Infection Control in Healthcare Facilities 200910 Influenza Season

1
Infection Control in Healthcare
Facilities2009-10 Influenza Season
New York State Department of HealthBureau of
Healthcare Associated Infectionsicp_at_health.state
.ny.us
2
Infection Control in Healthcare Facilities

• Basic Principles
• Hand Hygiene
• Respiratory hygiene / cough etiquette
• Exclusion of ill staff and visitors
• Transmission based precautions according to
  current guidance

3
Healthcare Continuum

• Facility-specific measures
• Hospitals
• Long Term Care (Nursing Homes, Adult Homes, Home
  Health Care)
• Ambulatory settings

4
Hand Hygiene

• Reduction or removal of infectious agents to
  prevent spread
• Alcohol-based Hand Rubs
• Best at removing transient flora
• Not appropriate for visibly soiled hands
• Soap and Warm water
• At least 15-20 seconds
• Necessary if hands are visibly soiled

5
Respiratory Hygiene and Cough Etiquette

• Mask symptomatic patients upon entry or when in
  common areas
• Sneeze or cough into tissue or elbow
• Discard tissue immediately
• Perform hand hygiene

6
Exclusion of ill Staff

• Not productive or useful to patients when staff
  work while ill
• NYS Regulations 10NYCRR405.3(b)(10) (14)
• Personnel includes all employees, members of the
  medical and dental staff, and volunteers
• Must be free from a health impairment which is of
  potential risk to the patient
• Facilities must assess employee health status and
  take appropriate measures to protect patients
• Patient safety is a facilitys responsibility

7
Exclusion of ill Staff

• Duration of exclusion
• Clinical improvement and afebrile (off
  antipyretics) for at least 24 hours
• Cough may persist for days to weeks
• Employer considerations
• Sick leave policy and compensation
• Staff backup system
• Do not require doctors note

8
Standard Precautions

• Basic infection prevention and control strategies
  to care for all patients
• Infectious agents may be found in
• Blood
• Body fluids
• Secretions
• Excretions except sweat
• Nonintact skin
• Mucous membranes

9
Standard Precautions

• For ALL patients, ALWAYS
• For blood borne pathogens, assume all patients
  infected
• Hand hygiene prior to contact
• Don appropriate personal protective equipment
  (PPE) for the task
• Remove PPE and perform hand hygiene when done

10
Personal Protective Equipment

• Dependent on task and likelihood of exposure to
  infectious material
• Gloves
• Mask or Respirator
• Face shield or eye protection
• Gown

11
Droplet Precautions

• Agents that generate large respiratory droplets
• Do not remain suspended in the air for prolonged
  period
• Do not travel far and maintain infectivity
• Mask when within 6 feet or upon room entry
• Influenza
• Pertussis

12
Airborne Precautions

• Agents that are transmitted by small particles
• Remain suspended and travel through air
• Persist and remain infectious
• Infect lower airway
• N95 respirator or higher plus AIIR (Airborne
  Infection Isolation Room)
• If no AIIR, then private room with door closed
• If no AIIR or private room, then ensure spatial
  separation and pull curtain

13
Aerosol-Generating Procedures

• Procedures during which small airborne particles
  may be generated
• Airborne precautions for full protection
• Procedures
• Intubation
• Extubation
• Open tracheal suction
• Bronchoscopy

14
CDC Recommendations

• Seasonal influenza
• Standard and Droplet Precautions
• Routine care and aerosol-generating procedures
• 2009 H1N1 Influenza
• Airborne Precautions
• Routine care and aerosol-generating procedures
• Limited N95 Mask Supply
• Allows for prioritization for aerosol-generating
  procedures

15
Hierarchy of Controls

• Elimination of sources of infection
• Engineering controls
• Administrative controls
• Personal protective equipment

16
2009 H1N1 Precautions Prioritized Use Mode

• Routine care Standard plus Droplet
• Large respiratory droplets
• Infect upon contact with mucous membranes
• Aerosol-Generating Procedures
• Airborne precautions
• Small airborne particles generated during
  aerosol-generating procedures
• Intubation, extubation, open tracheal suction,
  bronchoscopy
• Gloves and eye protection as per Standard
  precautions

