AHRQ Safety Program for Long-term Care: HAIs/CAUTI Personal Protective Equipment and Standard and Transmission-based Precautions Training Module #3 for the LTC Core Team Current as of July 2015

Upon completing this module team members will be able to: understand the role that contact and standard precautions play in preventing health care-associated infections (HAIs); describe how precautions are individualized and applied for their facility population; describe when to use personal protective equipment; demonstrate how to put on and take off PPE; and engage all facility staff in appropriate PPE use. 2 Learning Objectives

Remember the Chain of Infection… Chain of Infection Harmful germ spread by contact MRSA Norovirus C. difficile RSV Hide/Grow/ Multiply GI Tract Nose Wound Way out Nose Skin Rectum Urine Going mobile HCW Hands Environmental Surfaces Equipment Way in Nose Mouth Wound Devices Next person at risk Siedlaczek G. SJMHS. Courtesy of R. Olmstead, CAUTI prevention training module 2 3

What Are Standard Precautions? Group of infection prevention practices applied during care of all individuals, regardless of suspected or confirmed infection status, in any health care setting Assumes that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious microbes “Implementation of Standard Precautions constitutes the primary strategy for the prevention of healthcare-associated transmission of infectious agents among patients and healthcare personnel.” CDC/HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

Elements of Standard Precautions Hand hygiene (Training Module 1) Environmental cleaning and disinfection (Training Module 2) Soiled resident care equipment and devices (Training Module 2) Personal protective equipment (PPE) Resident placement—single resident rooms, cohorting Respiratory hygiene/cough etiquette Safe injection practices—needles and other sharps Textiles and laundry handling CDC/HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

What PPE to Wear and When? Based on the type of task being performed Anticipated contact with blood and/or body fluids, or pathogen exposure Prevention of fluid penetration from splashing/sprays STOPSTOP CDC/HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Table

When to Wear Gloves Any anticipated contact with: Blood or body substances—fluids and solids Mucous membranes—oral, nasal, conjunctival, rectal, genital Non-intact skin—wounds, surgical incisions Indwelling device insertion site—urinary catheter, IVs, feeding tube Handling potentially contaminated items in the resident’s environment Visibly soiled equipment, supplies or linens that may have been in contact with blood or body fluids Shared equipment moving between residents CDC/HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

Glove Use: Putting On and Taking Off Putting on gloves If wearing gown, then extend to cover wrist of gown Removing gloves Remember: outside of gloves are contaminated. 1.Grasp outside of glove with opposite gloved hand; peel off. 2.Hold removed glove in gloved hand. 3.Slide fingers of ungloved hand under remaining glove at wrist. CDC/HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

When to Wear Gowns When anticipating contact of clothing or exposed skin with blood or body fluids, secretions or excretions During procedures likely to generate splashes, sprays or droplets of blood and body fluids (e.g., catheter insertion, emptying urine collection bags) When in contact with non-intact skin (e.g., large wounds, rashes, burns) Handling fluid containers likely to leak, splash or spill when moved (e.g., bedside commodes, bedpans, urinals, emesis basins) CDC/HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

Gown Use: Putting On and Taking Off Putting on Gown: 1.Put on before gloves. 2.Fasten at back of neck and waist. Removing gown: Remember: outside of gown is contaminated. 1.Remove gloves first. 2.Unfasten neck, then waist ties. 3.Remove gown using a peeling motion; gown will turn inside out. 4.Hold removed gown away from body, roll into a bundle and discard in room. CDC/HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

Masks and Eye Protection Wear during procedures likely to generate splashes, sprays, or droplets of blood and body fluids Masks Dressing changes for PICC/central vascular access devices Dressing changes on large open wounds Care of residents with new onset or exacerbation of respiratory condition with increased sputum or nasal sections Consider when emptying urine collection bags (splash) or inserting/changing urinary catheters (spray) Mask and goggles/face shield Irrigation of open wounds (infected or non-infected) Oral or tracheal suctioning CDC/HICPAC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

Transmission-based Precautions Specific practices added to standard precautions when the spread of infection or organisms is not completely stopped using standard precautions alone These practices are used based on how organisms spread in health care settings: – Contact Precautions—exposure to “touching/oozing” – Droplet Precautions—exposure to “sneezing, dripping” – Airborne Precautions—exposure to “coughing” CDC/HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

Contact Precautions Prevention of transmission of infectious pathogens that are spread by direct or indirect contact with a resident or their environment Contact Precautions are indicated when a resident has: uncontained excessive wound drainage; uncontained fecal incontinence or other body fluids; and/or infection or colonization with MDROs or other epidemiologically significant organisms. Examples: MRSA, VRE, resistant gram-negative bacilli such as ESBLs or CREs, C. difficile and scabies CDC/HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

