1. Hand Hygiene and Cleaning Update

2. Introduction
In this section the reader will be introduced to policies that address infection prevention and control practices at Tulare Regional Medical Center which support specific goals: 1. Hand Hygiene and cleaning recommendations 2. Employees, medical staff, visitors, volunteers free of illness
and injury 3. An organization that is prepared for outbreaks and emerging
infectious diseases

3. Infection Prevention Key Points:
Infection Prevention and Control Program
Hand Hygiene
Cleaning
Respiratory Etiquette
5. Seasonal Influenza Vaccine
6. Tuberculosis (ATD)
7. Principles of isolation
8. Risks associated with construction
9. Healthcare Associated Infections (HAIs)

4. at Tulare Regional Medical Center.
Policy
Infection Prevention and Control Program Policy
The Infection Control Officer has the authority to perform ongoing and/or immediate surveillance, prevention and control measures or studies instituting prevention and control activities such as appropriate isolation, maintenance of a sanitary environment, assurance of proper sterile processing, and other measures that reduce patient, employee, and/or visitor harm related to transmission of disease
at Tulare Regional Medical Center.

5. Policy 20-8022 Infection Prevention and Control Program continued:
All employees must receive education annually regarding:
Hand hygiene practices
Standard precautions
Standard Blood and body fluid exposure plan
Tuberculosis and respiratory prevention plan
Multidrug resistant organisms

6. Up to 80% of infectious diseases are transmitted by touch.
CDC Hand hygiene Guidelines
Policy Key Points:
Tulare Regional Medical Center’s “Are You Gellin?” hand hygiene campaign (use alcohol-based hand sanitizer prior to entering and upon exiting patient rooms)
Soap and water is used in place of alcohol-based hand sanitizer when hands are visibly dirty, after use of the bathroom, and when there is an outbreak of Clostridium difficile or Norovirus in the hospital
Fingernails shall remain less than ¼ inch in length and artificial nails are prohibited for staff providing patient care
Procedural areas (i.e. Operating Room) must use a hand sanitizer with persistence (i.e. Chlorhexidine gluconate) between patients
Up to 80% of infectious diseases are transmitted by touch.

7. “There Can Be Consequences For Putting Patients At Risk“
CDC Hand Hygiene
Key Points Continued:
Perform hand hygiene – you’re eligible to receive an honorary infection prevention award
Forget to perform hand hygiene once in 12 months – receive a citation and an educational pamphlet on hand hygiene
Forget to perform hand hygiene twice in 12 months – receive a citation and complete a competency assessment on hand hygiene practice
Forget to perform hand hygiene three times in 12 months – receive a citation, notification to employee’s supervisor, and a memo to Human Resources that requires 1 point deduction from employee’s annual evaluation from “Safety/Infection Control” column.
“There Can Be Consequences For Putting Patients At Risk“

8. Cleaning Policy 20-8030 Key Points:
• Cleaning is the physical removal of organic material or
soil from objects • Disinfection is the killing or inactivation of microorganisms • When medical equipment is cleaned/disinfected it is
bagged in plastic indicating that it has been
cleaned/disinfected • Clean and dirty processes are performed exclusive from
one another, and clean items will remain separate from
dirty items at all times.

9. Cleaning cont. Policy 20-8030 Key Points continued:
In order to appropriately disinfect it is important to use a disinfectant according to the manufacturer’s recommended “contact time” – the length of time the disinfected surface must remain wet to effectively kill microorganisms on that surface. If a product has the “contact time” of 2 minutes it is important to keep the surface wet (with the product) for 2 minutes (it is recommended to actually check the clock to know the time). This applies to cleaning all surfaces and patient care equipment (for example a glucometer or IV pump).

10. Blood Exposure Control
Policy Key Points:
• Blood and Body fluid exposures can occur as a result of a needle stick, splash to the face, or a contaminated sharp such as a scalpel poking you after used on a patient. • If you perform tasks that involve blood, blood- contaminated body fluids, other body fluids or sharps you may be eligible to receive vaccinations against Hepatitis B through the hospital. • If you are exposed to blood or body fluids while working at
TRMC remember to wash and treat the affected area first, then notify your supervisor. You will be directed to receive follow-up care at the Emergency Department. • Remember to slow down, anticipate risks for blood and body fluid exposure, and be prepared with appropriate personal protective equipment (PPE) to reduce risk of exposure.

11. Your Infection Prevention Team is waiting for your ISOLATION call!
Isolation Precautions
Your Infection Prevention Team is waiting for your ISOLATION call!
Policy Key Points:
There are respiratory hygiene/cough etiquette kiosks stationed at the entrances of the hospital and located in lobbies and waiting rooms at the hospital and clinics. Visitors and patients are encouraged to use these kiosks to cover their cough or don a mask and/or perform hand hygiene. Standard precautions involves being prepared with the appropriate PPE (i.e. gloves, gown, goggles, mask, respirator) based on what you might anticipate coming in contact with. The standard suggests healthcare workers should treat everybody as if they are potentially infectious so that they may safeguard themselves from potential exposure to disease causing microorganisms. When there is a question about isolation contact the Infection Prevention and Control Program at extension #3487.

