culture and sensitivity Isopropyl alcohol
Withdrawal of blood for 70% Isopropyl alcohol Until dry

other studies
Preparation of skin site Adults: 2% CHG with Until dry Amuchina 10% (Except Plus)
before insertion of 70% Isopropyl alcohol for hemodialysis
arterial, central, or patients/residents with skin
epidural lines, Neonates: 2% CHG (no allergy or sensitivity
hemodialysis access or alcohol)
any inserting any
scope through the skin
PURPOSE OF SKIN
AGENT(S) CONTACT TIME COMMENTS
PREPARATION
Ongoing care of sites 2% CHG with 4% Until dry
used for line access to alcohol preservative
a sterile space
Care of wounds post Sterile normal saline Wipe dry with sterile Open containers to be
surgical or trauma gauze discarded and replaced after
24 hours
Care of pin sites Sterile normal saline Until dry Ortho: Cleanse daily and prn
and/or hydrogen with normal saline; gently
peroxide 3%; or remove scabbing. Other
Povidone Iodine 10% Specialties: Check with MRP
for orders.
Care of decubiti Sterile normal saline or Saline used if discharge is
CHG 2% solution present
or Povidone Iodine 10%
Preparation for None (see comments) Good perineal washing.

gynecologic Colposcopy – Povidone Iodine
examination 10%.
Urinary Normal Saline (see Good perineal washing

Catheterization/Urology comments)
Pre-operative skin prep
In-house CHG 4% (see comment) Shower night before and

morning of surgery with CHG
4%. Rinse well.
Same day surgical 3 minutes Coach patient to allow lather

admissions: to remain on skin for 3
Patient arrives with: minutes
only 1 application of Apply once to surgical area for
CHG 4% 3 minutes. Rinse area
thoroughly.
Patient arrives with: CHG 4% (see comment) As per VIHA Nursing Policy &
no applications of CHG Procedure Manual.
4% completed; or allergy PCMX; or Povidone
to CHG 4% Iodine scrub.
Note: Once opened, bottles of sterile normal saline should be dated, and used up or discarded, preferably by
the end of each shift and certainly within 24 hours of opening.
2. Environment and Furniture

A. Storage of Decorative Items
Decorations must be stored in a designated area, which is not used to store clean
supplies or linen
Decorations will be cleaned prior to storage
Damaged or broken decorations will be discarded as they cannot be cleaned
All decorations will be stored within a lidded, cleanable box
Decorations which cannot be cleaned and are displayed in areas where they are handled
or on the floor will be discarded at the end of the celebration
B. Furniture
General
All furniture should be constructed in a way that permits cleaning of all surfaces
The size, shape and design of the furniture must allow easy access to cleaning staff
Risk Levels
Vinyl is required for furnishings in high risk areas
High level of risk applies to any area specifically used by patients/residents (i.e. patient
rooms, waiting rooms) and any area where a healthcare worker goes after providing
direct patient care (e.g. nursing station, staff lounge, report area, conference rooms,
offices within patient care areas
Durable, cleanable fabrics are appropriate in low risk areas
Low level of risk applies to any office areas where staff are not providing direct patient
care, or return to after providing direct patient care
Fabric
Fabric must be impermeable to water, stain resistant and made of a material that does not
promote the growth of microorganisms
The material should be durable, easily cleaned and withstand cleaning with institutional
cleaning/disinfecting solutions. Their selection should be based on an understanding of
the principles of decontamination and maintenance requirements (e.g. able to withstand
multiple application of diluted disinfectants over time)
Limit the amount of pleating in fabric and make sure the seams are sealed
There should be limited off-gassing from the fabric
Other Materials
Plastic laminate furniture offer good designs and realistic wood grain patterns. Another
option combines polyurethane sealed woods on vertical surfaces with solid surfacing on
horizontal surfaces
The purchasing of new wood furniture is not recommended. Existing wood furniture must
be assessed regularly to assure that the finish remains sealed (note: wood furniture
requires regular maintenance to keep lacquer intact)
Note: The above criteria apply to all clinical areas throughout the healthcare system – patient
rooms, waiting rooms, unit offices (i.e. social worker, coordinator, manager), nurses‘ station,
staff rooms and conference rooms. Fabric, if desired, is acceptable in
administrative/executive offices and related meeting areas.
C. Fixtures and Fittings

General
All fixtures and fittings should prevent the collection of dust and growth of mold, mildew
and other microorganisms
They must be easy to maintain, and have proven durability under actual conditions of use
and maintenance in healthcare facilities
Curtains and blinds

Curtains can easily become contaminated with microorganisms. All curtains must be able
to withstand a washing process at disinfection temperatures (71 c for 25 minutes or
more), or be able to withstand the washing/drying sanitizing processes that occur in an
industrial or institutional setting
Venetian horizontal blinds are not recommended as they become dusty and difficult to
clean. Certain vertical blinds may be acceptable if design allows appropriate cleaning
Blinds need to be of a construction that allows cleaning of all surfaces and functional parts
Fittings
The use of lamps with fabric shades is not recommended
If fabric shades used, the fabric must be removable and be able to withstand washing
temperatures of 71 c for 3 minutes or 65 c for 10 minutes
It is recommended to avoid lamps that have pull strings for operation, unless it is a
material that is easily cleaned and will not rust
Ceiling lights and wall mounted fixtures should have lenses and enclosed housings
Vanity tops
Vanity top within patient bathrooms must be constructed of a solid surface material, with
integrated bowl and backsplash
Hand Wash Facilities

For all new construction and renovations all dedicated hand wash sinks will follow
requirements outlined in CSA‘s Z8000 standards
Handrails and Other Hardware

Stainless steel remains the material of choice for handrails and other hardware, because
of its durability and ease of maintenance
Wood is acceptable if sealed, but requires ongoing maintenance
Ceilings
The ceiling must be cleanable and built to prevent the infiltration of dust from the plenum
space
The ceiling should be made of a material that does not promote the growth of
microorganisms
Walls
Low volatile organic compound (VOC) scrub-able paint must be used
If vinyl wall covering is selected, it should have minimal texture to facilitate thorough
cleaning
All wall coating/covering and adhesives used must have antimicrobial treatments where
available
Floors
Sheet vinyl flooring with welded seams and an integral cove base
Carpeting in patient care areas is strongly discouraged
Posted Signage and Other Posted Materials

Most signage presents a very low risk for transmission of organisms.
Determination of whether a sign/poster that is posted should be laminated is based upon the
following considerations:
Length of time it is likely to be posted
Whether the signage is for long term use and is stored between uses
Whether the signage would require a wipe down of its surfaces when area is cleaned
Risk of contamination based on where it will be posted – low frequency or high
frequency touch areas
Where it will be used – patient care area, staff rooms, office/business area.
When a poster/sign is developed for posting and a decision needs to be made regarding
lamination, the following four basic principles should be considered:
1. Laminate the poster/sign if it will be posted for a long-term period (30 days or
greater), or stored and re-used (i.e. precaution signs)
2. Don‘t laminate if poster/sign is to be posted for short term (less than 30 days)
3. If not laminated, remove and replace if it becomes dirty, tattered, or torn
4. If the poster/sign is to be posted in a patient or staff bathroom or dirty utility room, it

must be laminated regardless of the duration of use
Please note: Sheet protectors are not recommended as an alternate to lamination because
they cannot be easily cleaned and require tape to seal the top.
APPENDICES
APPENDIX A: Type and Duration of Additional Precautions
Where Recommended for Selected Infections and Conditions
Legend:
Precautions used in addition to Routine Practices
Type of Precautions:
A - AIRBORNE
C - CONTACT
D - DROPLET
R - ROUTINE PRACTICES
Duration of Precautions:
CN - Until off antimicrobial treatment and culture negative

DI - Duration of illness (with wound lesions, DI means
until wounds stop draining)
DE - Until the environment is completely decontaminated
U - Until time specified in hours (hrs) after initiation of
effective therapy
Unknown - Criteria for establishing eradication of pathogen has
not bee determined
Adapted from: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices
Advisory Committee, 2007 Guideline for Isolation Precautions: preventing Transmission of Infectious Agents in
Healthcare Settings, June 2007
TYPE AND DURATION OF ROUTINE PRACTICES AND

PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS
AND CONDITIONS
Infection/Condition Precautions
Type Duration Comments
Abscess
Draining, major C DI No dressing or containment of
drainage; until drainage stops or can be
contained by dressing.
Draining, minor or limited R Dressing covers and contains drainage.
Acquired human R Post-exposure chemoprophylaxis for
immunodeficiency syndrome some blood and body fluid exposures.
(HIV)
Actinomycosis R Not transmitted from person to person.
Adenovirus infection (see agent-
specific guidance under
gastroenteritis, conjunctivitis,
pneumonia)
Amebiasis R Person to person transmission is rare.
Transmission in settings for the
mentally challenged and in a family
group has been reported. Use care
when handling diapered infants and
mentally challenged persons.
Anthrax R Infected patients/residents do not
generally pose a transmission risk.
Cutaneous Anthrax R Transmission through non-intact skin
contact with draining lesions possible,
therefore use Contact Precautions if
large amount of uncontained drainage.
Handwashing with soap and water
preferable to use of waterless alcohol
based antiseptics since alcohol does
not have sporicidal activity.
Pulmonary Anthrax R Not transmitted from person to person.
Environmental Anthrax: R DE Until decontamination of environment
aerosolizable spore-containing complete. Wear respirator (N95 mask
powder or other substance or PAPRs), protective clothing;
decontaminate persons with powder on
them.
Hand hygiene: Handwashing for 30-60

seconds with soap and water or 2%
chlorhexidine gluconate after spore
contact (alcohol based hand rubs
inactive against spores).
Post-exposure prophylaxis following
environmental exposure: 60 days of
antimicrobials (either doxycycline or
ciprofloxacin) and post-exposure

