© australian government 2010 - nhmrc · a2.1 risk-management basics a2.2 risk-management process...

© Australian Government 2010

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The evidence has been drawn from the Australian Guidelines for the Prevention and Control of Infection in Health Care (2010). For more information on the guideline visit www.nhmrc.gov.au.

Infection Control Guidelines Steering Committee The production of the Guidelines required considerable effort over a long period. Special thanks and acknowledgment are due to the Infection Control Guidelines Steering Committee members for their generous donation of time, their technical advice and ongoing commitment to the project.

Dr Ann Koehler (Chair)Prof Chris BaggoleyClinical Prof Keryn ChristiansenDr Liz CoatesProfessor Peter CollignonDr Celia CooperDr Nick DemediukMs Sylvia GandossiA/Prof Tom GottliebMr Brett MitchellAssoc Prof Peter MorrisMs Claire Boardman

AUSTRALIAN GUIDELINES FOR THE PREVENTION AND CONTROL OF INFECTION IN HEALTHCARE – EXECUTIVE SUMMARY

Executive summary

NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL 1

■ Executive Summary

Effective infection prevention and control is central to providing high quality health care for patients and a safe working environment for those that work in healthcare settings.

Healthcare-associated infection is preventableThere are around 200,000 healthcare-associated infections (HAIs) in Australian acute healthcare facilities each year.1 This makes HAIs the most common complication affecting patients in hospital. As well as causing unnecessary pain and suffering for patients and their families, these adverse events prolong hospital stays and are costly to the health system. The problem does not just affect patients and workers in hospitals—HAIs can occur in any healthcare setting, including office-based practices (e.g. general practice clinics, dental clinics) and long-term care facilities. Any person working in or entering a healthcare facility is at risk. However, healthcare-associated infection is a potentially preventable adverse event rather than an unpredictable complication. It is possible to significantly reduce the rate of HAIs through effective infection prevention and control.

Infection prevention and control is everybody’s business Understanding the modes of transmission of infectious organisms and knowing how and when to apply the basic principles of infection prevention and control is critical to the success of an infection control program. This responsibility applies to everybody working and visiting a healthcare facility, including administrators, staff, patients and carers.

Successful approaches for preventing and reducing harms arising from HAIs involve applying a risk-management framework to manage ‘human’ and ‘system’ factors associated with the transmission of infectious agents. This approach ensures that infectious agents, whether common (e.g. gastrointestinal viruses) or evolving (e.g. influenza or multi-resistant organisms [MROs]), can be managed effectively.

Development of the guidelinesAs part of the Australian Commission on Safety and Quality in Health Care’s (ACSQHC) HAIs priority program, the National Health and Medical Research Council (NHMRC) was asked to develop national guidelines that would provide a coordinated approach to the prevention and management of HAI. The NHMRC appointed an expert group to guide the development process. The guidelines are based on the best available evidence. They build on existing guidelines and reviews, as well as systematic reviews of the evidence.

AimBy assisting healthcare workers to improve the quality of the care they deliver, these guidelines aim to promote and facilitate the overall goal of infection prevention and control:

The creation of safe healthcare environments through the implementation of practices that minimise the risk of transmission of infectious agents.

1 Cruickshank M & Ferguson J (eds) (2008) Reducing Harm to patients from Health care Associated Infection: The Role of Surveillance. Australian Commission for Safety and Quality in Health Care. p3.


Executive summary

2 NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL

ScopeThe scope of these guidelines was established, following an initial period of consultation that included forums involving a wide range of stakeholders.

The guidelines were developed to establish a nationally accepted approach to infection prevention and control, focusing on core principles and priority areas for action. They provide a basis for healthcare workers and healthcare facilities to develop detailed protocols and processes for infection prevention and control specific to local settings.

This approach is underpinned by a risk-management framework to ensure the basic principles of infection prevention and control can be applied to a wide range of healthcare settings including office-based practice, long-term care facilities, remote area health services, home and community nursing and emergency services.

