vsnf workgroup to prevent mdro kick-off workshop document... · 2020-04-17 ·...

HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM

Healthcare-Associated Infections ProgramCenter for Health Care Quality

California Department of Public Health

vSNF Workgroupto Prevent MDROKick-off Workshop

April 3, 2020

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Agenda12-12:05PM Welcome and Project Overview

12:05-12:40PM The Importance of Hand Hygiene12:40-1:20PM The Role of the Environment in Infection Prevention

1:20-1:50PM Personal Protective Equipment and Precautions1:50-2:15PM COVID-19: Guidance for Skilled Nursing Facilities2:15-2:30PM Next Steps

• Onsite Assessment: Overview & Adherence Monitoring Tools• Quality Improvement Project: Workbook, Materials, and Tools

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Workgroup Overview

• Medical device and antibiotic use in vSNF predispose patients to multi-drug resistant organism (MDRO) transmission and infections.

• C. auris outbreak highlights the need for a proactive approach to preventing emergence and spread of MDRO in vSNF.

• MDRO spread can be prevented by basic infection prevention practices of hand hygiene and environmental cleaning and disinfection.

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Participants

• vSNF

• Local public health

• Healthcare-Associated Infections (HAI) Program

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Partnership Goals

• Improve hand hygiene and environmental cleaning and disinfection in vSNF

• Quality improvement (QI) project that includes adherence monitoring

• Observe a measurable improvement in adherence to hand hygiene and environmental cleaning and disinfection practices

• Increase awareness and knowledge of MDRO in vSNF

• Build relationships among local health departments and local vSNF

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Workshop 1 Background• Although the action of hand hygiene is simple, lack of adherence among healthcare

workers (HCW) continues to be a problem.

• Ensuring a clean environment of care requires all HCW to take responsibility for cleaning the environment and patient care items, but this shared responsibility is often overlooked.

• Multiple evidence-based guidelines exist to support facilities with improving these practices:

• Ensuring adequate infrastructure

• Enhancing knowledge and perception among HCW

• Monitoring adherence

• Providing performance feedback

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Workshop 1 and COVID-19

• Personal protective equipment and precautions• CDPH resources:

– Webinar: COVID-19 Guidance for Skilled Nursing Facilities (PDF) (https://www.cdph.ca.gov/Programs/CHCQ/HAI/CDPH%20Document%20Library/COVID.19_GuidanceFor_SNF_HAI%20WebinarFINAL_03.13.20.pdf)

– AFL 20-25: Preparing for Coronavirus Disease 2019 (COVD-19) in California Skilled Nursing Facilities (https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-25.aspx)

– AFL 20-23: COVID-19 Health Care System Mitigation Playbook(https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-23.aspx)

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https://www.cdph.ca.gov/Programs/CHCQ/HAI/CDPH%20Document%20Library/COVID.19_GuidanceFor_SNF_HAI%20WebinarFINAL_03.13.20.pdf

https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-25.aspx



THE IMPORTANCE OF HAND HYGIENE

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Objectives

• Describe strategies to prevent MDRO, the most common infections in vSNF

• List the 5 moments of hand hygiene and discuss barriers to effective hand hygiene

• Describe the importance of hand hygiene and the correct hand hygiene techniques

• Describe key points of glove use and hand hygiene • Describe how to improve hand hygiene compliance

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Why Does Transmission Occur?

• Multifactorial– Systems and processes of healthcare provision– Human behavior conditioned by many factors,

including education• Hands of healthcare workers are the most common

mode of pathogen transmission

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Transmission of Healthcare-Associated Pathogens from One Patient to Another via Healthcare Workers’ Hands

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Hand Hygiene Terminology

• Hand hygiene includes: – Handwashing: Washing hands

with plain soap and water– Antiseptic hand wash: Washing

hands with water and soap containing an antiseptic agent

– Alcohol-based hand rub (ABHR): Rubbing hands with an alcohol-containing agent

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Transmission Can Occur via Healthcare Worker Hands

• Transmission is a way germs (such as viruses, bacteria, or other microbes) are moved from a person or object to another person.

• Germs don’t move themselves. Germs depend on people and the environment, including medical equipment, to move in healthcare settings.

• Healthcare worker hands are the most common way that germs are spread.