AND CONDITIONS
vaccine under IND.
Antibiotic-associated colitis (see
Clostridium difficile)
Antibiotic Resistant Organisms R/C AROs judged by the Infection
(AROs), infection or colonization (e.g. Prevention and Control Program, based
MRSA, VRE, VISA/VRSA, ESBLs, on local, provincial or national
resistant S. pneumoniae) recommendations, to be of clinical and
epidemiologic significance. Contact
Precautions recommended in settings
with evidence of ongoing transmission,
acute care settings with increased risk
for transmission or wounds that cannot
be contained by dressings.
Arthropod-borne viral encephalitides R Not transmitted from person to person
(eastern, western, Venezuelan except rarely by transfusion, and for
equine encephalomyelitis; St. Louis, West Nile virus by organ transplant,
California encephalitis; West Nile breastmilk or transplacentally. Install
Virus) and viral fevers (dengue, screens in windows and doors in
yellow fever, Colorado tick fever) endemic areas. Use DEET-containing
mosquito repellents and clothing to
cover extremities.
Ascariasis R Not transmitted from person to person.
Aspergillosis R Contact Precautions and Airborne
Precautions if massive soft tissue
infection with copious drainage and
repeated irrigations required.
Avian influenza (see influenza, avian,
below)
Babesiosis R Not transmitted from person to person
except rarely by transfusion.
Blastomycosis, North American, R Not transmitted from person to person.
cutaneous or pulmonary
Botulism R Not transmitted from person to person.
Bronchiolitis (see respiratory C DI Use mask according to Routine
infections in infants and young Practices. (Droplet precautions if
children) patient coughing).
Brucellosis (undulant, Malta, R Not transmitted from person to person
Mediterranean fever) except rarely via banked spermatozoa
and sexual contact. Provide
antimicrobial prophylaxis following
laboratory exposure and monitor
serology.
Campylobacter gastroenteritis (see
gastroenteritis)

AND CONDITIONS
Candidiasis, all forms including R
mucocutaneous
Cat-scratch fever (benign inoculation R Not transmitted from person to person.
lymphoreticulosis)
Cellulitis R
Chancroid (soft chancre) (H.ducreyi) R Transmitted sexually from person to
person.
Chickenpox (see varicella) A
Chlamydia trachomatis
Conjunctivitis R
Genital R
(lymphogranuloma Venereum)
Pneumonia (infants 3 months R
of age or less)
Chlamydia pneumoniae R Outbreaks in institutionalized
populations reported, rarely.
Cholera (see Gastroenteritis)
Closed-cavity infection
Open drain in place; R Contact Precautions if there is copious
limited or minor drainage uncontained drainage.
No drain or closed drainage R
system in place
Clostridium
C. botulinum R Not transmitted from person to person
C. difficile (see Gastroenteritis) C DI
C. perfringens
Food poisoning R Not transmitted from person to person.
Gas gangrene R Transmission from person to person
rare; one outbreak in a surgical setting
reported. Use Contact Precautions if
wound drainage is extensive.
Coccidioidomycosis (valley fever)
Draining lesions R Not transmitted from person to person.
Pneumonia R Not transmitted from person to person.
Colorado tick fever R Not transmitted from person to person.
Congenital rubella C Until 1 year Routine Practices if nasopharyngeal
of age and urine cultures repeatedly negative
after 3 months of age.
Conjunctivitis

AND CONDITIONS
Acute bacterial R
Chlamydia R
Gonococcal R
Acute viral (acute hemorrhagic) C DI Adenovirus most common; Enterovirus
70, Coxsackie virus A24, also
associated with community outbreaks.
Highly contagious; outbreaks in eye
clinics, pediatric and neonatal settings,
institutional settings reported. Eye
clinics should follow Routine Practices
when handling patients/residents with
conjunctivitis. Routine use of infection
prevention and control measures in the
handling of instruments and equipment,
and disinfection of eye equipment
between patients/residents, will prevent
the occurrence of outbreaks in this and
other settings.
Corona virus associated with SARS
(SARS-CoV) (see severe acute
respiratory syndrome)
Coxsackie virus disease (see
enteroviral infection)
Creutzfeldt-Jakob disease R Use disposable instruments or special
(CJD, vCJD) sterilization/ disinfection for surfaces,
objects contaminated with neural tissue
if CJD or vCJD suspected and has not
been ruled out; No special burial
procedures.
Croup (see respiratory infections in
infants and young children)
Crimean-Congo Fever (see Viral R
Hemorrhagic Fever)
Cryptococcosis R Not transmitted from person to person.
Cryptosporidiosis (see also C
gastroenteritis)
Cysticercosis R Not transmitted from person to person.
Cytomegalovirus infection, including R No additional precautions for pregnant
in neonates and immunosuppressed Healthcare Workers (requires saliva
patients/residents. contact for transmission).
Decubitus ulcer (see pressure ulcer) R Not transmitted from person to person.
Dengue fever R Not transmitted from person to person.

AND CONDITIONS
Diarrhea, acute-infective etiology
suspected (see gastroenteritis)
Diphtheria
Cutaneous C CN Until 2 cultures taken 24 hrs apart
negative
Pharyngeal D CN Until on appropriate treatment and 2
cultures taken 24 hrs apart negative.
Ebola virus (see viral hemorrhagic
fevers)
Echinococcosis (hydatidosis) R Not transmitted from person to person.
Echovirus (see enteroviral infection)
Encephalitis or encephalomyelitis
(see specific etiologic agents)
Endometritis (endomyometritis) R
Enterobiasis (pinworm disease, R
oxyuriasis)
Enterococcus species (see multidrug-
resistant organisms if
epidemiologically significant or
vancomycin resistant)
Enterocolitis, C. difficile (see C.
difficile, gastroenteritis)
Enteroviral infections (i.e. Group A R Use Contact Precautions for diapered
and B Coxsackie viruses and Echo or incontinent children for duration of
viruses) (excludes polio virus) illness and to control institutional
outbreaks.
Epiglottitis, due to Haemophilus D U 24 hrs See specific disease agents for
influenzae type b epiglottitis due to other etiologies)
Epstein-Barr virus infection, including R
infectious mononucleosis
Erythema Infectiosum (also see Pregnant staff should not provide care.
Parvovirus B19)
Escherichia coli gastroenteritis (see
gastroenteritis)
Food poisoning
Botulism R Not transmitted from person to person.
C. perfringens or welchii R Not transmitted from person to person.
Staphylococcal R Not transmitted from person to person.

AND CONDITIONS
Furunculosis, staphylococcal R Contact Precautions if drainage not
controlled. Follow institutional policies
if MRSA.
Infants and young children C DI
Gangrene (gas gangrene) R Not transmitted from person to person.
Gastroenteritis C/D Use Contact Precautions for incontinent
persons of any age for the duration of
illness or to control institutional
outbreaks for gastroenteritis caused by
all of the agents below.
Adenovirus R Use Contact Precautions for incontinent
outbreaks.
Campylobacter species R Use Contact Precautions for incontinent
outbreaks.
Cholera (Vibrio cholerae) R Use Contact Precautions for incontinent
outbreaks.
C. difficile C DI Discontinue antibiotics if possible. Do
not share electronic thermometers;
ensure consistent environmental
cleaning and disinfection. Hypochlorite
solutions are required for cleaning for
all cases. Handwashing with soap and
water preferred because of the
absence of sporicidal activity of alcohol
in alcohol-based hand rubs.
Cryptosporidium species C DI
E. coli
Enteropathogenic R Use Contact Precautions for incontinent
O157:H7 and other shiga persons of any age for the duration of
toxin-producing strains illness or to control institutional
outbreaks.
Other species R Use Contact Precautions for incontinent
outbreaks.
Giardia lamblia R Use Contact Precautions for incontinent

AND CONDITIONS
outbreaks.
Noroviruses C/D DI Use Contact Precautions for all infected
and exposed cases for the duration of
illness and to control institutional
outbreaks. Persons who clean areas
heavily contaminated with feces or
vomitus may benefit from wearing
masks since virus can be aerosolized
from these body substances; ensure
consistent environmental cleaning and
disinfection with focus on bathrooms
even when apparently unsoiled.
Hypochlorite solutions are required for
cleaning for all cases. Alcohol is less
active, but there is no evidence that
alcohol based hand rubs are not
effective for hand decontamination.
Cohorting of affected patients/residents
to separate airspaces and toilet
facilities may help interrupt
transmission during outbreaks.
Rotavirus C DI Ensure consistent environmental
cleaning and disinfection and frequent
removal of soiled diapers. Prolonged
shedding may occur in both
immunocompetent and
immunocompromised children and the
elderly.
Salmonella species (including R Use Contact Precautions for incontinent
S. typhi) persons of any age for the duration of
outbreaks.
Shigella species R Use Contact Precautions for incontinent
(Bacillary dysentery) persons of any age for the duration of
outbreaks.
Vibrio parahaemolyticus R Use Contact Precautions for incontinent
outbreaks.
Viral (if not covered elsewhere) C/D Use Contact Precautions for incontinent
outbreaks.
Yersinia enterocolitica R Use Contact Precautions for diapered
or incontinent persons for the duration