Contact Precaution Strategies Place signs and PPE caddies at room entry. Promote gown and glove use for contact with the resident or their immediate surroundings. Gown/glove at room entry, removed before exiting room Reduces contamination of hands and clothes, and helps to contain pathogens and reduce environmental spread Hand hygiene before and after gown/glove use Ensure proper environment and equipment care Use disposable equipment or equipment dedicated to that resident when possible. Clean and disinfect common equipment before use for another resident. Clean and disinfect resident room (at least daily) with a focus on high- touch surfaces. 14

Contact Precaution Strategies (cont’d) Assess resident placement (e.g., single room, cohort, existing roommates, roommates at lower risk) Establish policies for movement of residents outside of the room based on level of risk of transmission Consider the following issues: Presence of active signs/symptoms of infection (e.g., new vomiting or diarrhea, undiagnosed cough, and/or new fever) Inability to contain excretions or secretions Challenges with maintaining personal hygiene CDC/HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. CDC/HICPAC. Management of Multidrug-Resistant Organisms in Healthcare Settings,

Resident Placement Principles Determine placement based on the following principles: Route(s) of transmission e.g., draining wounds, diarrhea, uncontrolled secretions Risk of transmission Availability of single rooms Options for room-sharing e.g., cohorting, placement with a resident at lower risk of infection 16

Guidance on Resident Placement Single rooms (when available) should be prioritized to residents requiring transmission-based precautions. When single rooms are not available, cohort residents with the same infection or MDRO in the same room. When cohorting is not possible, place colonized/infected resident with a low risk resident. In multi-resident rooms, more than three feet of spatial separation between beds is advised to reduce the opportunities for inadvertent sharing of items between infected/colonized resident and other residents. Department of Health and Human Services. Centers for Medicare and Medicaid Services. Revisions to Appendix PP Interpretive Guidelines for Long Term Care Facilities, Tag 441. Effective 9/30/

Risk Factors for MDRO Colonization Know if a resident has any of the high risk exposures for being an MDRO carrier. These exposures also increase risk for acquiring an MDRO: Presence of wounds o Higher risk if draining, multiple, or large Presence of indwelling medical devices o IV lines, urinary catheters, tracheostomy, PEG tubes Inability to maintain continence of urine/stool Increased dependence on caregivers for activities of daily living Current or recent antibiotic use 18

Challenges with Precautions in LTC Large population of residents with unrecognized MDRO carriage Limited communication about new residents colonized with MDROs No active screening/surveillance to detect colonized individuals Leads to underestimating the sources of potential transmission Lack of private rooms/limited ability to move residents Moving people is disruptive to residents and staff Determining duration of precautions Unable to restrict resident mobility and participation in social events/therapy for prolonged periods Unlikely to document clearance of carriage 19

How Will You Help Engage Your Facility? Engage senior leaders Share the all staff presentation at your next in-service Make posters of your staff engaging in positive behaviors, hang them up in key common areas Hold live demonstrations on appropriate gown and glove use Role model positive behaviors 20

How Will You Help Engage Your Facility? Identify barriers, nominate unit champions Use pre-/post-quiz to assess staff knowledge Use this as your QI project: audit compliance and give positive feedback Hold unit level competitions, give some simple prizes to winners Reminders on Appropriate Use 21

Take the Pledge… 22

Stay Updated with Useful Resources 1.AHRQ Safety Program for Long-Term Care: HAIs/CAUTI websiteAHRQ Safety Program for Long-Term Care: HAIs/CAUTI website Login information Username: ltcsafety Password: ltcsafety 2.TeamSTEPPS ® for Long-Term CareTeamSTEPPS ® for Long-Term Care 23 3.LTC Safety ToolkitLTC Safety Toolkit 4.Centers for Disease Control and Prevention: Guideline for Isolation Precautions Protecting Healthcare Personnel 5.Journal Articles Joint Infection Prevention Control Guidelines Enhancing Standard Precautions (ESP) in California Long-Term Care Facilities, 2010 Joint Infection Prevention Control Guidelines Enhancing Standard Precautions (ESP) in California Long-Term Care Facilities, 2010 Keeping the “Home” in Nursing Home, Implications for Infection Prevention Conceptual Model for Reducing Infections and Antimicrobial Resistance in Skilled Nursing Facilities: Focusing on Residents with Indwelling Devices. Conceptual Model for Reducing Infections and Antimicrobial Resistance in Skilled Nursing Facilities: Focusing on Residents with Indwelling Devices.

References Courtesy of R. Olmstead, CAUTI prevention training module 2. CDC. PPE Guidance and Training Materials, Centers for Disease Control and Prevention. CDC/HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Mody L et al. Clinical Infectious Diseases 2011; 52(5): Mody L, Bradley SF, Huang SS. Keeping the “Home” in Nursing Home: Implications for Infection Prevention. JAMA Intern Med. 2013;173(10): doi: /jamainternmed Siedlaczek, G. Infection Prevention & Control Services. [Powerpoint slide]. Retrieved from