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Step 1: Germs on Patient Skin and Environment

• Germs are present on patients’ skin. Nearly 1 million dead skin flakes containing viable germs are shed daily from normal skin to a patient’s immediate surroundings such as the bed linen and furniture.

• Surrounding patient surfaces may be contaminated by a patient’s own germs or by other people’s germs and by inanimate objects.

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Step 2: Healthcare Worker Hand Contamination • By direct and indirect

contact, patient germs contaminate healthcare worker hands

• Healthcare worker hands become contaminated by touching germs present on patients, medical equipment, and high touch surfaces.

• Healthcare workers carry the germs on their hands and can spread germs when proper hand hygiene is not performed.

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Step 3: Germs Survive and Multiply on Healthcare Worker HandsWhen proper hand hygiene is not performed after contact with patients or their environment, germs can survive and increase in number on healthcare worker hands.

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Step 4: Hands Remain Contaminated if Hand Hygiene is Missed or Poorly Performed

• When hand hygiene opportunities are missed or when hand hygiene is performed poorly, hands remain contaminated with germs.

• Poor hand hygiene occurs when an insufficient amount of product is used or when there is an insufficient duration of hand hygiene action.

• Transient microorganisms are still recovered on hands following handwashing with soap and water, whereas handrubbing with an alcohol-based solution has been proven to be significantly more effective.

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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAMStep 5: Transmission from One Patient to Another via Healthcare Worker Hands

• Transmission occurs when healthcare workers with contaminated hands come in direct contact with another patient, or with an object that may come into direct contact with a patient.

• Touching invasive devices (for example, urinary catheters, IV lines, or respiratory tubes) with contaminated hands may cause infections.

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Determinants of Hand Hygiene Compliance

• Risk factors for poor compliance:– Morning and weekday shifts, being a physician, working in

intensive care• Main reasons for non-compliance reported by healthcare

workers:– Too busy/time constraints, skin irritation, glove use, don’t think

about it

• Other relevant obstacles in some settings:– Lack of sinks, soap, paper towels or ABHR at the point of care

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When to Hand Wash Versus Hand Rub

• Wash hands with soap and water when:– Hand are visibly soiled– Before and after eating– After toileting

• If hands are not visibly soiled, use an ABHR for routine decontamination of hands

• During outbreaks of certain pathogens (e.g., C.difficile infections, Norovirus) consider using only handwashing with soap and water

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Efficacy of Hand Hygiene Products

*less effective in presence of organic material

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Application Time of Hand Hygiene and Reduction of Bacterial Contamination

Pittet D and Boyce J. Lancet Infect Dis 2003;3:269-70.

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Indications for Hand Hygiene: “5 Moments” Before• Patient contact • Donning gloves • Accessing devices• Giving medicationAfter• Contact with a patient’s

skin and/or environment • Contact with body fluids or

excretions, non-intact skin, wound dressings

• Removing gloves

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Indications for Hand Hygiene Apply to Any Setting Where Healthcare Involving Direct Contact with Patients Takes Place

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Perform Hand Hygiene Before Touching a PatientClean your hands before touching a patient to protect them against harmful germs carried on your hands. Examples of direct contact include:• Shaking hands, stroking a child’s

forehead • Helping a patient move around or get

washed• Applying an oxygen mask, giving

physiotherapy• Taking pulse, blood pressure, chest

auscultation, abdominal palpation, recording ECG

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Perform Hand Hygiene Before Clean / Aseptic Procedures

Clean your hands before accessing critical sites to protect the patient against harmful germs.

Examples of clean/aseptic procedures include: • Brushing the patient's teeth, instilling eye

drops• Skin lesion care, wound dressing,

subcutaneous injection• Catheter insertion, opening a vascular access

system or a draining system, secretion aspiration

• Preparation of food, medication, pharmaceutical products, sterile material

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Perform Hand Hygiene After Body Fluid Exposure RiskClean your hands after body fluids exposure risk to protect yourself and the healthcare environment from harmful germs.Examples of body fluid exposure risk include: • Brushing the patient's teeth, instilling eye drops,

secretion aspiration• Skin lesion care, wound dressing, subcutaneous

injection• Drawing and manipulating any fluid sample,

opening a draining system, endotracheal tube insertion and removal

• Clearing up urine, feces, vomit; handling waste; cleaning of contaminated and visibly soiled material or areas

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Perform Hand Hygiene After Touching a Patient• Clean your hands after touching a

patient to protect yourself and the healthcare environment from harmful germs.