The evidence base for the guidelines addresses the highest level of risk of infection transmission in the healthcare setting, and has predominantly been drawn from the acute-care setting. However, case studies giving examples of risk assessments have been included to help illustrate how these recommendations can be applied to other settings.

Supporting documents have been developed for healthcare workers, patients and health facility managers to assist with implementation of the guidelines. These materials will be available on the NHMRC website.

The guidelines make reference to but do not include detailed information on:

• infectious diseases

• pandemic planning

• the reprocessing of reusable medical instruments or devices

• occupational health and safety

• hospital hotel services such as food services, laundry services or waste disposal

or

• engineering/health facility design.

The guidelines do not duplicate information provided in existing Australian Standards but refer to specific standards wherever relevant.

Target audienceThe guidelines are for use by all those working in healthcare—this includes healthcare workers, management and support staff.

Evidence base These guidelines are based on the best available evidence and knowledge of the practicalities of clinical procedures. They draw from other work in this area, including the two previous national infection control guidelines2, international infection control guidelines, systematic literature reviews conducted to inform the development of these guidelines, work on HAI prevention from ACSQHC, national discipline-based infection control guidelines, and Australian Standards relevant to infection prevention and control. Australian data are used wherever available.

2 CDNA (2004) Infection Control Guidelines for the Prevention of Transmission of Infectious Disease in the Health Care Setting. Communicable Diseases Network of Australia.

NHMRC (1996) Infection Control in the Healthcare Setting. Guidelines for the Prevention of Transmission of Infectious Diseases. National Health and Medical Research Council. Rescinded.


Executive summary


Structure of the guidelinesThese guidelines are based around the following core principles:

• an understanding of the modes of transmission of infectious agents and of risk management

• effective work practices that minimise the risk of transmission of infectious agents

• governance structures that support the implementation, monitoring and reporting of infection prevention and control work practices

• compliance with legislation, regulations and standards relevant to infection control.

The parts of the document are based on these core principles and are organised according to the likely readership.

Part A presents background information that should be read by everyone working in health care (for example as orientation or as part of annual review)—this includes important basics of infection prevention and control, such as the main modes of transmission of infectious agents and the application of risk-management principles. This part of the guidelines does not include recommendations.

Part B is specific to the practice of healthcare workers and support staff, and outlines effective work practices that minimise the risk of transmission of infectious agents. Recommendations are given in Sections B1 to B3. Each section includes advice on putting the recommendations into practice, a risk-management case study and resources.

Section B1 describes standard precautions used at all times to minimise the risk of transmission of infectious agents.

Section B2 outlines transmission-based precautions to guide staff in the presence of suspected or known infectious agents that represent an increased risk of transmission.

Section B3 outlines approaches to the management of multi-resistant organisms (MROs) or outbreak situations.

Section B4 outlines processes for risk identification and the application of standard and transmission-based precautions for certain procedures.

Section B5 includes supplementary information to assist in the application of standard and transmission-based precautions.

Part C describes the responsibilities of management of healthcare facilities, including governance structures that support the implementation, monitoring and reporting of effective work practices. The chapters outline the main components of a systems approach to facility-wide infection prevention and control, giving guidance on management and staff responsibilities, protection of healthcare workers, requirements for education and training of all staff, considerations for facility design and renovation, and other important activities such as surveillance and antibiotic stewardship.

Legislation, regulations and standards relevant to infection prevention and control are listed at the end of each section before the references.


Executive summary


Table 3: Overview of the Guideline

Modes of transmission of infectious

Effective work practices that minimise the risk of transmission of infectious agents

Govenance structures that support implementation, monitoring and reporting of infection prevention and control practices

PART A PART B PART C

Basics of Infection prevention and control Standard and transmission-based precautions Organisational support

A1 Infection prevention and control in the healthcare setting

A1.1 Risks of contracting a healthcare-associated infection

A1.2 Standard and transmission-based precautions

A2 Overview of risk management in infection prevention and control

A2.1 Risk-management basics

A2.2 Risk-management process

A3 A patient-centred approach

A3.1 Patient-centred health care

A3.2 How does patient-centred care relate to infection prevention and control?