12. Isolation Precautions
There are a total of 7 types of Isolation Precautions used at Tulare Regional Medical Center:
Type of Precaution
Examples
Appropriate PPE
Special considerations
Standard
Anticipate risks for exposure and don appropriate PPE
Any combination of PPE
Treat everybody as if they are potentially infectious
Contact
(i.e. MRSA infection, Clostridium difficile, Norovirus, Scabies, Shingles)
Gloves, Gown
May wear a Mask with multidrug resistant organisms
Droplet
(i.e. Seasonal Influenza, Group A Streptococcus)
Mask within 3 feet of patient
Remember the “within 6 feet of patient” rule
Airborne
(i.e. Tuberculosis, Chickenpox, Measles)
Respirator or P.A.P.R.
A HEPA-filter is required and the door must remain closed
Enhanced Airborne
(i.e. Bronchoscopy procedures, Novel Influenza, S.A.R.S.)
Gloves, Gown, Goggles, Respirator or P.A.P.R.
This precaution is used for procedures like Bronchoscopies and unknown or new organisms
Protective
(i.e. AIDS patient, patient receiving chemotherapy)
Gloves, Mask
This is a form of reverse isolation
Special Pediatric
(i.e. child with Respiratory Syncytial Virus (RSV)
Gloves, Gown, Mask
Combination of Contact and Droplet Precautions

13. Isolation Precautions
Continued:
Remember nurses need to document the patient’s isolation status every shift. Review the Safe Injection Practices Grid on pages 4 & 5 in policy # or see next slide.

14. Blood Glucose Monitoring Devices
Table 1: Safe Injection Practices Grid
General
IV Solutions
Syringes
Vials
Blood Glucose Monitoring Devices
Perform hand hygiene
Disinfect IV ports and vial stoppers by wiping and using friction with a sterile 70% isopropyl alcohol
Use single-dose containers for flush solutions
Utilize sharps safety devices
Use single-dose vials whenever possible
Clean and disinfect glucometers if they must be shared between multiple patients
Store and prepare medications and supplies in a clean area on a clean surface
Use a USP 797 primary engineering control with an ISO class 5 atmosphere to prepare admixtures of IV solutions when immediate use is not required
When using a multi-dose vial, the vial must be dedicated to one patient and a sterile syringe used for each entry into the vial
Discard syringes, needles, and cannulas after use
Always use a new sterile syringe and new needles/cannulas when entering a vial
Restrict the use of finger stick capillary blood sampling devices to individual patients
Discard all opened vials, IV solutions, and prepared or opened syringes
Do use spiking devices, even if they have a 1-way valve, to remove fluid from IV bottles/bags for multiple uses or patients
Do not prepare medication in one syringe to transfer to another syringe
Cleanse the access diaphragm of vials using friction and a sterile 70% isopropyl alcohol
Use single-use lancets that permanently retract after puncture
Avoid contacting sterile drugs and sterile areas
Discard single-use vials after use
Never reuse finger stick devices and lancets
Never store or transport syringes in clothing or pockets
Discard any vial that has been placed on a contaminated surface or a used procedure tray
Lancets in a pen should be removed by mechanical means (hemostat) to avoid finger contact
Always prepare syringes and IV fluids as close to administration as feasible
Use multi-dose medication vials for single patient whenever possible and access all vials using a new sterile syringe
Thoroughly clean all visible soil or organic material (eg, blood) from the glucometer before disinfection
Always dispose syringes (sharps) at the point of use in an approved sharps container
Keep multi-dose vials away from the immediate patient environment
Disinfect the exterior surfaces of the glucometer after each use following the manufacturer's directions
Never use infusion supplies, such as needles, syringes, flush solutions, administration sets or IV fluids on more than one patient ( DEVICE - PATIENT)
Never pool or combine leftover contents of vials for later use
Never leave a needle, cannula or spike device (even if it has a 1-way valve) inserted into a medication vial rubber stopper because it leaves the vial vulnerable to contamination
Dolan et. al. APIC position paper: Safe injection, infusion, and medication vial practices in health care, American Journal of Infection Control April 2010 (pg ), Copyright ª 2010 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc.
*SPECIAL NOTE: Additional precautions are recommended for Lumbar Puncture Procedures:
IV.I. Infection control practices for special lumbar puncture procedures wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space (i.e., during myelograms, lumbar puncture and spinal or epidural anesthesia , , Category IB
2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

15. Influenza Vaccination
Policy Key Points:
-Healthcare staff receiving/declining or having received
Seasonal influenza vaccination elsewhere will have
their individual vaccination data added to an electronic
database maintained by Human Resources. -Healthcare staff that decline the seasonal influenza vaccine
for any reason will be required to wear a simple surgical mask
at all times during their scheduled shift with the exception of during scheduled breaks for the duration of the influenza season. -Clinical Directors are required to enforce a simple surgical mask is worn by healthcare staff that have declined influenza vaccination.