• Examples of direct contact include: • Shaking hands, stroking a child’s

forehead • Helping a patient move around or get

washed• Applying oxygen mask, giving

physiotherapy• Taking pulse, blood pressure, chest

auscultation• Abdominal palpation, recording ECG

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Perform Hand Hygiene After Touching Patient Surroundings

Clean your hands after touching any object or furniture in patient surroundings, even if you haven’t touched the patient.

Examples of contact with patient surroundings include:• Changing bed linen, with the patient out of

the bed• IV perfusion adjustment• Monitoring alarm • Holding a bed rail, leaning against the bed• Clearing the bedside table

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Correct Hand Hygiene Technique: How to Handrub

To effectively reduce the growth of germs on hands, handrubbing must be performed following all of the illustrated steps.This takes 20–30 seconds.

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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAMCorrect Hand Hygiene Technique: How to Handwash

To effectively reduce the growth of germs on hands, handwashing must last 40–60 seconds and should be performed following all of the illustrated steps.

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Nails

• Artificial nails and gel polishes should not be worn by healthcare workers

• Polish may be worn but must be intact (not chipped)

• Nail tips should be kept to ¼ inch in length

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Glove Use

• Always wear gloves when contact with blood or infectious material is possible

• Remove gloves after caring for each patient– Remove gloves, perform hand hygiene, and re-glove

when transitioning care from a soiled to a clean area • Do not wash gloves• Do not reuse gloves• Do not apply ABHR on gloves

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Hand Hygiene and Glove Use

• Glove use does not replace hand hygiene• Always perform hand hygiene before putting on and after taking off gloves• Gloves must be removed to perform hand hygiene as required, and

changed as needed

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How to Improve Hand Hygiene Compliance

• Make hand hygiene a facility priority– Educate staff about hand hygiene– Ensure competency– Encourage patients and families to remind healthcare workers to clean their

hands– Make handrubs easily available (e.g., place at entrance to patient room, at

bedside)

• Monitor adherence to hand hygiene and provide feedback to staff– Train/re-train secret shoppers – Explore electronic hand hygiene monitoring systems

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Adherence Monitoring Tool: Hand Hygiene

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Establish an Adherence Monitoring Program

• Include adherence monitoring in manager performance evaluations• Train all staff performing adherence monitoring using consistent

training materials• Make the Adherence Monitoring Program sustainable by

– Training staff from every department– Require pre-determined scheduled adherence monitoring– Feedback results to staff, leadership, and committees

• Validate the adherence monitoring program by having different departments periodically monitor each other

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Summary

• Hand hygiene reduces MDRO transmission and the incidence of healthcare-associated infections

• Remember your “5 Moments” of hand hygiene• Follow proper technique when performing hand

hygiene• Use ABHR as the preferred method of hand hygiene

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THE ROLE OF THE ENVIRONMENT IN INFECTION PREVENTION

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Objectives

• Describe the role of the environment in transmitting infections

• Discuss strategies to ensure effectiveness of cleaning and disinfection

• Identify determinants for low level disinfection• Review examples of non-critical devices• Demonstrate use of adherence monitoring tools and

feedback

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Role of Environmental Surfaces in Infection Transmission

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Transmission of Healthcare-Associated Pathogens from Contaminated Environmental Surfaces Leads to Patient Infection

The Inanimate Environment. , Bennett & Brachman’s Hospital Infections 6th Ed. 2014Chou. APIC Text of Infection Control & Epidemiology. 2013HICPAC /CDC Isolation Guidelines. 2007

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Multiple Factors Influence Duration of Survival

• Type of microbe• Temperature• Humidity

C.difficile spores are shed in high numbers, are resistant to desiccation and some disinfectants, and can live on surfaces for up to 5 months

Kramer et al. BMC Infect Dis. 2006

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Admission to a Room Previously Occupied by a Colonized or Infected Patient is a Significant Risk Factor for Infection

• C.difficile acquisition– 11% of patients admitted to an ICU room previously occupied by a

CDI patient developed CDI– 4.6% of patients admitted to a room without a prior CDI positive

occupant developed CDI• Other pathogens

– Patients have an average of a 120% increased risk of acquisition from prior infected room occupants

http://www.idse.net/download/HAI_IDSE13_WM.pdf Weber DJ et.al. AJIC 2013

Shaughnessy et al. Infect Contr Hosp Epidemiol. 2011

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Effective Cleaning Strategies

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Terminology• Cleaning is the removal of visible soil (e.g., organic

and inorganic material) from objects and surfaces. • Disinfection removes most germs present on

surfaces that can cause infection or disease.