B1 Standard precautions

B1.1 Hand hygiene

B1.2 Personal protective equipment

B1.3 Handling and disposing of sharps

B1.4 Routine management of the physical environment

B1.5 Reprocessing of reusable instruments and equipment

B1.6 Respiratory hygiene and cough etiquette

B1.7 Aseptic technique

B1.8 Waste management

B1.9 Handling of linen

B2 Transmission-based precautions

B2.1 Application of transmission-based precautions

B2.2 Contact precautions

B2.3 Droplet precautions

B2.4 Airborne precautions

B2.5 Putting it into practice

B2.6 Resources

B2.7 References

B3 Management of multi-resistant organisms and outbreak situations

B3.1 Management of multi-resistant organisms

B3.2 Outbreak investigation and management


B3.4 Resources

B3.5 References

B4 Applying standard and transmission-based precautions during procedures

B4.1 Taking a risk-management approach to procedures

B4.2 Therapeutic devices

B4.3 Surgical procedures


B4.5 Resources

B4.6 References

C1 Management and clinical governance

C1.1 Clinical governance in infection prevention and control

C1.2 Roles and responsibilities

C1.3 Infection prevention and control program

C1.4 Risk management

C1.5 Taking an organisational systems approach to infection prevention quality and safety

C2 Staff health and safety

C2.1 Roles and responsibilities

C2.2 Health status screening and immunisation

C2.3 Exclusion periods for healthcare workers with acute infection

C2.4 Healthcare workers with specific circumstances

C2.5 Exposure-prone procedures

C2.6 Occupational hazards for healthcare workers

C3 Education and training

C3.1 Universities and training colleges

C3.2 Healthcare worker education

C3.3 Education strategies

C3.4 Example of education in practice — hand hygiene

C3.5 Patient engagement

C3.6 Compliance and accreditation

C4 Healthcare-associated infection surveillance

C4.1 Role of surveillance in reducing HAI

C4.2 Types of surveillance programs

C4.3 Data collection and management

C4.4 Outbreak surveillance

C4.5 Disease surveillance in office-based practice

C4.6 Notifiable diseases

C5 Antibiotic stewardship

C5.1 Background

C5.2 Antibiotic stewardship programs

C5.3 Antibiotic stewardship surveillance methods

C6 Influence of facility design on healthcare-associated infection

C6.1 Facility design and its impact on infection prevention and control

C6.2 Mechanisms for influencing healthcare-associated infection through environmental design

C6.3 The benefits of single-bed rooms for patient isolation

Legislation, regulations and standards relevant to infection prevention and control

B1.1 Hand hygiene

B1.2.9 PPE

B1.3.6 Sharps

B1.6.4 Waste and linen handling

B2.6 Transmission-based precautions

B3.4 MROs and outbreaks

B4.5 Procedures

B5 Supplementary information

C7 Resources for organisations


Summary of recommendations


■ Summary of recommendations

These guidelines provide recommendations that outline the critical aspects of infection prevention and control. The recommendations were developed using the best available evidence and consensus methods by the Infection Control Steering Committee. They have been prioritised as key areas to prevent and control infection in a healthcare facility. It is recognised that the level of risk may differ according to the different types of facility and therefore some recommendations should be justified by risk assessment. When implementing these recommendations all healthcare facilities need to consider the risk of transmission of infection and implement according to their specific setting and circumstances.

The recommendations should be read in the context of the evidence base. This is discussed in Sections B1, B2 and B3 of the guidelines, which also include advice on the practical application of the recommendations.

Recommendation

Standard precautions (see Section B1)

Hand hygiene

1 Routinehandhygiene

Hand hygiene must be performed before and after every episode of patient contact.

This includes:

• before touching a patient

• before a procedure

• after a procedure or body substance exposure risk

• after touching a patient

• after touching a patient’s surroundings.

Hand hygiene must also be performed after the removal of gloves.

2 Choiceofproductforroutinehandhygienepractices

For all routine hand hygiene practices in healthcare settings, use alcohol-based hand rubs that:

• contain between 60% and 80% v/v ethanol or equivalent

• meet the requirements of EN1500.

