Session 4: Standard and Transmission

Based Precautions and

Novel Approaches to Controlling the
Spread of MDROs

Session 4
 Approaches to Controlling the Spread of MDROs

Our primary objectives in this session are as follows

1. Describe HICPAC/CDC precautions for preventing
transmission
2. Understand literature on adherence to precaution
measures

We would like to hear from you about your facility’s efforts

to monitor and evaluate precaution measures and
spread of infection

Session 4 2
 Approaches to Controlling the Spread of MDROs

In this session, we are going to discuss

• Standard and Transmission (including Contact) precaution
guidelines
• Literature on effectiveness of contact precautions,
including Universal Glove and Gown
• Other techniques such as Red Box Entry
• Local efforts to control C. difficile or other MDROs

Session 4 3
Precautions to Prevent Transmission of Infectious
Agents
• HICPAC/CDC has two tiers of precautions for preventing transmission
– Standard Precautions
• Intended for all patients in all healthcare settings, regardless
of suspected infection
– Transmission-based Precautions
• Intended for patients who are known or suspected to be
infected or colonized with infectious agents

Session 4 4
Precautions to Prevent Transmission of Infectious
Agents

• Standard Precautions
– Assume that every person is potentially infected or
colonized
Hand Hygiene
– Avoid unnecessary touching of surfaces in close
proximity to patient
– When hands are visibly dirty, contaminated with
proteinaceous material, or visibly soiled with blood or
body fluids, wash hands with either a
nonantimicrobial soap and water or an antimicrobial
soap and water

Session 4 5
Precautions to Prevent Transmission of Infectious
Agents

• Standard Precautions
Hand Hygiene
– If hands are not visibly soiled, or after removing
visible material with non-antimicrobial soap and
water, decontaminate hands
• The preferred method of hand decontamination is
with an alcohol - based hand rub
• Alternatively, hands may be washed with an
antimicrobial soap and water.
• Frequent use of alcohol - based hand rub
immediately following hand-washing with non-
antimicrobial soap may increase the frequency of
dermatitis Session 4 6
 Precautions to Prevent Transmission of Infectious
Agents

• Standard Precautions
– Perform hand hygiene:
• Before having direct contact with patients
• After contact with blood, body fluids or excretions,
mucous membranes, non-intact skin, or wound dressings
• After contact with a patient’s intact skin (e.g., when
taking a pulse or blood pressure or lifting a patient)
• If hands will be moving from a contaminated - body site
to a clean – body site during patient care.
• After contact with inanimate objects (including medical
equipment) in the immediate vicinity of the patient
• After removing gloves
Session 4 7
Precautions to Prevent Transmission of Infectious
Agents

• Standard Precautions
– Wash hands with non-antimicrobial soap and water or
with antimicrobial soap and water if contact with
spores (e.g., C. difficile or Bacillus anthracis) is likely to
have occurred
• The physical action of washing and rinsing hands
under such circumstances is recommended
because alcohols, chlorhexidine, iodophors, and
other antiseptic agents have poor activity against
spores

Session 4 8
 Precautions to Prevent Transmission of Infectious
Agents
• Standard Precautions
– Do not wear artificial fingernails or extenders if duties include direct
contact with patients at high risk for infection and associated adverse
outcomes (e.g., those in ICUs or operating rooms)
• Develop an organizational policy on the wearing of non – natural
nails by healthcare personnel who have direct contact with certain
patients

Summer décor?
Session 4 9
Precautions to Prevent Transmission of Infectious
Agents

Personal Protection Equipment

• When close to, or are handling, blood, body fluid, body
tissues, mucous membranes, or areas of open skin, HCWs
must use personal protective equipment, depending on
the anticipated exposure, such as:
– Gloves
– Mask and goggles
– Apron, gown, and shoe covers

Session 4 10
Precautions to Prevent Transmission of Infectious
Agents

• Transmission-based Precautions
– Three categories
• Contact Precautions
• Airborne Precautions
• Droplet Precautions

Session 4 11
 Precautions to Prevent Transmission of Infectious
Agents
Transmission-based Precautions
• Should be initiated when illness is
first suspected, and discontinued
only when the illness has been
treated or ruled-out and the room
has been cleaned
– Contact precautions may be
needed
• Wear a gown and gloves
• CRE, MDR-Ab, C. difficile and
norovirus, and respiratory
syncytial virus (RSV)

Session 4 12
 Precautions to Prevent Transmission of Infectious
Agents
Transmission-based Precautions
– Patients may need to wear a mask if they must leave
their room
– Droplet precautions are used to prevent
contact with mucus and other secretions from
the nose and sinuses, throat, airways, and
lungs.
• Influenza (flu), pertussis (whooping
cough), and mumps
• Wear surgical mask
– Airborne precautions may be needed
• Chicken pox, measles, and active
tuberculosis (TB)
• Patients should be in a negative pressure
room
http://infectioncontrol.ucsfmedicalcen
• Secure respiratory mask before entering ter.org/FAQS.html
the room Session 4 13
 Discontinuation of Contact Precautions

Per HICPAC 2006 guidelines: Unresolved

“In general, it seems reasonable to discontinue Contact
Precautions when three or more surveillance cultures
for the target MDRO are repeatedly negative over the
course of a week or two in a patient who has not
received antimicrobial therapy for several weeks,
especially in the absence of a draining wound, profuse
respiratory secretions, or evidence implicating the
specific patient in ongoing transmission of the MDRO
within the facility.”

