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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.
AUSTRALIAN GUIDELINES FOR THE PREVENTION AND CONTROL OF INFECTION IN HEALTHCARE – EXECUTIVE SUMMARY
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.
AUSTRALIAN GUIDELINES FOR THE PREVENTION AND CONTROL OF INFECTION IN HEALTHCARE – EXECUTIVE SUMMARY
Executive summary
NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL 3
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.
AUSTRALIAN GUIDELINES FOR THE PREVENTION AND CONTROL OF INFECTION IN HEALTHCARE – EXECUTIVE SUMMARY
Executive summary
4 NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL
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
B3.3 Putting it into practice
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
B4.4 Putting it into practice
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
AUSTRALIAN GUIDELINES FOR THE PREVENTION AND CONTROL OF INFECTION IN HEALTHCARE – EXECUTIVE SUMMARY
Summary of recommendations
NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL 5
■ 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.
AUSTRALIAN GUIDELINES FOR THE PREVENTION AND CONTROL OF INFECTION IN HEALTHCARE – EXECUTIVE SUMMARY
Summary of recommendations
6 NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL
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.
Exceptions to this should be justified by risk assessment.
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.
AUSTRALIAN GUIDELINES FOR THE PREVENTION AND CONTROL OF INFECTION IN HEALTHCARE – EXECUTIVE SUMMARY
Summary of recommendations
NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL 7
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.
Exceptions to this should be justified by risk assessment.
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)
AUSTRALIAN GUIDELINES FOR THE PREVENTION AND CONTROL OF INFECTION IN HEALTHCARE – EXECUTIVE SUMMARY
Putting it into practice
NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL 9
■ 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
If splash risk likely
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
— —
If splash risk likely
—
Intravascular access device insertion
—
(Where max. barrier precautions are used)
Intravascular access device care
— — — —
AUSTRALIAN GUIDELINES FOR THE PREVENTION AND CONTROL OF INFECTION IN HEALTHCARE – EXECUTIVE SUMMARY
Putting it into practice
10 NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL
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
If exposure risk likely
If exposure risk likely
Urinary catheter care — —
When emptying drainage
bag
If exposure risk likely
Suctioning: endotracheal tube, tracheostomy
—
Dominant hand (open
suction system)
If exposure risk likely
Major dental procedures*
Routine intra-oral dental procedures
—
If exposure risk likely
* Including most dental implants, surgical removal or exposure of completely impacted teeth or tooth fragments, vital
endodontics, surgical periodontics, maxillo-facial surgery.
AUSTRALIAN GUIDELINES FOR THE PREVENTION AND CONTROL OF INFECTION IN HEALTHCARE – EXECUTIVE SUMMARY
Putting it into practice
NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL 11
Tabl
e 5:
App
licat
ion
of s
tand
ard
and
tran
smis
sion
-bas
ed p
reca
utio
ns
Type
of
prec
auti
ons
E
xam
ples
ofi
nfec
tio
usa
gent
sS
ingl
ero
om
or
coho
rtG
love
sG
own
Mas
kE
ye
pro
tect
ion
Han
dlin
go
feq
uipm
ent
Vis
ito
rs*
Sta
ndar
dSt
anda
rd p
reca
utio
ns a
pply
for
all w
ork
prac
tices
to
prev
ent
the
likel
ihoo
d of
tra
nsm
issio
n of
infe
ctio
n.
Han
d hy
gien
e
Resp
irato
ry h
ygie
ne
and
coug
h et
ique
tte
Co
ntac
tM
ROs,
C. d
iffici
le, i
ntes
tinal
tra
ct
path
ogen
s (e
.g. n
orov
irus)
, hig
hly
cont
agio
us s
kin
infe
ctio
ns
♣
Sing
le u
se o
r re
proc
ess
befo
re
reus
e on
nex
t pa
tient
Sam
e pr
ecau
tions
as
staf
f
Dro
plet
Influ
enza
, RSV
, nor
oviru
s, pe
rtus
sis
(who
opin
g co
ugh)
, men
ingo
cocc
us
Su
rgic
al
mas
k
Sing
le u
se o
r re
proc
ess
befo
re
reus
e on
nex
t pa
tient
Rest
rict
visit
or
num
bers
and
pr
ecau
tions
as
for
staf
f
Air
born
ePu
lmon
ary T
B, c
hick
enpo
x (v
aric
ella
)#,
mea
sles
(rub
eola
)#, S
ARS
,
N
egat
ive
pres
sure
P2
(N
95)
resp
irato
r
Sing
le u
se o
r re
proc
ess
befo
re
reus
e on
nex
t pa
tient
Rest
rict
visit
or
num
bers
and
pr
ecau
tions
as
for
staf
f
Note
s:
Ess
entia
l co
mponen
t of tran
smis
sion-b
ased
pre
cautio
ns
♣ su
rgic
al m
ask
required
if in
fect
ious
agen
t is
ola
ted in s
putu
m
A
s re
quired
— G
love
s to
be
worn
when
ever
ther
e is
the
pote
ntia
l of direc
t or
indirec
t co
nta
ct w
ith b
lood o
r body
subst
ance
s
G
ow
ns
to b
e w
orn
for
pro
cedure
s w
hen
ther
e is
the
pote
ntia
l of direc
t or
indirec
t co
nta
ct to b
ody
subst
ance
s
Fa
ce a
nd e
ye p
rote
ctio
n to b
e w
orn
when
ther
e is
the
pote
ntia
l of ex
posu
re to s
pla
shes
or
spra
ys to m
uco
sa (
incl
udin
g during
aero
sol-ge
ner
atin
g pro
cedure
s)
*
Vis
itors
should
be
give
n inst
ruct
ion a
bout co
rrec
t pro
cedure
s w
hen
tra
nsm
issi
on-b
ased
pre
cautio
ns
are
applie
d a
nd g
iven
appro
priat
e re
sourc
es to s
upport them
in m
eetin
g th
ese
requirem
ents
.
# If s
taff o
r vi
sito
r H
AVE H
AD
chic
kenpox
/ m
easl
es in the
pas
t or
vacc
inat
ion for
thes
e dis
ease
s, m
ask,
gow
n a
nd g
love
s ar
e not re
quired
Envi
ronm
enta
l cl
eanin
g h
as n
ot bee
n a
ddre
ssed
in this
tab
le b
ut it
is a
n e
ssen
tial co
mponen
t of in
fect
ion p
reve
ntio
n a
nd c
ontrol.
Sourc
e: A
dap
ted fro
m T
he
Can
ber
ra H
osp
ital I
npa
tien
t Is
ola
tion
Gu
idel
ines
Notes
Notes
Notes