3 Choiceofhandhygieneproductwhenhandsarevisiblysoiled

If hands are visibly soiled, hand hygiene should be performed using soap and water.

4 HandhygieneforClostridiumdifficileandnon-envelopedviruses

Hand hygiene should be performed using soap and water when Clostridium difficile or non-enveloped viruses such as norovirus are known or suspected to be present and gloves have not been worn. After washing, hands should be dried thoroughly with single-use towels.

Personal protective equipment

5 Wearingofaprons/gowns

Aprons or gowns should be appropriate to the task being undertaken. They should be worn for a single procedure or episode of patient care and removed in the area where the episode of care takes place.

6 Useoffaceandprotectiveeyewearforprocedures

A surgical mask and protective eyewear must be worn during procedures that generate splashes or sprays of blood, body substances, secretions or excretions into the face and eyes.




Recommendation

7 Wearingofgloves

Gloves must be worn as a single-use item for :

• each invasive procedure

• contact with sterile sites and non-intact skin or mucous membranes

• any activity that has been assessed as carrying a risk of exposure to blood, body substances, secretions and excretions.

Gloves must be changed between patients and after every episode of individual patient care.

8 Sterilegloves

Sterile gloves must be used for aseptic procedures and contact with sterile sites.

Handling and disposal of sharps

9 Safehandlingofsharps

Sharps must not be passed directly from hand to hand and handling should be kept to a minimum.

Needles must not be recapped, bent or broken after use.

10 Disposalofsingle-usesharps

The person who has used the single-use sharp must be responsible for its immediate safe disposal. Used disposable sharps must be discarded into an approved sharps container at the point-of-use. These must not be filled above the mark that indicates the bin is three-quarters full.

Routine environmental cleaning

11 Routinecleaningofsurfaces

Clean frequently touched surfaces with detergent solution at least daily, and when visibly soiled and after every known contamination.

Clean general surfaces and fittings when visibly soiled and immediately after spillage.

12 Cleaningofsharedclinicalequipment

Clean touched surfaces of shared clinical equipment between patient uses, with detergent solution.

Exceptions to this should be justified by risk assessment.

13 Surfacebarriers

Use surface barriers to protect clinical surfaces (including equipment) that are:

• touched frequently with gloved hands during the delivery of patient care

• likely to become contaminated with blood or body substances

• difficult to clean.


14 Sitedecontaminationafterspillsofbloodorotherpotentiallyinfectiousmaterials

Spills of blood or other potentially infectious materials should be promptly cleaned as follows:

• wear utility gloves and other PPE appropriate to the task;

• confine and contain spill, clean visible matter with disposable absorbent material and discard the used cleaning materials in the appropriate waste container

• clean the spill area with a cloth or paper towels using detergent solution.

Use of chemical disinfectants such as sodium hypochlorite should be based on assessment of risk of transmission of infectious agents from that spill.




Recommendation

Transmission-based precautions (see Section B2)

Contact precautions

15 Implementationofcontactprecautions

In addition to standard precautions, implement contact precautions in the presence of known or suspected infectious agents that are spread by direct or indirect contact with the patient or the patient’s environment.

16 Handhygieneandpersonalprotectiveequipmenttopreventcontacttransmission

When working with patients who require contact precautions:

• perform hand hygiene

• put on gloves and gown upon entry to the patient-care area

• ensure that clothing and skin do not contact potentially contaminated environmental surfaces

• remove gown and gloves and perform hand hygiene before leaving the patient-care area.

17 Patient-careequipmentforpatientsoncontactprecautions

Use patient-dedicated equipment or single-use non-critical patient-care equipment.

If common use of equipment for multiple patients is unavoidable, clean the equipment and allow it to dry before use on another patient.

Droplet precautions

18 Implementationofdropletprecautions

In addition to standard precautions, implement droplet precautions for patients known or suspected to be infected with agents transmitted by respiratory droplets that are generated by a patient when coughing, sneezing or talking.

19 Personalprotectiveequipmenttopreventdroplettransmission

When entering the patient-care environment, put on a surgical mask.