Surfaces must be cleaned in order to be disinfected.

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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAMCleaning Process• Select PPE as required• Change gloves and perform

hand hygiene as required• Disinfect (or clean)

environmental surfaces on a regular basis (for example, daily, three times per week) and when surfaces are visibly soiled.

• Communicate issues to your supervisors

This materials is downloadable, free of charge. All may be adapted for use at your facility, except for the pre-recorded audio versions of module presentations” (https://apic.org/resources/topic-specific-infection-prevention/environmental-services/)

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https://apic.org/resources/topic-specific-infection-prevention/environmental-services/


Follow a Standard Process for Cleaning that Ensures Consistency and Prevents Contamination

• Work around the room in the same direction every time

• Start from the highest surfaces and work down

• Always move from clean areas to dirty areas, for example, clean the patient room first before the bathroom

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Perform at Least Daily Cleaning / Disinfection on Surfaces Likely to Be Contaminated (High Touch Surfaces)

• Include a list of high touch surfaces and equipment in your cleaning and disinfection policy.

• Examples of high touch surfaces include: Doorknobs or door handlesLight switchesBedpan cleanersBedrailCall bellTV remoteIV pumpComputer keyboardIV polesSee example list in CDC Environmental Cleaning Toolkit

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https://www.cdc.gov/hai/toolkits/Evaluating-Environmental-Cleaning.html


Everyone is Responsible for Environmental Cleaning and Disinfection• Everyone has a role in environmental

cleaning and disinfection. Make sure you know who is responsible for cleaning particular items in the patient room.

• Clean medical equipment and disinfect shared medical equipment after each patient use / prior to use with another resident.

• Ensure appropriate cleaning and disinfectant products are easily accessed at points of use.

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Use Cleaning Equipment in a Manner to Prevent Contamination

• Change cleaning cloths as needed• Use separate cleaning cloths for each

patient area in multi-bed rooms• Use separate cloths for bathroom and

patient’s room• Use the toilet brush to clean inside the

toilet bowl only• Clean and disinfect the cart and

equipment routinely and after cleaning isolation rooms

• Change gloves and perform hand hygiene as required

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Reduce Bioburden for Effective Cleaning• Clean visible soil in order for

disinfectant to be effective• Clean and disinfect high-

touch surfaces daily• Clean and disinfect rooms

thoroughly after discharge of patients

• Clean and disinfect portable equipment

• Follow proper cleaning and disinfection practices at all times

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Detergents and Disinfectants• Detergent

• Used for cleaning• Contains surfactants, lifts dirt• Can become easily contaminated; does not kill microorganisms• Less toxic, generally less odor, less costly than disinfectant

• Disinfectant• Inhibits growth or kills microorganisms• More toxic, more costly than detergent

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EPA Label Claim for Disinfectant• Clarifies manufacturer’s instructions for

use• Wet contact time is the time required for

a disinfectant to kill microorganisms on a pre-cleaned surface

• The EPA label claim states if the product is – Virucidal– Bactericidal– Tuberculocidal– Fungicidal– Sporicidal

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Disinfectant Selection55


Why Bleach for C. difficile?

• C. difficile spores are difficult to kill and adhere to environmental surfaces for extended periods

• Use of a 1:10 dilution of bleach (500 ppm) for cleaning – Reduces surface contamination – Instrumental in outbreak control

Note: Alternatives to bleach are available. For EPA-approved disinfectants with label claims for killing C. difficile spores(http://www.epa.gov/oppad001/chemregindex.htm)

Hota. CID. 2004.CDC. MMWR. Dec 19, 2003

Rutala et al. Clinical Micro

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http://www.epa.gov/oppad001/chemregindex.htm


Microfiber vs. Cotton • Microfiber is comprised of densely constructed

synthetic strands

• Microfiber cleans 50% better than comparable cotton• Attracts dust• Easier to use, lighter• Designed for repeat usage

• UC Davis study found microfiber was initially more expensive than cotton, but cleaned better, used less water and chemicals, and decreased labor costs.