AND CONDITIONS
of illness or to control institutional
outbreaks.
German measles (see rubella; see
congenital rubells)
Giardiasis (see gastroenteritis)
Gonococcal Ophthalmia neonatorum R
(gonorrheal Ophthalmia, acute
conjunctivitis of newborn)
Gonorrhea
Granuloma inguinale (Donovanosis, R
granuloma venereum)
Guillain-Barré syndrome Not an infectious condition.
Haemophilus influenzae (see
disease-specific recommendations)
Hand, foot and mouth disease (see
enteroviral infection)
Hansen‘s Disease (see Leprosy)
Hantavirus pulmonary syndrome R Not transmitted from person to person
Helicobacter pylori R
Hepatitis, viral
Type A R Provide Hepatitis A vaccine post-
exposure as recommended by Public
Health.
Incontinent patients/residents C Maintain Contact Precautions in infants
with diarrhea and children less than 3 years of age
for duration of hospitalization; for
children 3 – 14 years of age for 2
weeks after onset of symptoms; more
than 14 years of age for 1 week after
onset of symptoms.
Type B – HbsAg positive; acute R See specific recommendations for care
or chronic of patients/residents in hemodialysis
centres
Type C and other unspecified R See specific recommendations for care
non-A, non-B of patients/residents in hemodialysis
centres.
Type D (seen only with R
hepatitis B)
Type E R Use Contact Precautions for all
symptomatic individuals and incontinent
individuals for the duration of illness.
Type G R

AND CONDITIONS
Herpangina (see enteroviral infection)
Hookworm R
Herpes simplex (Herpesvirus
hominis)
Encephalitis R
Mucocutaneous, disseminated C Until lesions
or primary, severe dry and
crusted
Mucocutaneous, recurrent C Until lesions
(skin, oral, genital) dry and
crusted
Neonatal C Until lesions Also, for asymptomatic, exposed
dry and infants delivered vaginally or by C-
crusted Section and if mother has active
infection and membranes have been
ruptured for more than 4 to 6 hrs until
infant surface cultures obtained at 24-
36 hrs of age are negative.
Herpes zoster (varicella-zoster)
(shingles)
Disseminated disease in any A/C DI Susceptible healthcare workers should
patient. not enter room if immune caregivers
Localized disease in immuno- are available; no recommendation for
compromised patient until protection of immune healthcare
disseminated infection ruled out workers; no recommendation for type of
protection, i.e. surgical mask or
respirator, for susceptible healthcare
workers.
Localized in patient with intact C DI Susceptible healthcare workers should
immune system with lesions not provide direct patient care when
that can be contained/ covered. other immune caregivers are available.
Histoplasmosis R Not transmitted from person to person.
Human immunodeficiency virus (HIV) R Post-exposure chemoprophylaxis for
some blood and body fluid exposures.
Human metapneumovirus C DI HAI reported, but route of transmission
not established. Assumed to be
Contact / Droplet transmission as for
RSV since the viruses are closely
related and have similar clinical
manifestations and epidemiology.
Wear masks according to Routine
Practices.
Impetigo C U 24 hrs

AND CONDITIONS
Infectious mononucleosis R
Influenza
Human (seasonal influenza) D 5 days except Single patient room when available or
DI in immuno- cohort; avoid placement with high-risk
compromised patients/residents; mask patient when
persons transported out of room;
chemoprophylaxis / vaccine to control /
prevent outbreaks. Use gown and
gloves according to Routine Practices;
may be especially important in pediatric
settings. Duration of precautions for
immuno-compromised
patients/residents cannot be defined;
prolonged duration of viral shedding
(i.e. for several weeks) has been
observed; implications for transmission
are unknown.
Avian (e.g. H5N1, H7, H9 See
strains) www.cdc.gov/flu/avian/professional/infe
ct-control.htm for current avian
influenza guidance.
Pandemic influenza D 5 days See http://www.pandemicflu.gov for
(also a human influenza virus) current pandemic influenza guidance.
Kawasaki syndrome Not an infectious condition.
Lassa fever (see viral hemorrhagic
fevers)
Legionnaires‘ disease Not transmitted from person to person.
Leprosy R
Leptospirosis R Not transmitted from person to person.
Lice http://www.cdc.gov/ncidod/dpd/parasite
s/lice/default.htm
Head (Pediculosis) C U 4 hrs
Body R Transmitted person to person through
infested clothing. Wear gown and
gloves when removing clothing; bag
and wash clothes according to CDC
guidance above.
Pubic R Transmitted person to person through
sexual contact.
Listeriosis (listeria monocytogenes) R Person-to-person transmission rare;
cross-transmission in neonatal settings
and endoscopy.
Lyme disease R Not transmitted from person to person.

AND CONDITIONS
Lymphocytic choriomeningitis R Not transmitted from person to person.
Lymphogranuloma venereum R
Malaria R Not transmitted from person to person
except through transfusion rarely and
through a failure to follow Routine
Practices during patient care. Install
screens in windows and doors in
endemic areas. Use DEET-containing
mosquito repellents and clothing to
cover extremities.
Marburg virus disease (see viral
hemorrhagic fevers)
Measles (rubeola) A 4 days after Susceptible healthcare workers should
onset of not enter room if immune care
rash; providers are available; no
DI in recommendation for face protection for
immuno- immune healthcare worker; no
compro- recommendation for type of face
mised protection for susceptible healthcare
workers, i.e. mask or respirator. For
exposed susceptibles, post-exposure
vaccine within 72 hrs or immune
globulin within 6 days when available.
Place exposed susceptible
patients/residents on Airborne
Precautions and exclude susceptible
healthcare workers from duty from day
5 after first exposure to day 21 after last
exposure, regardless of post-exposure
vaccine.
Melioidosis, all forms R Not transmitted from person to person.
Meningitis
Aseptic (nonbacterial or viral; R Contact Precautions for infants and
also see enteroviral infections) young children.
Bacterial, gram-negative R
enteric,
in neonates
Fungal R
Haemophilus influenzae, type D U 24 hrs
B, known or suspected
Listeria monocytogenes R
(See Listeriosis)
Neisseria meningitidis D U 24 hrs See meningococcal disease below
(meningococcal) known or

AND CONDITIONS
suspected
Streptococcus pneumoniae R
M. tuberculosis R Concurrent, active pulmonary disease
or draining cutaneous lesions may
necessitate addition of Contact and/or
Airborne Precautions. For children,
Airborne Precautions until active
tuberculosis ruled out in visiting family
members (see tuberculosis below).
Other diagnosed bacterial R
Meningococcal disease: sepsis, D U 24 hrs Post-exposure chemoprophylaxis and
pneumonia, meningitis immunoprophylaxis for household
contacts, healthcare workers exposed
to respiratory secretions.
Molluscum contagiosum R
Monkeypox A/C A-Until See www.cdc.gov/ncidod/monkeypox
monkeypox for most current recommendations.
confirmed and Transmission in hospital settings
smallpox unlikely. Pre- and post-exposure
excluded; smallpox vaccine recommended for
C-Until lesions exposed healthcare workers.
crusted
Mucormycosis R
Multidrug-resistant organisms
(MDROs)
(See Antibiotic Resistant Organisms)
Mumps (infectious parotitis) D U 9 days After onset of swelling susceptible
healthcare workers should not provide
care if immune caregivers are
available.
Note: Recent assessment of outbreaks
in health 18-24 year olds has indicated
that salivary viral shedding occurred
early in the course of illness and that 5
days of Additional Precautions after
onset of parotitis may be appropriate in
community settings; however, the
implications for healthcare personnel
and high-risk patient populations
remain to be clarified.
Mycobacteria, non-tuberculosis Not transmitted from person to person.
(atypical)
Pulmonary R
Wound R

AND CONDITIONS
Mycoplasma pneumonia D DI
Necrotizing enterocolitis R Contact Precautions when cases
clustered temporally.
Nocardiosis, draining lesions, or other R Not transmitted from person to person.
presentations
Norovirus (see gastroenteritis)
Norwalk agent gastroenteritis (see
gastroenteritis)
Orf R
Parainfluenza virus infection, C DI Viral shedding may be prolonged in
respiratory in infants and young immuno-suppressed patients/residents.
children
Parvovirus B19 (Erythema D Maintain precautions for duration of
Infectiosum) hospitalization when chronic disease
occurs in an immuno-compromised
patient. For patients/residents with
transient aplastic crisis or red-cell crisis,
maintain precautions for 7 days.
Duration of precautions for immuno-
suppressed patients/residents with
persistently positive PCR not defined,
but transmission has occurred.
Pregnant staff should not provide care.
Pediculosis (lice) C U 24 hrs
after
treatment
Pertussis (whooping cough) D U 5 days Single patient room preferred.
Cohorting an option. Post-exposure
chemoprophylaxis for household
contacts and healthcare workers with
prolonged exposure to respiratory
secretions.
Recommendations for Tdap vaccine in
adults (pediatric nurses, doctors) under
development.
Pinworm infection (Enterobiasis) R
Plague (Yersinia pestis)
Bubonic R
Pneumonic D U 48 hrs Antimicrobial prophylaxis for exposed
healthcare worker.
Pneumonia
Adenovirus D/C DI Outbreaks in pediatric and institutional
settings reported. In immuno-

