20. Infection Control

In order to prevent the transmission of infection from person to person, all personnel have a responsibility to prevent transmission of pathogens and exposure to blood or other bodily fluids that are always considered potentially infectious.

It is easy to avoid illness and reduce the risk of exposure to others by practicing good personal health and hygiene, receiving the flu vaccine every year, waste disposal, wearing proper PPE and the most effective and simplest practice of all – WASHING YOUR HANDS!

Standard precautions are practiced with every resident at all times, regardless of the health status of the resident or provider as a minimum expectation.

These practices include:

• Washing your hands upon entering and leaving any and every facility, dining areas, resident’s private rooms
• Observe for any isolation or outbreak notices posted on residents’ doors
• Hand washing before and after interacting with any resident
• Use of PPE as indicated by the resident situation
• Appropriate disposal of sharps and blood or bodily fluids
• Ongoing surveillance to identify infections early
• Performing risk assessments for exposure to blood or bodily fluids in order to decide which barriers or precautions are correct for that situation. Resident, provider, and environmental factors may all affect the risk of exposure

EDUCATION

In order for the resident and family to understand the term precautions, it is vital that the nurse and/or supervisor:

• Explain the rationale of routine practices and precautions, which is to minimize the possibility of transmission of infectious agents from body substances by direct or indirect routes.
• Explain the use of protective attire/equipment.
• Educate the residents, their family members and staff in proper hand washing techniques, especially before and after contact with the resident and his/her environment and on leaving the room.

ENVIRONMENTAL CONDITIONS

Being conscious of the environmental conditions helps to control and reduce the level of microorganisms in the environment. These control measures include:

• Consistent and stringent equipment and work area cleaning
• Clearly accessible and identifiable waste dispensers (e.g., Biomedical sharps containers, laundry bins, etc.)
• Disposing of any potentially hazardous or contaminated materials immediately (e.g., needles, garbage, soiled laundry, etc.)
• Proper ventilation

ONGOING OBSERVATION TO IDENTIFY INFECTIONS EARLY

When a resident exhibits signs/symptoms of suspected infection the caregiver will:

• Identify that the resident meets the criteria for an infection.
• Notify the RPN/RN who will complete the individual infection report form and then forward to the occupational health nurse.
• Notify the family of infection, outcome and additional precautions if required.
• Document in progress notes every shift relating to presence/absence of signs or symptoms.
• Documentation should continue until symptoms subside or 48 hours after antibiotics are completed.
• Evaluation will be ongoing to identify trends regarding organisms, procedures that may generate infections, educational needs of residents, their families and staff.

The use of PPE and other barriers will be consistent with established policies and procedures. Additional precautions also include:

• IC additional precaution sign
• Yellow dot by resident’s name to identify which resident
• Grey mobile cart containing all PPE
• Reminder signs for donning and removing PPE

RISK ASSESSMENTS

Before beginning a task, it is important to conduct a risk assessment in order to identify the risk of transmission. This should include:

• The amount of time it will take to complete the task
• Type of bodily fluids you may come into contact with
• Presence of microorganisms in the bodily fluids
• Susceptibility of the worker (feeling weak, low immune system)
• The environment in which the task is carried out (proper air ventilation)

The Ontario Ministry of Health and Long-Term Care list the following questions for health care providers to ask themselves while assessing risk:

• What task am I going to perform?
• What is the risk of exposure to bodily fluids / non-intact skin / mucous membranes or respiratory secretions/body tissue / contaminated equipment?
• How competent/experienced am I in performing this task?
• Will the resident be cooperative while I perform this task?

ISOLATION & OUTBREAK MANAGEMENT

An outbreak is a sudden increase of infection, contracted disease or infection within a small, localized group. Generally, procedures will be similar in most facilities, however, each individual home may have particular precautionary policies of their own and it is important to become familiar with these procedures and adhere to them when indicated. An example of this will be a yellow dot by the resident’s name to indicate an infection (airborne, contact, droplet, etc.).

If you or a family member is sick with an infectious disease STAY HOME! If you have begun to display symptoms including coughing, congestion, sneezing, diarrhea, vomiting, pink eye, etc. please inform the office immediately. When you have been symptom-free for a minimum of 48 hours you may return to work.

The Flu Vaccine (or Tamiflu pill) is mandatory when working in Long Term Care facilities. If an Influenza A or B outbreak occurs, Plan A will be required to show that our employees have flu vaccine documentation. For this reason, it is important for employees to frequently update their file. Otherwise, Homes reserve the right to turn down workers who do not have an updated vaccine.

SIGNAGE

Signs are used to alert staff, family and other residents at key points in the facility (e.g., main entrance, nursing stations, patient doors, and bedsides) of a particular infection control situation and will often include appropriate resident care or visitation instructions. Signs will usually be kept in the RNs office. There are four (4) different types of isolation signage that may be posted: Airborne, Droplet, Droplet/Contact and Contact Precautions.