UC Davis Case Study. Nov 2002; Trajtman. AJIC. 2015; Smith. J Hosp Infect. 2011; HICPAC/CDC 2008

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Cleaning Porous Surfaces

• Fabric– Vacuum regularly and re-cover when worn– Organic material and excess liquid should be extracted as much as

possible

• Carpets – Steam cleaning is recommended as appropriate– Allow to dry for 72 hours to prevent growth of fungi

• No epidemiological evidence to show that pathogens found on fabric are linked to increased risk of HAIs

MMWR. 2003Chou . APIC Text of Infection Control and Epidemiology. 2013

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Linen

• New laundry technologies allow linen washing without requirements for hot water and chlorines– Hot water: 160°F x 25 minutes– Cold water: 71-77°F with 125ppm chlorine bleach rinse – Detergents not required to have stated antimicrobial claims

• Follow manufacture’s instructions for use

CDC Guidelines for Environmental Infection Control in Health-Care Facilities (PDF)(https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf) Title 22, Division 5, Chapter 1, Article 8 §70825. Laundry Service(https://govt.westlaw.com/calregs/Document)

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https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf

https://govt.westlaw.com/calregs/Document


Bedside Curtains

• Bacteria and fungi can survive on polyester, cotton, wool, and other fabrics

• Privacy curtains are considered high-touch surfaces and can become rapidly contaminated especially when used in Transmission-based precautions isolation rooms

• Hands can become contaminated after handling curtains– Study found 50% of hands contaminated after handling curtains

Ohl et.al. Am J Infect Control. 2012https://www.inspq.qc.ca/pdf/publications/1729_NoticeRecommCINQ_DividCurtainsInfectRisk.pdfKoca et.al. Eurasian J Med. 2012

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https://www.inspq.qc.ca/pdf/publications/1729_NoticeRecommCINQ_DividCurtainsInfectRisk.pdf


Floors and Carpets• Non-carpeted floors

– Disinfection of floors offers no advantage over regular detergent and water cleaning

• Carpets– Evidence linking carpets to HAI rates is limited; no recommendation

against carpet use– Carpets have been shown to become contaminated– Vacuuming and steam cleaning temporarily reduces the number of

organisms

CDC. MMWR. June 6, 2003The Inanimate Environment, Bennett & Brachman’s Hospital Infections 6th Ed. 2014

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Effective Cleaning and Disinfection Programs

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Cleaning Responsibility• Define responsibility and frequency for cleaning and disinfecting patient

care equipment and surfaces (who cleans what list)• All personnel are responsible for cleaning the environment

• Nursing services• Environmental services• Physical therapy• Respiratory therapy

• Put individual responsibilities into policy; assign responsibilities with checklist

• All personnel must be oriented to proper cleaning methods

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Allotted Cleaning Times • Proper cleaning requires adequate time

– Daily cleaning can take 20-25 minutes per room– Terminal/deep cleaning will take 40-45 minutes or longer

• Create an individualized benchmark time for the facility based on time needed to expediently complete a checklist of items to be cleaned and disinfected– Input from front line staff is essential – Consider room size, amount of equipment, furniture and clutter that need

to be cleaned or cleaned around – Disseminate information to all nursing units

Increased time spent on terminal cleaning of patient rooms may not improve disinfection of high-touch surfaces.(http://www.ahe.org/ahe/learn/press_releases/2009/20090924_minimal_time_guidelines.html)

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http://www.ahe.org/ahe/learn/press_releases/2009/20090924_minimal_time_guidelines.html


Monitoring the Thoroughness of Cleaning

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How Do You Know a Patient Room is Clean?

• Appears visually clean or finger-swipe clean• Fast and inexpensive, but lacks objectivity

• Confirmed via technology• Fluorescence: Environmentally stable marker is visible to UV light if still

present after cleaning• Adenosine Triphosphate (ATP) monitoring: Measures residual organic

matter left on a surface after cleaning

Lillis. ATP Testing: A Proven Method to Measure Cleanliness. 2015(http://www.cdc.gov/hai/toolkits/Evaluating-Environmental-Cleaning.html)

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http://www.cdc.gov/hai/toolkits/Evaluating-Environmental-Cleaning.html


Monitoring Quality of Environmental Cleaning

• Develop an auditing & feedback program– Direct observation to evaluate use of

appropriate products and procedures– Evaluate consistency of cleaning by use of

fluorescent gel markings– Record and summarize data routinely (e.g.