AND CONDITIONS
compromised hosts, extend duration of
Droplet and Contact Precautions due to
prolonged shedding of virus.
Bacterial not listed elsewhere R
(including gram-negative
bacterial)
B. cepacia in patients/residents C Avoid exposure to other persons with
with Cystic Fibrosis (CF), CF; private room preferred, including
including respiratory tract clinic visits. Criteria for discontinuing
colonization Precautions not established. Use
Precautions for duration of
hospitalization if other CF
patients/residents on the unit. See CF
Foundation guideline.
B. cepacia in patients/residents
without Cystic Fibrosis (see
Antibiotic Resistant Organisms)
Chlamydia R
Fungal R
Haemophilus influenzae,
type b
Adults R
Infants and children C U 24 hrs
Legionella spp. R
Meningococcal D U 24 hrs See meningococcal disease above
Multidrug resistant bacterial
(see Antibiotic Resistant
Organisms)
Mycoplasma (primary atypical D DI
pneumonia)
Pneumococcal pneumonia R Use Droplet Precautions if evidence of
transmission within a patient care unit
or facility.
Pneumocystis jiroveci R
(Pneumocystis carinii)
Staphylococcus aureus R For MRSA, see Antibiotic Resistant
Organisms
Streptococcus, group A For Invasive Group A Streptococcus,
Contact or Droplet Precautions for 24
hrs until appropriate antibiotic treatment
given. Includes pneumonia, toxic
shock syndrome, necrotizing fasciitis,
but not cellulitis.

AND CONDITIONS
Adults D U 24 hrs See streptococcal disease (group A
streptococcus) below.
Contact Precautions if skin lesions
present.
Infants and young D U 24 hrs Contact Precautions if skin lesions
children present.
Varicella-zoster (See Varicella-
zoster)
Viral
Adults R
Infants and young
children (see respiratory
infectious disease, acute,
or specific viral agent)
Poliomyelitis C DI
Pressure ulcer (Decubitus ulcer,
pressure sore) infected
Major C DI If no dressing or containment of
drainage – until drainage stops or can
be contained by dressing.
Minor or limited R If dressing covers and contains
drainage.
Prion disease (See Creutzfeld-Jacob
Disease)
Psittacosis (ornithosis) (Chlamydia R Not transmitted from person to person.
psittaci)
Q fever R
Rabies R Person to person transmission rare;
transmission via corneal, tissue and
organ transplants has been reported. If
patient has bitten another individual or
saliva has contaminated an open
wound or mucous membrane, wash
exposed area thoroughly and
administer post-exposure prophylaxis.
Rat-bite fever (Streptobacillus R Not transmitted from person to person.
moniliformis disease, Spirillum minus
disease)
Relapsing fever R Not transmitted from person to person.
Resistant bacterial infection or
colonization (see Antibiotic Resistant
Organisms)

AND CONDITIONS
Respiratory infectious disease, acute
(if not covered elsewhere)
Adults R
Infants and young children C DI
Respiratory syncytial virus infection, C DI Wear mask according to Routine
in infants, young children and Practices. In immuno-compromised
immuno-compromised adults patients/residents, extend the duration
of Contact Precautions due to
prolonged shedding.
Reye‘s syndrome R Not an infectious condition.
Rheumatic fever R Not an infectious condition.
Rhinovirus D DI Droplet most important route of
transmission. Outbreaks have
occurred in NICUs and LTCFs. Add
Contact Precautions if copious moist
secretions and close contact likely to
occur (e.g. young infants).
Rickettsial fevers, tickborne (Rocky R Not transmitted from person to person
Mountain spotted fever, tickborne except through transfusion, rarely.
typhus fever)
Rickettsialpox (vesicular rickettsiosis) R Not transmitted from person to person.
Ringworm (Dermatophytosis, R Rarely, outbreaks have occurred in
dermatomycosis, tinea) healthcare settings (e.g. NICU,
rehabilitation hospital. Use Contact
Precautions for outbreak.
Ritter‘s disease (staphylococcal C DI See staphylococcal disease, scalded
scalded skin syndrome) skin syndrome below.
Rocky Mountain spotted fever R Not transmitted from person to person
except through transfusion, rarely.
Roseola infantum (exanthem R
subitum; caused by HHV-6)
Rotavirus infection (see
gastroenteritis)
Rubella (German measles) (also see D U 7 days Susceptible healthcare workers should
congenital rubella) after onset of not enter room if immune caregivers
rash are available. No recommendation for
wearing face protection (e.g. a surgical
mask) if immune. Pregnant women
who are not immune should not care for
these patients/residents. Administer
vaccine within three days of exposure
to non-pregnant susceptible individuals.
Place exposed susceptible

AND CONDITIONS
patients/residents on Droplet
Precautions; exclude susceptible
healthcare personnel from duty from
day 5 after first exposure to day 21
after last exposure, regardless of post-
exposure vaccine.
Rubeola (see measles)
Salmonellosis (see gastroenteritis)
Scabies C U 24 hrs
following
treatment
Scalded skin syndrome, C DI See staphylococcal disease, scalded
staphylococcal skin syndrome below.
Schistosomiasis (bilharziasis) R
Severe acute respiratory syndrome A/D/C DI Airborne Precautions preferred; Droplet
(SARS) plus 10 days Precautions if Airborne Infection
after resolution Isolation Room unavailable. N95 or
of fever, higher respiratory protection; surgical
provided mask if N95 unavailable; eye protection
respiratory (goggles, face shield); aerosol-
symptoms are
absent or
generating procedures and ―super
improving shedders‖ highest risk for transmission
via small droplet nuclei and large
droplets. Vigilant environmental
disinfection. (See
www.cdc.gov/ncidod/sars)
Shigellosis (see gastroenteritis)
Smallpox (variola; see vaccinia for A/C DI Until all scabs have crusted and
management of vaccinated persons) separated (3–4 weeks). Non-
vaccinated healthcare workers should
not provide care when immune
healthcare workers are available; N95
or higher respiratory protection for
susceptible and successfully
vaccinated individuals; post-exposure
vaccine within 4 days of exposure
protective.
Sporotrichosis R
Spirillum minor disease (rat-bite R Not transmitted from person to person.
fever)
Staphylococcal disease (S. aureus)
Skin, wound, or burn
Major C DI No dressing or dressing does not
contain drainage adequately.

AND CONDITIONS
Minor or limited R Dressing covers and contains drainage
adequately.
Multi-drug resistant (see
Pneumonia R
Scalded skin syndrome C DI Consider healthcare personnel as
potential source of nursery, NICU
outbreak.
Toxic shock syndrome R
Streptobacillus moniliformis disease R Not transmitted from person to person
(rat-bite fever)
Streptococcal disease (group A
streptococcus)
Invasive Group A D U 24 hrs Outbreaks of serious invasive disease
Streptococcus (iGAS) have occurred secondary to
(including pneumonia, toxic transmission among patients/residents
shock syndrome, necrotizing and healthcare personnel. Contact
fasciitis, but not cellulitis) Precautions for draining wounds as
below; follow recommendations for
antimicrobial prophylaxis in selected
conditions.
Skin, wound, or burn
Major C/D U 24 hrs No dressing or dressing does not
contain drainage adequately
Minor or limited R Dressing covers and contains drainage
adequately
Endometritis (puerperal sepsis) R
Pharyngitis in infants and D U 24 hrs
young children
Pneumonia D U 24 hrs
Scarlet fever in infants and D U 24 hrs
young children
Streptococcal disease (group B R
streptococcus), neonatal
Streptococcal disease (not R
group A or B) unless covered
elsewhere
Multidrug-resistant (see
Strongyloidiasis R
Syphilis

AND CONDITIONS
Latent (tertiary) and R
seropositivity without lesions
Skin and mucous membrane, R Contact Precautions for primary or
including congenital secondary stage of disease.
Tapeworm disease
Hymenolepsis nana R Not transmitted from person to person.
Taenia solium (pork) R Not transmitted from person to person.
Other R Not transmitted from person to person.
Tetanus R Not transmitted from person to person.
Tinea (e.g. Dermatophytosis, R Rare episodes of person-to-person
dermatomycosis, ringworm) transmission.
Toxoplasmosis R Transmission from person to person is
rare; vertical transmission from mother
to child, transmission through organs
and blood transfusion rare.
Toxic shock syndrome R Droplet Precautions for the first 24 hrs
(staphylococcal disease, after implementation of antibiotic
streptococcal disease) therapy if Group A streptococcus is a
likely etiology.
Trachoma, acute R
Transmissible spongiform
encephalopathy (see Creutzfeld-
Jacob disease, CJD, vCJD)
Trench mouth (Vincent‘s angina) R
Trichinosis R
Trichomoniasis R
Trichuriasis (whipworm disease) R
Tuberculosis (M. tuberculosis)
Extrapulmonary, draining lesion A/C Discontinue precautions only when
patient is improving clinically, and
drainage has ceased or there are three
consecutive (one week apart) negative
cultures of continued drainage.
Examine for evidence of active
pulmonary tuberculosis.
Extrapulmonary, no draining R Examine for evidence of pulmonary
lesion, meningitis tuberculosis. For infants and children,
use Airborne Precautions until active
pulmonary tuberculosis in visiting family
members ruled out.
Pulmonary or laryngeal A Discontinue precautions only after
disease, confirmed consultation with Infection Prevention &