20 Placementofpatientsrequiringdropletprecautions

Place patients who require droplet precautions in a single-patient room.

Airborne precautions

21 Implementationofairborneprecautions

In addition to standard precautions, implement airborne precautions for patients known or suspected to be infected with infectious agents transmitted person-to-person by the airborne route.

22 Personalprotectiveequipmenttopreventairbornetransmission

Wear a correctly fitted P2 respirator when entering the patient-care area when an airborne-transmissible infectious agent is known or suspected to be present.

23 Placementofpatientsrequiringairborneprecautions

Patients on airborne precautions should be placed in a negative pressure room or in a room from which the air does not circulate to other areas.


24 ImplementationofcorestrategiesinthecontrolofMROs(MRSA,MRGN,VRE)

Implement transmission-based precautions for all patients colonised or infected with a multi-resistant organism, including:

• performing hand hygiene and putting on gloves and gowns before entering the patient-care area

• using patient-dedicated or single-use non-critical patient-care equipment

• using a single-patient room or, if unavailable, cohorting patients with the same strain of multi-resistant organism in designated patient-care areas

• ensuring consistent cleaning and disinfection of surfaces in close proximity to the patient and those likely to be touched by the patient and healthcare workers.

Recommendation

Multi-resistant organisms (MROs) (see Section B3)


Putting it into practice


■ Putting it into practice

Checklist of standard precautions for proceduresThis table outlines the use of standard precautions for a range of procedures. It is assumed that there is no known or suspected infection. Decision-making about the level of protection required involves a risk assessment of the procedure to be performed; for example, usual wound irrigation is unlikely to require surgical mask and eye protection in primary care, but may be required more often in the hospital setting.

Table 4: Checklist of standard precautions for procedures

Procedure Hand hygiene

Gloves Sterile gloves

Surgical mask

Eye protection

Gown

Activities of daily living (washing, toilet etc)

— — — — —

Routine observations (e.g. blood pressure measurement)

— — — — —

General medical examination

For contact with broken skin/ rash/ mucous

membrane

—

If splash risk likely



Wound examination/dressing

For contact with body substances

For direct contact

with wound

For wound irrigation if splash likely

For wound irrigation if splash likely

For grossly infected wounds

Blood glucose and haemoglobin monitoring

— — — —

Vaginal delivery — —

Intravenous cannula insertion

— —


—

Intravascular access device insertion

—

(Where max. barrier precautions are used)

Intravascular access device care

— — — —




Procedure Hand hygiene

Gloves Sterile gloves

Surgical mask

Eye protection

Gown

Surgical aseptic technique procedure (e.g. lumbar puncture)

—

Insertion of urinary catheter

—

If exposure risk likely



Urinary catheter care — —

When emptying drainage

bag


Suctioning: endotracheal tube, tracheostomy

—

Dominant hand (open

suction system)


Major dental procedures*

Routine intra-oral dental procedures

—


* Including most dental implants, surgical removal or exposure of completely impacted teeth or tooth fragments, vital

endodontics, surgical periodontics, maxillo-facial surgery.




Tabl

e 5:

App

licat

ion

of s

tand

ard

and

tran

smis

sion

-bas

ed p

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ns

Type

of

prec

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Han

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ent

Vis

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utio

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pply

for

all w

ork

prac

tices

to

prev

ent

the

likel

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d of

tra

nsm

issio

n of

infe

ctio

n.

Han

d hy

gien

e

Resp

irato

ry h

ygie

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and

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Co

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C. d

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kin

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Rest

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visit

or

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as

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staf

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Air

born

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B, c

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num

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Note

s:

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smis

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ased

pre

cautio

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♣ su

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ask

required

if in

fect

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agen

t is

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ted in s

putu

m

A

s re

quired

— G

love

s to

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when

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the

pote

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for

pro

cedure

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Fa

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when

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the

pote

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pla

shes

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incl

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aero

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*

Vis

itors

should

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give

n inst

ruct

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bout co

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cedure

s w

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tra

nsm

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on-b

ased

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cautio

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are

applie

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sourc

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upport them

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g th

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requirem

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ssen

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idel

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