monthly or quarterly)– Provide feedback to EVS/housekeeping staff

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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAMMonitoring Cleaning68


Monitoring Cleaning (continued)

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Does Monitoring Improve Cleaning? • In 36 hospitals, mean

percentage of high-risk objects cleaned:• 48% prior to

intervention• 78% after

intervention

Carling. ICHE. 2008

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Adherence Monitoring Tool: EnvironmentalCleaning andDisinfection

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Adherence Monitoring Tool: FluorescentMarker Assessment

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Slide 73

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Slide 74

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Adherence Monitoring Tool: Environmental Cleaning and DisinfectionResponsibilityAssessment

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Slide 76

CDPH HAI Program Environmental Cleaning(https://www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/EnvironmentalCleaning.aspx)

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https://www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/EnvironmentalCleaning.aspx

HEALTHCARE-ASSOCIATED INFECTIONS PROGRAMC. auris Cleaning and ManagementTraining Video

GNYHA C. Auris Cleaning and Management video(https://vimeo.com/350168460)

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https://vimeo.com/350168460


Summary

• A properly cleaned care environment is essential to prevent MDRO transmission and infections

• Follow a standard process that ensures consistency and prevents cross-contamination

• Clean/disinfect high-touch surfaces at least daily • Follow manufacturers’ instructions on the label including wet contact time for

proper use of disinfectant• All staff members have roles in ensuring a clean patient care environment

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Resources• Environmental Protection Agency Guide to Registered Disinfectants

Pesticide Registration (https://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants)

• CDC Guideline for Disinfection and Sterilization in Health Care Facilities (PDF) Disinfectants Cleaning, Sterilization (https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines.pdf)

• CDC Guidelines for Environmental Infection Control in Healthcare Facilities (PDF) Water, Air, Medical Waste, Pet Therapy, Construction (https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf)

• CDC Tool kit: Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings (PDF) (https://www.cdc.gov/legionella/downloads/toolkit.pdf)

• California Medical Waste Management Act (PDF) (https://cchealth.org/eh/solid-waste/pdf/medical_waste_management_act.pdf)

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https://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants

https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines.pdf

https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf

https://www.cdc.gov/legionella/downloads/toolkit.pdf

https://cchealth.org/eh/solid-waste/pdf/medical_waste_management_act.pdf


PERSONAL PROTECTIVE EQUIPMENT (PPE) AND PRECAUTIONS

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Objectives

• Review recommended personal protective equipment (PPE)

• Demonstrate safe donning and doffing sequences • Explain fit-testing for N95 respirators

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Key Points for Donning and Doffing PPE

• Don before contact with the patient, ideally just before entering the room

• Use carefully – avoid contamination • Remove and discard carefully, either at the doorway or

immediately outside patient room; remove respirator outside room

• Immediately perform hand hygiene

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Sequence for Donning PPE

Perform hand hygiene before donning PPE.1. Gown first2. Mask or respirator3. Goggles or face shield4. Gloves

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How to Don a Gown

• Select appropriate type and size• Opening is in the back• Secure at neck and waist• If gown is too small, use two gowns

– Gown #1 ties in front– Gown #2 ties in back

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How to Don a Mask

• Place over nose, mouth and chin• Fit flexible nose piece over nose bridge• Secure on head with ties or elastic• Adjust to fit

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How to Don a Respirator

• Select a fit tested respirator, preferably• Place over nose, mouth and chin• Fit flexible nose piece over nose bridge• Secure on head with elastic• Adjust to fit• Perform a fit check:

– Inhale – respirator should collapse– Exhale – check for leakage around

face

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How to Don Eye and Face Protection

• Position goggles over eyes and secure to the head using the ear pieces or headband

• Position face shield over face and secure on brow with headband

• Adjust to fit comfortably


How to Don Gloves• Don gloves last• Select correct type and size• Insert hands into gloves• Extend gloves over isolation gown cuffs


Use Safe PPE Practices

• Keep gloved hands away from face• Avoid touching or adjusting other PPE• Remove gloves if they become torn;

perform hand hygiene before donning new gloves

• Limit surfaces and items touched


Sequence for Removing PPE 1. Remove gloves*

• Perform hand hygiene2. Remove gown*

• Perform hand hygiene3. Remove face shield/ goggles

• Perform hand hygiene4. Remove mask or respirator

• Perform hand hygiene* Gown and gloves may be removed together.