AND CONDITIONS
Control Practitioner (minimum of 2
weeks on treatment, clinical
improvement, and three consecutive
sputum smears negative for acid-fast
bacilli collected on separate days).
Reference BCCDC.
Pulmonary or laryngeal A Discontinue precautions only when the
disease, suspected likelihood of infectious TB disease is
deemed negligible, and either 1) there
is another diagnosis that explains the
clinical syndrome, or 2) the results of
three sputum or BAL smears for AFB
are negative. Each of the three
specimens should be collected 24 hrs
apart, preferably early each morning.
Skin-test positive with no R
evidence of current active
disease
Tularemia
Draining lesion R Not transmitted from person to person.
Pulmonary R Not transmitted from person to person.
Typhoid (Salmonella typhi) fever (see
gastroenteritis)
Typhus
Rickettsia prowazekii (Epidemic R Transmitted from person to person
or Louse-borne typhus) through close personal or clothing
contact.
Rickettsia typhi R Not transmitted from person to person.
Urinary tract infection (including R
pyelonephritis), with or without
urinary catheter
Vaccinia (vaccination site, adverse Only vaccinated healthcare workers
events following vaccination) have contact with active vaccination
sites and care for persons with adverse
vaccinia events; if unvaccinated, only
healthcare workers without
contraindications to vaccine may
provide care.
Vaccination site care (including R Vaccination recommended for
autoinoculated areas) vaccinators; for newly vaccinated
healthcare workers: semi-permeable
dressing over gauze until scab
separates, with dressing change as
fluid accumulates, approx. 3–5 days;

AND CONDITIONS
gloves, hand hygiene for dressing
change; vaccinated healthcare worker
or healthcare worker without
contraindication to vaccine for dressing
changes.
Eczema vaccinatum C Until lesions For contact with virus-containing
dry and lesions and exudative material
Fetal vaccinia C crusted,
scabs
Generalized vaccinia C separated
Progressive vaccinia C
Post vaccinia encephalitis
Blepharitis or conjunctivitis R/C Use Contact Precautions if there is
copious drainage.
Iritis or keratitis R
Vaccinia-associated erythema R
multiforme (Stevens Johnson Not an infectious condition.
Syndrome)
Secondary bacterial infection R/C Follow organism-specific (strep, staph
(e.g. S. aureus, group A beta most frequent) recommendations and
hemolytic streptococcus) consider magnitude of drainage.
Varicella Zoster A/C Until lesions Susceptible healthcare workers should
dry and not enter room if immune caregivers
crusted are available; no recommendation for
face protection of immune healthcare
workers; no recommendation for type of
protection, i.e. surgical mask or
respirator for susceptible healthcare
workers. In immuno-compromised host
with varicella pneumonia, prolong
duration of precautions for duration of
illness. Post-exposure prophylaxis:
provide post-exposure vaccine ASAP
but within 120 hours; for susceptible
exposed persons for whom vaccine is
contraindicated (immuno-compromised
persons, pregnant women, newborns
whose mother‘s varicella onset is 5
days or less before delivery or within 48
hrs after delivery) provide VZIG, when
available, within 96 hours; if
unavailable, use IVIG; Use Airborne
Precautions for exposed susceptible
persons and exclude exposed
susceptible healthcare workers
beginning 8 days after first exposure

AND CONDITIONS
until 21 days after last exposure or 28
days if received VZIG, regardless of
post-exposure vaccination.
Variola (see smallpox)
Vibrio parahaemolyticus (see
gastroenteritis)
Vincent‘s angina (trench mouth) R
Viral hemorrhagic fevers, due to A DI Single-patient negative pressure room
Lassa, Ebola, Marburg, Crimean- preferred. Emphasize: 1) use of
Congo fever viruses sharps safety devices and safe work
practices; 2) hand hygiene; 3) barrier
protection against blood and body fluids
upon entry into room (single gloves and
fluid-resistant or impermeable gown,
face/eye protection with masks,
goggles or face shields); and 4)
appropriate waste handling. Use N95
or higher respirators when performing
aerosol-generating procedures.
Largest viral load in final stages of
illness when hemorrhage may occur;
additional PPE, including double
gloves, leg and shoe coverings may be
used, especially in resource-limited
settings where options for cleaning and
laundry are limited. Notify public health
officials immediately if Ebola is
suspected.
Viral respiratory diseases (not
covered elsewhere
Adults R
Infants and young children (see
respiratory infectious disease,
acute)
Whooping cough (see pertussis)
Wound infections
Major C DI No dressing or dressing does not
contain drainage adequately.
Minor or limited R DI
Yersinia enterocolitica gastroenteritis
(see gastroenteritis)
Zoster (varicella-zoster) (see herpes
zoster)

AND CONDITIONS
Zygomycosis (phycomycosis, R
Not transmitted from person to person.
mucormycosis)
APPENDIX B: Glossary of Terms
Admission Restrictions – any restrictions placed on unit during an outbreak that limits the
normal admission pattern (e.g. no off-service admissions to a unit)
Aseptic technique. The measures taken to purposefully reduce the number of

microorganisms (germs) to an irreducible number for the purpose of preventing transmission
of infection. These include handwashing, disinfection and sterilization
Antisepsis/Sanitation. This method of infection prevention and control includes using soap
and water to wash the hands and body as well as the use of antiseptics such as alcohol,
iodine and betadine to clean the skin for medical procedures, as these inhibit the growth of
pathogenic microorganisms. This level of asepsis may kill or inhibit some microbes but is
generally not effective against spores.
American Institute of Architects. A professional organization that develops standards for

building ventilation, The ―2001Guidelines for Design and Construction of Hospital and Health
Care Facilities‖, the development of which was supported by the AIA, Academy of
Architecture for Health, Facilities Guideline Institute, with assistance from the U.S.
Department of Health and Human Services and the National Institutes of Health, is the
primary source of guidance for creating airborne infection isolation rooms (AIIRs) and
protective environments.
Ambulatory care settings. Facilities that provide healthcare to patients/residents who do

not remain overnight (e.g. hospital-based outpatient clinics, nonhospital-based clinics and
physician offices, urgent care centers, surgicenters, free-standing dialysis centers, public
health clinics, imaging centers, ambulatory behavioral health and substance abuse clinics,
physical therapy and rehabilitation centers, dental practices and outpatient clinics.
Antibiotic Resistant organisms (AROs). Also known as multidrug resistant organisms

(MDRO). In general, bacteria that are resistant to several classes of antimicrobial agents and
usually are resistant to most commercially available antimicrobial agents (e.g. MRSA, VRE,
extended spectrum beta-lactamase [ESBL]-producing or intrinsically resistant gram-negative
bacilli).
Bed closure – a bed space is closed to admissions or transfers in
Bioaerosols. An airborne dispersion of particles containing whole or parts of biological

entities, such as bacteria, viruses, dust mites, fungal hyphae, or fungal spores. Such
aerosols usually consist of a mixture of mono-dispersed and aggregate cells, spores or
viruses, carried by other materials, such as respiratory secretions and/or inert particles.
Infectious bioaerosols (i.e. those that contain biological agents capable of causing an
infectious disease) can be generated from human sources (e.g. expulsion from the respiratory
tract during coughing, sneezing, talking or singing; during suctioning or wound irrigation), wet
environmental sources (e.g. HVAC and cooling tower water with Legionella) or dry sources
(e.g. construction dust with spores produced by Aspergillus spp.). Bioaerosols include large
respiratory droplets and small droplet nuclei (Cole EC. AJIC 1998;26: 453-64).
Caregivers. All persons who are not employees of an organization, are not paid, and provide
or assist in providing healthcare to a patient (e.g. family member, friend) and acquire
technical training as needed based on the tasks that must be performed.
Cohorting. In the context of this guideline, this term applies to the practice of grouping
patients/residents infected or colonized with the same infectious agent together to confine
their care to one area and prevent contact with susceptible patients/residents (cohorting
patients/residents). During outbreaks, healthcare personnel may be assigned to a cohort of
patients/residents to further limit opportunities for transmission (cohorting staff).
Colonization. An individual who has been found to be culture positive at one or more body
sites but who has no signs or symptoms of infection.
Disinfection: The process of using chemical agents or boiling water to destroy or kill
pathogenic microbes.
Droplet nuclei. Microscopic particles more than 5 microns in size that are the residue of
evaporated droplets and are produced when a person coughs, sneezes, shouts, or sings.
These particles can remain suspended in the air for prolonged periods of time and can be
carried on normal air currents in a room or beyond, to adjacent spaces or areas receiving
exhaust air.
Engineering controls. Removal or isolation of a workplace hazard through technology.