Airborne Precautions

• Single room occupancy (door closed)
• An “Airborne Precautions” sign at the resident’s door to alert the staff that special precautions are required, visitors must report to a nurse before entering a room when this signage is posted.
• Higher-efficiency dust/mist mask N-95 is required for certain diseases such as TB, Varicella, SARS, and is to be put on before entering the residents’ room.
• If surgical masks are being used, they are to be discarded after every use. Do not reuse surgical masks in highly infectious situations.
• Residents are required to be in their own room/isolation.
• The door to the room should be closed at all times.
• Isolation gowns, gloves, and any other PPE must be worn upon entering the room (Follow proper PPE donning and removing procedures).
• Wash hands thoroughly before and after leaving the room.
• Articles required to treat resident must be left in the room if possible.
• If contaminated articles must be removed from the room they must be disinfected when removed (thermometers, blood pressure cuffs, stethoscopes, lifts, etc.).
• The resident must remain in their room at all times.
• If for any reason the resident must leave the room, they must be wearing a surgical mask before exiting their room.
• Linen and waste are to be handled and disposed of as per the homes routine practices and proper contamination containment protocols. Please familiarize yourself with the specific protocols (laundry hamper color codes, location) during your orientation.
• Once the resident has been cleared of infection or has been admitted to hospital while still infected, a high-efficiency mask must be worn while the resident is out of their room, or while the room is being cleaned.
• The door should remain closed until the room is finished being cleaned.
• It may be necessary to exclude any person from entering the room that may be unable to follow precautions (wearing a mask and other PPE) or is immune-suppressed.

Droplet & Droplet/Contact Precautions (Body Fluids)

All the precautions listed above for “Airborne” infections will be applied for droplet infections and also including:

• A “Droplet Precautions” or “Droplet/Contact Precautions” sign at the resident’s bedside to alert the staff that special precautions are required
• Visitors are to report to a nurse before entering a room when this signage is posted.
• Surgical mask with a visor or a face shield must be worn at all times if within 2 meters (6 feet) of the resident
• Room door may remain open if desired.

Contact Precautions

• A “Contact Precaution” or “Droplet/Contact Precaution” sign to be posted at the resident’s bedside to alert the staff that special precautions are required
• Visitors are to report to a nurse before entering a room when this signage is posted.
• Wear a gown if contamination/contact is likely.
• Wear gloves upon entering the resident’s room.
• Wash hands upon entering and leaving the room.
• Mask is not necessary unless contamination via splashing is likely.
• Discard contaminated PPE in proper containers/laundry bins before leaving the room.
• Residents are to remain in their room unless absolutely necessary.
• All items and linen waste are to be handled and/or disposed of as per routine practices except for Hemorrhagic fevers (e.g., Lassa Fever, Ebola, Marburg Fever – for these, consultation with the Health Department is required).

Single Room Isolation Procedures

If a resident has been determined to have an infection or disease that requires them to be isolated, the following are examples of some of the procedures that will need to be followed

NOTE: Depending on your designation and the particular policies and procedures of the particular facility, these duties may vary.

Registered Staff:

• Initiate precautions when a resident has been identified with an infectious disease whether by signs or symptoms.
• Consult ICM-D (Infection Control Manual – Diseases) to determine necessary precautions.
• Send notification to all staff.
• Identify resident/residents on the Daily Monitoring of Infection form, Daily Surveillance form and Daily Shift Report.
• Obtain appropriate specimens if required.
• Post an “Infection Notification” indicator – whether it’s a sign or symbol – on the residents’ door and/or near the residents’ bed.
• Explain procedure to the resident.
• Update care plan.
• Notify family.

Isolation set up:

• Isolation cart placed outside of isolation room for supplies and PPE
• Restock when necessary.
• Signage on the door by resident’s name and/ or near the bed as designated by registered staff
• Biohazard or infection specific laundry container set up in the room, and a regular laundry bag on the outside
• Make sure there is hand sanitizer on the top of the drawers outside of the isolation room.

All Staff Entering the Room:

• Wash hands.
• Don appropriate PPE as per the directions on the resident’s door (gown and gloves are to be worn in every instance).
• All equipment, such as the lifts, are to remain in the room during the period of isolation if possible.
• If not, all equipment that is removed from an isolation room is to be disinfected with sanitizer.
• Be sure all supplies are gathered before entering the room such as briefs, creams, etc.

All Staff Exiting the Room:

• Remove all PPE in proper order, and place in the appropriate disposal or laundry bins provided.
• All dirty linen is to be discarded in isolation laundry.
• All garbage is to be placed in the isolation garbage bag.
• Wash hands.

Bagging Linen and Garbage:

• While still in PPE tie yellow/red laundry bag.
• A second person outside the room wearing gloves will hold a clean garbage bag open for the first person to place the contaminated yellow/red laundry bag into the clean garbage bag.
• Tie and transport to the dirty utility room.
• Follow the same procedure to double bag garbage.
• Wash hands.