Session 4 14
Time for a movie quiz!
How well do we adhere to contact precautions?

Session 4 16
 Contact Precautions for Multidrug Resistant Organisms
(MDROs): Current Recommendations and Actual Practice

This study by Clock et al. was conducted in a network of

three hospitals in New York City and sought to assess
availability of contact precautions equipment and
adherence to protocol by staff and visitors

Clock SA et al. Am J Infect Control 2010;38(2):105-111

Session 4 17
 Contact Precautions for Multidrug Resistant Organisms
(MDROs)

Results
• January – June 2008, 424 patients observed
– 67% positive MDRO cultures for one organism
– 33% positive for 2 to 6 organisms
– Most common VRE and MRSA
• Provision of supplies
– 85.4% of room observations in the 60 day study
period indicated contact precautions with a sign
display
– Approximately 95% of rooms with sign display
had isolation carts
Clock SA et al. Am J Infect Control 2010;38(2):105-111

Session 4 18
 Contact Precautions for Multidrug Resistant Organisms
(MDROs)

Patient Care Staff had higher adherence rates for all

contact precautions behavior, compared with other staff
(52 to 70%)

Visitors wore a gown 43 to 64% of the time

Clock SA et al. Am J Infect Control 2010;38(2):105-111

Session 4 19
 Contact Precautions for Multidrug Resistant Organisms
(MDROs)

Overall adherence rates on room entry and exit, respectively,

were
• 19.4% (entry) and 48.4% (exit) for hand hygiene
• 67.5% and 63.5% for gloves
• 67.9% and 77.1% for gowns

Conclusions: Findings support the recommendation that

methods to monitor contact precautions and identify and
correct non-adherent practices should be a standard
component of infection prevention and control programs
Clock SA et al. Am J Infect Control 2010;38(2):105-111

Session 4 20
Contact Isolation Precautions: More is not Necessarily
Better

• Kaye et al found a negative relationship between contact

isolation precautions and compliance

• Conclusions: Compliance with CIP was low across multiple

hospitals.
Hospitals
should weigh the implications of decreased HCW compliance when
implementing widespread CIP, and consider targeting CIP practices
towards MDROs that pose particular threats to their patient
populations.

Kaye, et. al., Oral abstract presentation Decennial Saturday, March 20, 2010

Session 4
Why might HCWs not be adherent to
precautions?

Session 4
 Adverse outcomes associated with contact
precautions: A review of the literature

Four main adverse outcomes related to Contact Precautions

• Less patient-health care worker contact
• Delays and more noninfectious adverse events
• Increased symptoms of depression and anxiety
• Decreased patient satisfaction with care

Morgan, et al. American Journal of Infection Control - March 2009 (Vol. 37, Issue 2, Pages 85-93)

Session 4
Local Example of Isolation Precautions Tool

Session 4 24
Novel Approaches to Transmission Prevention

Session 4
Taking Off the Gloves: Toward a Less Dogmatic
Approach to the Use of Contact Isolation
Conclusion:
…..Most importantly,

. For this reason, efforts to improve

hand hygiene should be prioritized by all hospitals. If
those efforts are successful, the role for contact
isolation will be limited.

Kirkland; Clin Infect Dis. (2009) 48 (6): 766-771.

Session 4
New Rules for Contact Precautions
Contact Precautions will be instituted for patients who have:

1.Diarrhea known or suspected to be infectious or toxin-mediated (e.g. C-diff), or

diarrhea in a patient who is incontinent of stool, as detailed below:
a.Known infectious cause of diarrhea, even if patient is continent of stool or
stool is contained in a diaper or device.
b.Patient is being tested for C. difficile or other form of infectious diarrhea
c.Patient is incontinent of stool regardless of cause unless the the stool is
effectively contained in an incontinence brief or fecal collection device.

2.Draining wound that is not, or cannot be completely covered with a sealed

dressing that contains the drainage (regardless of organism or infection)

3.Uncontrolled uncontained respiratory secretions (most commonly in trached

patients, regardless of organism)

4.Selected specific infectious diseases (See “Isolation Guidelines 2007 for Specific
Diseases” on the Infection Prevention Intranet Site)

5. Emerging MDROs that are defined by IP and ID

Session 4
Contact Precautions require all of the elements of Standard
Precautions, and in addition require the following:
Patient must be in a private room (door may be left open)
Gloves must be worn by staff whenever they enter the room.
Gowns must be worn by staff when they enter the room unless there
will be NO contact with the patient or the patient’s environment.
Dedicated patient care equipment must be used when available. If
dedicated equipment is not available, equipment must be disinfected
between patients.
Limit transport and movement of patients outside of the room to
medically necessary purposes.