AIIRs, a Protective Environment, engineered sharps injury prevention devices and sharps
containers are examples of engineering controls.
Epidemiologically important pathogens. Infectious agents that have one or more of the
following characteristics: 1) are readily transmissible; 2) have a proclivity toward causing
outbreaks; 3) may be associated with a severe outcome; or 4) are difficult to treat. Examples
include Acinetobacter sp., Aspergillus sp., Burkholderia cepacia, Clostridium difficile,
Klebsiella or Enterobacter sp., extended-spectrum-beta-lactamase producing gram negative
bacilli [ESBLs], methicillin-resistant Staphylococcus aureus [MRSA], Pseudomonas
aeruginosa, vancomycin-resistant enterococci [VRE], methicillin resistant Staphylococcus
aureus [MRSA], vancomycin resistant Staphylococcus aureus [VRSA] influenza virus,
respiratory syncytial virus [RSV], rotavirus, SARS CoV, noroviruses and the hemorrhagic
fever viruses).
Hand hygiene. A general term that applies to any one of the following: 1) handwashing with
plain (nonantimicrobial) soap and water); 2) antiseptic hand rub (waterless antiseptic product,
most often alcohol-based, rubbed on all surfaces of hands); or 3) surgical hand antisepsis
(antiseptic hand wash or antiseptic hand rub performed preoperatively by surgical personnel
to eliminate transient hand flora and reduce resident hand flora).
Healthcare-associated infection (HAI). An infection that develops in a patient who is cared

for in any setting where healthcare is delivered (e.g. acute care hospital, chronic care facility,
ambulatory clinic, dialysis center, surgicenter) and is related to receiving healthcare (i.e. was
not incubating or present at the time healthcare was provided). In ambulatory and home
settings, HAI would apply to any infection that is associated with a medical or surgical
intervention within the previous one year. Since the geographic location of infection
acquisition is often uncertain, the preferred term is considered to be healthcare-associated
rather than healthcare-acquired.
Healthcare personnel, healthcare worker (HCW). All paid and unpaid persons who work in
a healthcare setting (e.g. any person who has professional or technical training in a
healthcare-related field and provides patient care in a healthcare setting or any person who
provides services that support the delivery of healthcare such as dietary, housekeeping,
engineering, maintenance personnel).
Hematopoietic stem cell transplantation (HSCT). Any transplantation of blood or bone

marrow-derived hematopoietic stem cells, regardless of donor type (e.g. allogeneic or
autologous) or cell source (e.g. bone marrow, peripheral blood, or placental/umbilical cord
blood); associated with periods of severe immunosuppression that vary with the source of the
cells, the intensity of chemotherapy required, and the presence of graft versus host disease
(MMWR 2000; 49: RR-10).
High-efficiency particulate air (HEPA) filter. An air filter that removes more than 99.97% of
particles more than 0.3 microns (the most penetrating particle size) at a specified flow rate of
air. HEPA filters may be integrated into the central air handling systems, installed at the point
of use above the ceiling of a room, or used as portable units (MMWR 2003; 52: RR-10).
Home care. A wide-range of medical, nursing, rehabilitation, hospice and social services
delivered to patients/residents in their place of residence (e.g. private residence, senior living
center, assisted living facility). Home health-care services include care provided by home
health aides and skilled nurses, respiratory therapists, dieticians, physicians, chaplains, and
volunteers; provision of durable medical equipment; home infusion therapy; and physical,
speech, and occupational therapy.
Immunocompromised patients/residents. Those patients/residents whose immune

mechanisms are deficient because of congenital or acquired immunologic disorders (e.g.
human immunodeficiency virus [HIV] infection, congenital immune deficiency syndromes),
chronic diseases such as diabetes mellitus, cancer, emphysema, or cardiac failure, ICU care,
malnutrition, and immunosuppressive therapy of another disease process [e.g. radiation,
cytotoxic chemotherapy, anti-graft-rejection medication, corticosteroids, monoclonal
antibodies directed against a specific component of the immune system]). The type of
infections for which an immunocompromised patient has increased susceptibility is
determined by the severity of immunosuppression and the specific component(s) of the
immune system that is affected. Patients/residents undergoing allogeneic HSCT and those
with chronic graft versus host disease are considered the most vulnerable to HAIs.
Immunocompromised states also make it more difficult to diagnose certain infections (e.g.
tuberculosis) and are associated with more severe clinical disease states than persons with
the same infection and a normal immune system.
Infection. The condition when an organism (bacterial, viral, or parasitic) has entered a body
site, is multiplying in tissue, is causing the clinical manifestations of disease, such as fever,
suppurative wound, or pneumonia, and is documented by positive cultures, such as from
blood, sputum, wound or urine cultures
Infection Control Practitioner (ICP). A person whose primary training is in either nursing or
epidemiology and who has acquired special training in infection prevention and control.
Responsibilities may include collection, analysis, and feedback of infection data and trends to
healthcare providers; consultation on infection risk assessment, prevention and control
strategies; performance of education and training activities; implementation of evidence-
based infection prevention and control practices or those mandated by regulatory and
licensing agencies; application of epidemiologic principles to improve patient outcomes;
participation in planning renovation and construction projects (e.g. to ensure appropriate
containment of construction dust); evaluation of new products or procedures on patient
outcomes; input into or collaboration with employee health services related to infection
prevention; implementation of preparedness plans; communication within the healthcare
setting, with local and Provincial health departments, and with the community at large
concerning infection prevention and control issues; and participation in research. Certification
in infection control (CIC) is available through the Certification Board for Infection Control.
Infection prevention and control program. A multidisciplinary program that includes a

group of activities to ensure that recommended practices for the prevention of healthcare-
associated infections are implemented and followed by Healthcare Workers, making the
healthcare setting safe from infection for patients/residents and healthcare personnel. The
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires the
following five components of an infection prevention and control program for accreditation: 1)
surveillance: monitoring patients/residents and healthcare personnel for acquisition of
infection and/or colonization; 2) investigation: identification and analysis of infection problems
or undesirable trends; 3) prevention: implementation of measures to prevent transmission of
infectious agents and to reduce risks for device- and procedure-related infections; 4) control:
evaluation and management of outbreaks; and 5) reporting: provision of information to
external agencies as required by local and Provincial law and regulation (www.jcaho.org).
The infection prevention and control program staff has the ultimate authority to determine
infection prevention and control policies for a healthcare organization with the approval of the
organization‘s governing body.
Long-term care facilities (LTCFs). An array of residential and outpatient facilities designed
to meet the bio-psychosocial needs of persons with sustained self-care deficits. These
include skilled nursing facilities, chronic disease hospitals, nursing homes, foster and group
homes, institutions for the developmentally disabled, residential care facilities, assisted living
facilities, retirement homes, adult day healthcare facilities, rehabilitation centers, and longterm
psychiatric hospitals.
Mask. A term that applies collectively to items used to cover the nose and mouth and
includes impermeable procedure masks, surgical masks, and N95 masks (respirators).
Negative Pressure Room (NPR). Also known as Airborne infection isolation room (AIIR), a
negative pressure room is a single-occupancy patient-care room used to isolate persons with
a suspected or confirmed airborne infectious disease. Environmental factors are controlled in
NPRs to minimize the transmission of infectious agents that are usually transmitted from
person to person by droplet nuclei associated with coughing or aerosolization of
contaminated fluids. Negative Pressure Rooms should provide negative pressure in the room
(so that air flows under the door gap into the room); and an air flow rate of 6–12 ACH (6 ACH
for existing structures, 12 ACH for new construction or renovation); and 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 (MMWR 2005; 54 [RR-17]).
Nosocomial infection. A term that is derived from two Greek words ―nosos‖ (disease) and
―komeion‖ (to take care of) and refers to any infection that develops during or as a result of an
admission to an acute care facility (hospital) and was not incubating at the time of admission
(signs and symptoms of infection develop after 48 hours of admission).
Personal protective equipment (PPE). A variety of barriers used alone or in combination to

protect mucous membranes, skin, and clothing from contact with infectious agents. PPE
includes gloves, masks, respirators, goggles, face shields, and gowns.
Procedure Mask. A covering for the nose and mouth that is intended for use in general
patient care situations. These masks generally attach to the face with ear loops rather than
ties or elastic. Unlike surgical masks, procedure masks are not regulated by the Food and
Drug Administration.
Protective Environment. A specialized patient-care area or room (also known as a Positive