16. TB Prevention Plan Policy 20-8013 Key Points:
Annually clinical employees are required to receive
A Tuberculosis skin test (TST) to determine if they
have been exposed to Tuberculosis (TB). Annually clinical employees will be required to
complete a TB questionnaire with questions about whether the employee has symptoms attributed to TB disease. If the employee is suspected of having active TB disease based on a prior positive TST and signs/symptoms attributed to active TB disease he/she will be required to receive a chest x-ray to better determine if the employee may have active TB disease.

17. TB Prevention Plan Continued:
Patients suspected of having Tuberculosis must be placed on Airborne Precautions with a HEPA-filter installed in their room. To have a HEPA-filter for a patient’s room there must: (a) be an electronic physician’s order for “negative pressure (HEPA- filter)” along with the appropriate airborne isolation precautions. (b) be notification of on duty supervisor and/or maintenance for installation, if not currently setup in patient’s room. Only employees who have been appropriately Fit Tested with a respirator (N95) can enter Airborne Precaution Isolation rooms. If a patient is suspected of having Tuberculosis, the Infection Prevention and Control Program and Case Management must be notified.

18. Reduction of Healthcare Associated Infections (HAI)
Policy Key Points:
There are 5 different types of HAI 1. Surgical Site Infection (SSI) 2. Multidrug Resistant Organism (MDRO) 3. Central Line Associated Bloodstream Infection (CLABSI) 4. Catheter Associated Urinary Tract Infection (CAUTI) 5. Ventilator Associated Pneumonia (VAP) Historically these types of HAI account for: - 2 million people infected a year nationwide; - 100,000 deaths related to an HAI annually nationwide; - a financial burden of $28 – 33 billion dollars spent a year nationally to treat patients with an HAI Hospitals are targeting for zero healthcare associated infections nationwide

19. HAI Continued Surgical Site Infection Prevention Bundle
Control blood glucose levels
Smoking cessation
Pre-operative antiseptic shower using Chlorhexidine gluconate (CHG) * TRMC also recommends CHG bathing in high risk circumstances
Pre-operative hair removal using clippers (NOT shaving)
Patient skin preparation using Chlorhexidine gluconate (CHG) or Betadine
Pre-operative antibiotics administered 1 hour prior to surgical incision
Proper draping of the patient prior to incision
Proper surgical attire and aseptic & sterile technique used throughout the surgical procedure
Maintenance of near baseline body temperature throughout procedure

20. HAI Continued Multidrug Resistant Organisms Prevention Bundle
•Right drug for the Right bug (appropriate antibiotic use), Vancomycin shouldn’t be
the first drug choice when the pathogen is unknown •Clean the patient’s environment with appropriate disinfectants regularly to
prevent the spread of multidrug resistant
organisms

21. HAI Continued Central Line Associated Bloodstream Infection Bundle
•Use the Central Line Insertion Procedure (CLIP) note when inserting a central line (requires that all evidence-based prevention criteria are adhered to during each step of the insertion procedure) •Always triple-swipe the access port to IV lines & Central Line ports prior to accessing – Known as “Scrub-the-hub!”

22. HAI Continued Catheter Associated Urinary Tract Infection Bundle
•Use order set “MED Foley – 631 Order set TULR” in Cerner for Foley catheter orders, and add physician signed yellow “Daily Assessment for Urinary Catheter Necessity” sticker in patient’s chart. •Assure the urinary catheter remains inserted for an approved medical indication •Maintain a sterile closed drainage system •Maintain good hygiene at catheter urethral interface •Maintain an unobstructed urine flow into urinary catheter bag •Drainage bag should remain below the level of the patient’s bladder at all times

23. HAI Continued Ventilator Associated Pneumonia Prevention Bundle
•Head of bed up 30 to 45 degrees if not medically prohibited •Frequent oral care and every 12 hours use Chlorhexidine gluconate solution wash •Ensure Endotracheal tube cuff is appropriately inflated to prevent tube becoming a conduit for bacterial/viral migration from the upper airway to the lower airways that could result in pneumonia •Check residuals for patient receiving tube-feedings to prevent gastric over distension and risk of aspiration •Assure that ventilator tubing remains below the level of the patient’s head to allow water condensation to drain away from the patient’s airway

24. The Power Is Yours! You have the power to make a difference everyday
Everyone, including you has the power to prevent Healthcare Associated Infections and keep patients safe. If you observe an unsafe or unsanitary practice taking place that is against TRMC Infection Prevention Policies, show your power and speak up! Tell your colleagues or the Infection Preventionist. It may be intimidating at the time, but holding yourself and your colleagues accountable upholds the basic mission of all hospitals:
To focus on wellness and improving the health status of the community (not make them sick)

25. Infection Prevention & Control
Conclusion:
To perform infection prevention and control effectively it takes participation from all stakeholders within the organization. You are a part of the infection prevention and control team. Familiarize yourself with policies that address infection prevention and control practices, and if you have questions please contact the Infection Prevention and Control Program. With your help, we can protect our patients, ourselves, our co-workers, and community from infection.