Remove PPE in Appropriate Areas• At doorway, before leaving patient

room or in anteroom• Remove respirator outside room,

after door has been closed*

*Ensure hand hygiene supplies are available at the points needed, either a sink or alcohol-based hand rub

UCSF Health PPE Video(https://www.youtube.com/watch?v=-sBNxli21n0&feature=emb_title)

https://www.youtube.com/watch?v=-sBNxli21n0&feature=emb_title


Recognize the “Contaminated” and “Clean” areas of PPE

• Contaminated • PPE areas likely to have been in contact with body sites,

materials, or surfaces with infectious organisms• Includes the outside and front of PPE

• Clean • PPE areas that are not likely to have been in contact with

the infectious organism • Includes the inside and the outside back of PPE


How to Remove Gloves (Method 1)

• Step 1: Grasp outside edge near wrist• Step 2: Peel away from hand, turning glove inside-out• Step 3: Hold in opposite gloved hand

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How to Remove Gloves (Method 1), continued

• Step 4: Slide ungloved finger under the wrist of the remaining glove

• Step 5: Peel off from inside, creating a bag for both gloves

• Step 6: Discard

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How to Remove Gloves (Method 2 - Beak)• Step 1: Using one gloved hand, pinch and pull the base of the other gloved

hand.• Step 2: Use the middle finger to scoop the cuff of the glove. • Step 3: Pull the glove inside out over all the fingers and thumb to form a

“beak”


How to Remove Gloves (Method 2 - Beak), continued• Step 4: With the beaked hand, pinch the opposite glove at the base and pull the cuff.• Step 5: Roll the glove inside out and off the hand.• Step 6: With the ungloved hand, use the index finger to pull the beaked glove off at the

base of the beak and dispose into the appropriate waste container.

Always perform hand hygiene after glove removal.

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How to Remove Isolation Gown

• Unfasten ties• Peel gown away from neck and

shoulder• Turn contaminated outside

toward the inside• Fold or roll into a bundle• Discard• Perform hand hygiene


How to Remove Gown and Gloves Together

• With gloved hands, grasp gown in front

• Pull gown away from body so ties break

• Fold or roll into a bundle; peel off gloves at same time

• Discard• Perform hand hygiene


How to Remove Goggles or Face Shield

• Grasp ear or head pieces with ungloved hands

• Lift away from face• Place in designated

receptacle for reprocessing or disposal


How to Remove a Respirator

• Remove outside the room or in the ante-room• Lift the bottom elastic over your head first• Then lift off the top elastic• Discard

CDC PPE Sequence (PDF)(https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf)

https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf


How to Remove a Tied Facemask

• Remove at least 6 feet away from the patient, e.g. at the door

• Untie the bottom, then top, tie

• Remove from face• Discard


Perform Hand Hygiene After All PPE Removed

• Perform hand hygiene immediately after removing PPE and preferably after each step

• Use alcohol-based hand rub or wash with soap and waterException: If hands become visibly contaminated during PPE removal, wash hands with soap and water before continuing PPE removal


Respirator and Fit Testing

• Ensure designated HCP are fit tested to the N95 respirator available in the SNF; can be within the past year

• Conduct fit testing using OSHA-accepted fit test methods(https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134AppA)

• Fit-testing is one aspect of a respiratory protection program– CAL/OSHA will provide guidance for SNF to meet regulatory

requirements

103

https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134AppA


Adherence Monitoring Tool: Contact Precautions

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Summary

• Select and use the appropriate PPEs as required

• Educate all HCWs on donning and doffing process of personal protective equipment (PPE).

• This process should be done in a safe manner to avoid self and cross contamination.

• Perform hand hygiene before donning and after each step of PPE removal

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Resources

• Donning and Doffing PPE video (UCSF Health) (https://www.youtube.com/watch?v=-sBNxli21n0&feature=emb_title)

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https://www.youtube.com/watch?v=-sBNxli21n0&feature=emb_title


Covid-19 GUIDANCE FOR SKILLED NURSING FACILITIES

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Objectives

• Describe what SNF need to do to prepare for COVID-19 to– Prevent and detect the introduction of COVID-19 into facility– Prepare to receive and care for residents with COVID-19– Prevent transmission of COVID-19 within facility