Pressure Room), usually in a hospital, that has a positive air flow relative to the corridor (i.e.,
air flows from the room to the outside adjacent space). The combination of high-efficiency
particulate air (HEPA) filtration, high numbers (more than 12) of air changes per hour (ACH),
and minimal leakage of air into the room creates an environment that can safely
accommodate patients/residents with a severely compromised immune system (e.g. those
who have received allogeneic hemopoietic stem-cell transplant [HSCT]) and decrease the risk
of exposure to spores produced by environmental fungi. Other components include use of
scrubbable surfaces instead of materials such as upholstery or carpeting, cleaning to prevent
dust accumulation, and prohibition of fresh flowers or potted plants.
Residential care setting. A facility in which people live, minimal medical care is delivered,
and the psychosocial needs of the residents are provided for.
Respirator. A personal protective device or mask worn by healthcare personnel to protect

them from inhalation exposure to airborne infectious agents that are more than 5 microns in
size. These include infectious droplet nuclei from patients/residents with M. tuberculosis,
variola virus [smallpox], SARS-CoV), and dust particles that contain infectious particles, such
as spores of environmental fungi (e.g. Aspergillus sp.). The CDC‘s National Institute for
Occupational Safety and Health (NIOSH) certifies respirators used in healthcare settings.
The N95 disposable particulate, air purifying, respirator/mask is the type used most
commonly by healthcare personnel. Other respirators used include N-99 and N-100
particulate respirators, powered air-purifying respirators (PAPRS) with high efficiency filters;
and non-powered full-face piece elastomeric negative pressure respirators. A listing of
NIOSH- approved respirators can be found at
http://www.cdc.gov/niosh/npptl/topics/respirators. Respirators must be used in conjunction
with a complete Respiratory Protection Program, as required by the Occupational Safety and
Health Administration (OSHA), that includes fit testing, training, proper selection of
respirators, medical clearance and respirator maintenance.
Respiratory Hygiene/ Cough Etiquette. A combination of measures designed to minimize

the transmission of respiratory pathogens via droplet or airborne routes in healthcare settings
and should be practiced by patients/residents, healthcare workers, and visitors. The
components of Respiratory Hygiene/Cough Etiquette are 1) covering the mouth and nose
during coughing and sneezing, 2) using tissues to contain respiratory secretions with prompt
disposal into a no-touch receptacle, 3) offering a surgical mask to persons who are coughing
to decrease contamination of the surrounding environment, and 4) turning the head away
from others and maintaining spatial separation, ideally more than 6 feet, when coughing. If a
tissue is not available, the mouth and nose can be covered by a sleeve. These measures are
targeted to all patients/residents with symptoms of respiratory infection and their
accompanying family members or friends beginning at the point of initial encounter with a
healthcare setting (e.g. reception/triage in emergency departments, ambulatory clinics,
healthcare provider offices) (Srinivasin A ICHE 2004; 25: 1020
Routine Practices (previously known as Standard or Universal Precautions). A group of

infection prevention practices that apply to all patients/residents, regardless of suspected or
confirmed diagnosis or presumed infection status. Routine Practices are based on the
principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and
mucous membranes may contain transmissible infectious agents. Routine Practices include
hand hygiene, and depending on the anticipated exposure, use of gloves, gown, mask, eye
protection, or face shield, as well as safe injection practices. Also, equipment or items in the
patient environment likely to have been contaminated with infectious blood or body fluids
must be handled in a manner to prevent transmission of infectious agents (e.g. wear gloves
for handling, contain heavily soiled equipment, properly clean and disinfect or sterilize
reusable equipment before use on another patient).
The application of Routine Practices during patient care is determined by the nature of the
HCW-patient interaction and the extent of anticipated blood, body fluid, or pathogen
exposure. For some interactions (e.g. performing venipuncture), only gloves may be needed;
during other interactions (e.g. intubation), use of gloves, gown, and face shield or mask and
goggles is necessary. Education and training on the principles and rationale for
recommended practices are critical elements of Routine Practices because they facilitate
appropriate decision-making and promote adherence when HCWs are faced with new
circumstances. An example of the importance of the use of Routine Practices is intubation,
especially under emergency circumstances when infectious agents may not be suspected,
but later are identified (e.g. SARS-CoV, Neisseria meningitides). Routine Practices are also
intended to protect patients/residents by ensuring that healthcare personnel do not carry
infectious agents to patients/residents on their hands or via equipment used during patient
care.
Safety culture/climate. The shared perceptions of workers and management regarding the
expectations of safety in the work environment. A hospital safety climate includes the
following six organizational components: 1) senior management support for safety programs;
2) absence of workplace barriers to safe work practices; 3) cleanliness and orderliness of the
worksite; 4) minimal conflict and good communication among staff members; 5) frequent
safety related feedback/training by supervisors; and 6) availability of PPE and engineering
controls.
Source Control. The process of containing an infectious agent either at the portal of exit
from the body or within a confined space. The term is applied most frequently to containment
of infectious agents transmitted by the respiratory route but could apply to other routes of
transmission, (e.g. a draining wound, vesicular or bullous skin lesions). Respiratory
Hygiene/Cough Etiquette that encourages individuals to ―cover your cough‖ and/or wear a
mask is a source control measure. The use of enclosing devices for local exhaust ventilation
(e.g. booths for sputum induction or administration of aerosolized medication) is another
example of source control.
Sterilization. The only level of asepsis that kills all microbes, including spores, viruses and
TB. It includes the use of gas, chemicals, steam under pressure and radiation. Sterilization
is used on medical instruments and equipment, surgical dressing, gowns, etc
Surgical mask. A device worn over the mouth and nose by operating room personnel during
surgical procedures to protect both surgical patients/residents and operating room personnel
from transfer of microorganisms and body fluids. Surgical masks also are used to protect
healthcare personnel from contact with large infectious droplets (more than 5 microns in size).
Surgical masks are evaluated by the FDA using standardized testing procedures for fluid
resistance, bacterial filtration efficiency, differential pressure (air exchange), and flammability
in order to mitigate the risks to health associated with the use of surgical masks. These
specifications apply to any masks that are labelled surgical, laser, isolation, or dental or
medical procedure
(http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm072549.htm).
Surgical masks do not protect against inhalation of smaller particles and should not be
confused with particulate respirators/masks that are recommended for protection against
selected airborne infectious agents, (e.g. Mycobacterium tuberculosis).
Unit closure – a unit or area is closed to admissions and transfers in
References:
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory
Committee, 2007 Guideline for Isolation Precautions: preventing Transmission of Infectious Agents in Healthcare
Settings, June 2007
APPENDIX C: Specific Cleaning Instructions

A. Procedure for Cleaning Agitator Tubs/Hydrotherapy
Tanks
Prior to cleaning an agitator tub it is important to don PPE (Personal Protective Equipment).
Nursing Responsibilities (between patient use):

drain dirty water
close drain and start filling tub
when water level, covers half of whirlpool intake, turn on whirlpool pump motor
turn water off when water starts to surge out the whirlpool outlet
add manufacturer approved disinfectant (MAP) to water in the bottom of tub (follow
manufacturers‘ directions on concentration and amount) and let the whirlpool run for
one minute
wash/scrub the interior of tub with brush/mop and the disinfectant in tub
swing chair over tub and clean with disinfectant
drain the system
shower down interior of tub and chair with clean water and back flush the pump
wipe down chair with clean cloth.
End of the Day Cleaning (Housekeeping Staff)

fill tub with water to point midway between chair and overflow
add manufacturers approved cleaning agent at appropriate strength to the water
lower chair into water
activate whirlpool for 3 – 5 minutes
scrub and clean all surfaces of chair(s)
rinse the chair thoroughly and drain the tub
drain the system
shower down interior of tub and chair with clean water and back flush the pump
wipe down chair with clean cloth
B. Procedure for Cleaning Fans

Fans must not be used in Acute Patient Care settings. When fans are used in other settings,
they must have a removable fan blade grill cover. When the fan is no longer required, or at a
minimum once per month, the grill cover must be removed and the fan blades cleaned with
the approved disinfectant wipes. When the grill is replaced, all surfaces of the fan including
the base and electrical cord are cleaned and sanitized. A dust cover is placed over the fan
head. The fan must be sent to Facilities Maintenance and Operations annually for inspection
and maintenance.
C. Procedure for Cleaning Commodes

Nursing Responsibilities
Contact surfaces of the commode (seat, armrests, and basin) must be cleaned and
sanitized following each patient use. The approved disinfectant ready to use wipes
must be readily available for this purpose.
When a commode dedicated for patient use is no longer required by the patient,
housekeeping is notified and a completed ―Housekeeping: cleaning and disinfection
required‖ sign is placed on the chair to prevent use by another patient. (A sign is being
developed.)
Housekeeping Responsibilities
Upon notification by nursing staff, the commode will be removed from circulation and
taken for cleaning and disinfection. Chairs that are constructed to withstand power
washing or automated washing in a machine designed for this purpose may be
processed in this manner, where such equipment is available.
When manual cleaning is done, all surfaces must be cleaned and then disinfected.
NOTE: If the chair is found to be in a state of disrepair or surfaces are cracked, the chair cannot be adequately
cleaned. This must be brought to the attention of the nursing manager or leader so that repair or replacement
can be facilitated.
D. Procedure for Cleaning Suction Regulators