17
Steps for 2009 H1N1 Season

• Review and enhance existing respiratory
  protection plan
• Hierarchy of controls
• Assessment of N95 need and supply
• How many needed for routine use, for prioritized
  use
• Through May 2010
• Determination of availability
• Can adequate supply be obtained?
• If no, go to Prioritized Use Mode

18
Duration of Isolation - Patients

• Minimum of 7 days and afebrile for at least 24
  hours without antipyretics
• ----or----
• Until another diagnosis is made and influenza is
  ruled out
• A negative RAT does not rule out H1N1 or
  influenza
• Follow transmission-based precautions for new
  diagnosis

19
Preventing Transmission

• Prevent exposure
• Dont come to work if ill
• Early appropriate action to isolate or exclude
  ill patients and staff
• No ill visitors
• Hyper-vigilance after known exposure

20
Cleaning

• Routine measures
• Enforce existing policies
• Concentrating on high touch surfaces
• Consider increasing frequency
• Cleaning and disinfection
• Clean visible soiling before disinfection
• Use hospital-grade disinfectants according to
  manufacturers instructions
• Dilute bleach acceptable

21
Nosocomial Outbreak

• Definition
• Single confirmed nosocomial case of influenza
• 2 or more residents/patients and/or staff with
  ILI or confirmed influenza on the same unit
  within 7 days
• Actions
• Immediate implementation of transmission based
  precautions
• Reinforcement of existing policies
• Report to Public Health

22
Outbreak

• Precautions
• Low threshold for implementation
• Affected and exposed patients
• May need to include entire units
• Treatment and Prophylaxis
• Any exposed patient or HCW at high risk of
  complications
• LTC Consider facility wide prophylaxis
• Antiviral selection per surveillance data
• Clinical judgment for all others

23
Outbreak

• Testing and Confirmation
• Local testing quickest
• If available, prioritized for confirmation at
  Public Health Laboratory
• Should NOT influence treatment decisions
• Other considerations
• Opportunity to vaccinate and educate
• Staff prophylaxis if exposed and at high risk of
  complications

24
Hospital Considerations

• Emergency Department
• Waiting areas and ambulatory nature
• Triage at point of entrance for febrile
  respiratory illness
• Masking and/or distancing in waiting rooms
• Tissues and trash receptacles
• Readily accessible alcohol-based hand rubs

25
Hospital Considerations

• All Units
• Droplet precautions with any ILI until diagnosis
  is made
• Restrict ill visitors from unit
• Use supervisors to enforce ill staff exclusion
• Coordinate management with Employee/ Occupational
  Health

26
Nursing Home Considerations

• Residence
• Limit interactive gatherings and activities
• Contingency plans to avoid social isolation
• Aggressive response to facility illness
• Limit staff floating
• Low threshold for precautions
• Develop and enforce IC policies

27
Nursing Home Considerations

• Chronic illness
• Change in baseline rather than overt illness
• Increased secretions, temperature instability
• Low threshold to suspect influenza or other
  communicable disease

28
Transfers from Nursing Home to Hospital

• Reserve ED for true emergencies only
• Evaluate on site whenever possible
• Based on patient assessment
• Severity of illness
• Not level of anxiety, community illness level,
  need for routine medical assessment
• Advance notice
• Notify EMS, ED, others of potentially infectious
  patient/resident

29
Home Health Considerations

• Source control
• Cover cough
• Proper PPE
• Early detection by caregivers
• Monitor patients for symptoms
• Early agency notification
• Agency to monitor employees
• Agency to report to LHD and medical provider

30
Adult Home Considerations

• Congregate setting
• Community mitigation strategies
• Source control
• Cover cough
• Hand hygiene is critical
• Early detection
• Monitor residents for symptoms
• Early notification
• Report to LHD and medical provider

31
Ambulatory Considerations

• Prior to visit to prevent exposures
• Phone triage
• Scheduling respiratory illness later in day
• Hand sanitizer, masks, and tissues at entrances
• Separation
• In room as quickly as possible
• Masks or physical distancing
• Signage and education
• For both staff and patients