***Contact Precautions may be discontinued when signs and symptoms

have resolved for at least 24 hours or according to disease-specific
recommendations, whichever is later.

Note: According to Standard Precautions gloves and gown are required

for any contact with stool or items contaminated with stool.

Session 4
New Rules for Contact Precautions
• No increase in MDR HAIs
• 3623 Nursing hours saved in one year
• $291, 316 saved (if compliance was perfect before)

Session 4 29
Red Box Entry

A hospital in Illinois created a 3 foot square area, marked

by red duct tape at the entrance to patient rooms placed
on contact precaution due to risk of infection spread.

Referred to as ‘safe zone’ where healthcare workers can

interact with patients without donning personal
protective equipment
• Saves time donning clothing
• Improved patient satisfaction
• Increased staff productivity
• No negative impact on HAI rate
Source: www.innovations.ahrq.gov. Accessed June 30, 2014
Webinar available at : http://webinars.apic.org/session.php?id=7272

Session 4 30
 Universal Glove and Gown Use and Acquisition of Antibiotic
Resistant Bacteria in the ICU: A randomized trial

This study by Harris et al. sought to determine whether wearing

gloves and gowns for all patient contact in the ICU decreased
MRSA or VRE compared to usual care
• 20 medical and surgical ICUs in 20 hospitals were randomized
– In the intervention group, all healthcare workers were
required to glove and gown for all patient contact and
when entering any patient room
– Primary Outcome:
• Acquisition of MRSA or VRE based on surveillance
cultures collected on admission and discharge from
ICU
Harris AD et al. JAMA 2013;310(15):1571-1580

Session 4 31
Universal Glove and Gown Use and Acquisition of Antibiotic
Resistant Bacteria in the ICU: A randomized trial
Results
• No differences in MRSA/VRE acquisition rates were seen between universal
glove and gown and ‘usual care’
– There were fewer MRSA acquisitions: 40.2% relative reduction in
intervention vs. 15% reduction in control
• Universal glove and gown
– Decreased HCW room entry
– Increased room-exit hand hygiene compliance
– Had no effect on rates of adverse events
• Adverse events were randomly sampled using the IHI Global trigger
tool

Harris AD et al. JAMA 2013;310(15):1571-1580

Griffin F, Ressar R. IHI global trigger tool for measuring adverse
Session 4 events. 2009 IHI Innovation Series White 32
Paper (second ed)
Session 4 33
 Core Measures for All Acute and Long-
term Care Facilities
• Hand Hygiene
– Promote hand hygiene
– Monitor hand hygiene adherence and provide feedback
– Ensure access to hand hygiene stations
• Contact Precautions
Acute care
– Place CRE colonized or infected patients on Contact Precautions (CP)
• Preemptive CP might be used for patients transferred from high-risk settings
– Educate healthcare personnel about CP
– Monitor CP adherence and provide feedback
– No recommendation can be made for discontinuation of CP
– Develop lab protocols for notifying clinicians and IP about potential CRE
• Long-term care
– Place CRE colonized or infected residents that are high-risk for
transmission on CP (as described in text); for patients at lower risk for
transmission use Standard Precautions for most situations

Session 4 34
 Core Measures for All Acute and Long-
term Care Facilities
• Patient and staff cohorting
– When available cohort CRE colonized or infected patients
and the staff that care for them even if patients are
housed in single rooms
– If the number of single patient rooms is limited, reserve
these rooms for patients with highest risk for
transmission (e.g., incontinence)
• Minimize use of invasive devices
• Promote antimicrobial stewardship
• Screening
– Screen patient with epidemiologic links to unrecognized
CRE colonized or infected patients and/or conduct point
prevalence surveys of units containing unrecognized CRE
patients
Session 4 35
Supplemental Measures for Healthcare
Facilities with CRE Transmission

• Conduct active surveillance testing

– Screen high-risk patients at admission or at admission
and periodically during their facility stay for CRE.
Preemptive CP can be used while results of admission
surveillance testing are pending
– Consider screening patients transferred from facilities
known to have CRE at admission
• Chlorhexidine bathing
– Bathe patients with 2% chlorhexidine

Session 4 36
Dealing with an Outbreak of C. difficile in a
Children’s Hospital
• Increase noted in high-risk frequent visit population
• Cases mapped throughout affected patients' stays
and clinic visits
• Some common locations noted
• Remedial education for care-givers and staff
regarding proper hand hygiene, isolation, cleaning,
etc.
• One physician reported not knowing he was
supposed to use soap and water for hand-hygiene
• EVS reminded to use bleach for cleaning of isolation
rooms
• Took an estimated 2 months to see significant drop,
but levels returned to baseline and remain
Session 4 37
Questions and Discussion

Session 4
What novel approaches to prevention have you
implemented in your facility?

Session 4 39