Procedure for ensuring safe Infection Prevention and Control practices to ensure appropriate
use of wall mounted suction equipment:
Hard Plastic Reusable Suction Canisters with fixed red tubing and fixed wall attachment along
with the single-use inner liners, red lids, and sealed suction tubing packages are placed in all
patient rooms. If used during the patient‘s admission, the Hard Plastic Reusable Suction
Canister with fixed red tubing and wall attachment is taken to the Dirty Utility Room cleaned
and returned to the patient bedside. The single-use inner liners, red lids, and suction tubing
are removed and discarded upon discharge. A new single-use liner and red lid is placed
within the clean hard outer canister and a new sealed suction tubing package is placed at the
bedside.
Hard Plastic Reusable Suction Canister with fixed red tubing and fixed wall attachment with
single-use inner liners and red lids within patient rooms that are not used are surface wiped
at discharge. The outside of the sealed suction tubing packaging is surface wiped upon
patient discharge. The sealed suction tubing packaging is an indicator that the suction bottle
was NOT used. If the Hard Plastic Reusable Suction Canister with fixed red tubing and wall
attachment and the single-use inner liners and red lids are clean and the suction tubing
package is open, discard the suction tubing
Within the Endoscopy suite, staff will cleans the Hard Plastic Reusable Suction Canisters with
fixed red tubing and fixed wall attachment and discard the single-use inner liners, red lids,
and the suction tubing between every patient case.
N.B. The Hard Plastic Reusable Suction Canisters with fixed red tubing and fixed wall
attachment are manufactured and sold as a reusable item. The Suction Canister inner liners
and sealed suction tubing packages are manufactured, sold, and labeled as single-use items
(i.e. one patient only).
E. Procedure for Cleaning and Use of Hot/Cold Pack

and Ice Bags
Ice Bag
Disposable bags designed to accommodate ice cubes and then secured, for use within the
health care setting. These bags, from an IC perspective, are recommended for use when
there is potential for exposure to blood, body fluids and/or mucus membranes. These are
single patient use items.
Hot/Cold pack
A re-usable, gel-filled pack which is marketed for use on any part of the body. Manufactures
advocate storage within a freezer until use. These packs, from an IC perspective, are
recommended for use when there is no risk of exposure to blood, body fluids and/or mucus
membranes.
Decontamination of these products will be in conjunction with the manufacturer‘s instructions
and IC recommendations.
Infection Control Recommendations:

Having contacted the companies of products currently purchased through VIHA, it was
established that written manufacturers cleaning instructions for the re-useable products are
not currently available.
As some of these products, according to the MSDS sheets are incompatible with strong
oxidizers (e.g. Chlorine, Peroxides, etc.) the products will be cleaned with an alcohol surface
disinfectant wipe which has a cleaning element included (e.g. Cavi Wipe).
It is not known whether using these decontamination guidelines will, in time, compromise the
integrity of the product. It is cautioned that the product shall be inspected prior to each use to
ensure that there are no breaches in the product fabrication which may result in leakage of
the internal material or make the pack difficult to decontaminate appropriately.
Table 29 - Products currently acquired through VIHA purchasing department:
CI/NI South Current

Normalized
MEDITECH Island Current Item Description Product Cleaning
Vendor
# AMS # Code
PACK INSTANT COLD DISP

0042414 - STEVENS 66018 Single use only
20/CS 6X9IN
ICE PACK RIGID 4 X 6.8" Decontaminate following

0052916 - STEVENS 88016
24/CA above recommendations
ICE PACK RIGID 8 X 8" Decontaminate following

0052917 - STEVENS 88046
24/CS above recommendations
CARDINAL
0001652 - PACK,ICE,LGE,TECNOL KC33500 Single patient use
HEALTH
PACK HOT/COLD
CARDINAL Decontaminate following
0007872 6E+09 REUSABLE 24/C 2498610 RAP12259
HEALTH above recommendations
6X10IN ICEPACK
F. Recommendations for Bath Mats Prior to Purchase

Products Reviewed
AMG Medical Inc. Small Bath Mat – containing dry natural rubber. This product has
suction cups on the underside of the mat to secure it to the bath/floor, these will make
cleaning difficult. The manufacturer provides the option of machine washing.
Stevens Sure-Step Bath Mat – made from poly-vinyl chloride (PVC). This product is a
tubular construction which does not provide easy access to all surfaces ensuring an
appropriate clean/decontamination of the product has occurred.
IPC Product Recommendation

Of the two products reviewed, the Aquasense product was the preferred option as there were
concerns with the tubular construction of the Stevens Sure-Step Bath Mat and its ability to be
cleaned/decontaminated appropriately.
Cleaning/Decontamination Recommendations
Ensure a written cleaning regime for these products is in place prior to purchase and
instillation
Follow manufacturers guidelines for cleaning product in a washing machine and
hanging to dry
If product cannot be cleaned using a washing machine:
o Thoroughly clean all surfaces using detergent and water
o Hang to dry after each use
RECENT CHANGES/ADDITIONS
February 7, 2013 – minor word updates to Table 12 and Table 15
January 7, 2013 – Table 17 has been updated for content and structure
November 9, 2012 – update to the Soiled Linen section (bullet #4 used to say ―Roll linen
carefully into itself. Avoid shaking or fluffing‖
October 12, 2012 –

Addition of procedures for negative pressure rooms after patient discharge or transfer
Update to Table 16 to keep in line with the MRSA Policy for patients in Residential
Care
Update to Vanity Top fixture section
Addition of fixture section on Hand Wash Facilities
Update to Table 21 to keep in line with the ILI algorithms
September 17, 2012 – Update to Table 15 - ARO Screening and Collecting Swabs
July 31, 2012 – Update to the information surrounding negative pressure rooms
July 13, 2012 –

Cleaning of Isolation Carts
Specific nursing responsibilities in the Housekeeping processes
Discontinuation of additional precautions
June 15, 2012 –

Clarification on the use of non-disposable household utility gloves
Hot/Cold Pack and Ice Bags
May 11, 2012 –

Addition of Recommendations for Bath Mats Prior to Purchase
Addition of Play Equipment and Toys section
April 13, 2012 –

Table 10 indicates Precaution Clean is to be used for all types of precautions
Type 4 has been added to the parainfluenza row in Table 18 – Respiratory Infections
Precaution Clean and Precaution Plus Clean replaces 2-Step and Routine Plus Clean
March 13, 2012 – Part 4 - Housekeeping has been completely revised
January 4, 2012 – updated hyperlinks to Policy 15.3 – Management of Patients with VRE
(Acute and Residential)

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INFECTION

PREVENTION AND CONTROL

2. Scope of the Document ................................................................................................ 8

3. Guiding Principles ......................................................................................................... 8

PART 2: UNDERSTANDING HOW INFECTIONS ARE SPREAD ...................... 9

A. Causative Agents ............................................................................................... 10

C. Portal of Exit ....................................................................................................... 12

E. Portal of Entry ..................................................................................................... 14

PART 3: INFECTION PREVENTION AND CONTROL PRACTICES AND

A. Risk Assessment ................................................................................................ 18

Table 2: Risk Assessment .................................................................................... 21

B. Risk Reduction ................................................................................................... 22

Nail and Skin Care .................................................................................................. 24

Hand Hygiene Procedure ........................................................................................ 26

Table 5: Glove Use in Patient Care...................................................................... 31

Figure 4: Choosing the Correct Glove ................................................................ 32

6. Safe Handling of Sharps ......................................................................................... 36

Table 7: Classes of Organisms in Order of Susceptibility to Disinfectants ... 40

Table 8: Disinfection Requirements for Equipment .......................................... 41

Table 9: Advantages and Disadvantages of Major Chemical Disinfectants ... 41

2. ADDITIONAL PRECAUTIONS ................................................................................... 55

A. Contact Precautions ........................................................................................... 55

B. Droplet Precautions ............................................................................................ 58

C. Airborne Precautions .......................................................................................... 59

D. SUMMARY OF PRECAUTIONS ........................................................................ 64

E. Protective (Reverse) Precautions ....................................................................... 65

F. Management of Cases on Additional Precautions in Diagnostic Areas .............. 65

G. Discontinuing Additional Precautions ................................................................. 68

B. EVALUATING PRODUCTS ................................................................................ 77

2. Bed Bug Infestation .................................................................................................... 77

A. Pests and Infestations in Home and Community Care ....................................... 77

PART 5: ANTIBIOTIC RESISTANT ORGANISMS............................................ 78

3. Acute Care Screening Protocol .................................................................................. 78

4. ARO Screening and Collecting Swabs ....................................................................... 80

5. Overview of Antibiotic Resistant Organisms ............................................................... 81

A. Methicillin-Resistant Staphylococcus aureus (MRSA) ........................................ 81

B. Vancomycin-Resistant Enterococci (VRE) ......................................................... 82

C. Extended Spectrum Beta-Lactamase (ESBL) Organisms .................................. 82

6. ARO Room Placement ............................................................................................... 83

7. Key Management Issues ............................................................................................ 85

PART 6: OUTBREAK MANAGEMENT ............................................................. 91

2. General Guidelines for Outbreak Management .......................................................... 92

A. Reporting a Suspected Outbreak ....................................................................... 92

Figure 8: Suspected Respiratory Infection or Gastroenteritis Outbreak

B. Influenza-Like Illness (ILI) Outbreaks ................................................................. 95

Table 20: Respiratory Infections .......................................................................... 97

C. Gastrointestinal Illness (GI) Outbreaks ............................................................. 106

Table 23: Gastrointestinal Illness Case Definition .......................................... 108

Figure 9: Requisition Form for GI Testing ........................................................ 114

D. Outbreaks Caused by Other Organisms ........................................................... 115

PART 7: DEPARTMENTAL GUIDELINES ...................................................... 120

3. Pediatrics .................................................................................................................. 126

Table 26: Assessment for Increased Risk of Communicable Disease

Figure 13: Surgical Housekeeping Algorithm .................................................. 137

5. Burn Unit Recommendations .................................................................................... 145

6. Renal Dialysis Department ....................................................................................... 147

7. Respiratory Department Guidelines .......................................................................... 159

PART 8: Specific Procedural Recommendations ............................................ 162

2. Environment and Furniture ....................................................................................... 166

A. Storage of Decorative Items ............................................................................. 166

B. Furniture ........................................................................................................... 166

C. Fixtures and Fittings ......................................................................................... 167