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Situation Update

• World Health Organization (WHO) declared COVID-19 a global pandemic

• Community transmission of COVID-19 is occurring in California • Elderly SNF residents with chronic conditions at higher risk for severe

illness and death from COVID-19• Persons with COVID-19 who do not require acute care hospitalization

may need ongoing care and monitoring in SNF• SNF must prepare to safely care for individuals with suspected or

confirmed COVID-19

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Prevent and Detect the Introduction of COVID-19 into the Facility

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Slide 5


Risk of COVID-19 Introduction and Spread in Long-term Care Facilities

• COVID-19 may be spread between • Residents and visitors• Residents and HCP • Residents, HCP, and visitors

• Ill HCP and visitors are the most likely sources of introduction into the facility• Take action now before widespread community transmission • Implement visitor restrictions and enforce HCP sick leave policies


Restrict Visitors• Actively screen and restrict visitors with:

• Signs or symptoms of respiratory infection (such as fever, cough, shortness of breath, or sore throat)

• Known contact with a person with suspected or confirmed COVID-19 infection

• International travel within the last 14 days to China, Iran, South Korea, Italy, Japan or other geographic area of concern identified by CDC (https://wwwnc.cdc.gov/travel/notices)

• Post signs “Do not enter until you are screened by staff member” at facility entrance

CDPH All Facilities Letter 20-22 (https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-22.aspx)CMS Memo, March 9, 2020 (PDF) (https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf)

https://wwwnc.cdc.gov/travel/notices


https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf


In Lieu of Visits• Offer alternative means of communication for people who would

otherwise visit, such as virtual communications (phone or video-communication)

• Create/increase listserv communication to update families, such as advising not to visit

• Assign staff as primary contact to families for inbound calls, and conduct regular outbound calls to keep families up to date

• Offer a phone line with a voice recording updated at set times (such as daily) with the facility’s general operating status, such as when it is safe to resume visits


Educate Visitors if Allowed to Visit in Certain Situations

Instruct visitors to:• Perform hand hygiene at entry to the facility and before entering

into a resident’s room• Follow respiratory hygiene and cough etiquette

• Use recommended personal protective equipment (PPE) • Avoid touching surfaces as possible • Limit movement within the facility and avoid common areas

HEALTHCARE-ASSOCIATED INFECTIONS PROGRAMPost Visible Signs for Hand Hygiene and Cough Etiquette


Healthcare Personnel Should Not Report to Work if Feeling Ill

• HCP must report symptoms to their supervisor and the person who oversees occupational health at the facility

• HCP who develop fever or respiratory symptoms while at work should • Immediately put on a facemask • Inform their supervisor• Leave the workplace

• Sick leave policies should be non-punitive, flexible, and consistent with public health recommendations

• HCP are strongly encouraged to receive annual seasonal flu vaccine –it’s not too late

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Healthcare Personnel Exposure to a COVID-19 Patient

• If there is an exposure of an employee to a COVID-19 patient, the employee should self-monitor for symptoms of fever and a lower respiratory tract infection.

– If the employee does not have symptoms of fever or respiratory tract infection, the employee may continue to work.

– If the employee experiences any symptoms of fever and lower respiratory tract infection, they should be tested for influenza and COVID-19 and furloughed according to the same practices used for influenza during flu season.

– If the employee tests positive for COVID-19, follow guidance on criteria to determine when the employee may return to work.

AFL 20-23: COVID-19 Health Care System Mitigation Playbook(https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-23.aspx)

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Detect COVID-19 in your Facility

• Perform active frequent monitoring of residents and HCP to promptly identify • Residents with new or worsening respiratory symptoms • HCP with new-onset of respiratory symptoms in the setting of residents with

respiratory infection symptoms• Report clusters of symptomatic residents to local public health• Track suspect and confirmed respiratory infections using a line list (PDF)

(https://www.cdph.ca.gov/Programs/CHCQ/HAI/CDPH%20Document%20Library/RecommendationsForThePreventionAndControlOfInfluenzaNov2018_FINAL.pdf)

• Increase frequency of monitoring if widespread transmission is occurring in your community

Stay tuned to your local health department for updates.

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https://www.cdph.ca.gov/Programs/CHCQ/HAI/CDPH%20Document%20Library/RecommendationsForThePreventionAndControlOfInfluenzaNov2018_FINAL.pdf


Detect COVID-19 in your Facility• Perform active frequent monitoring of residents and HCP to promptly

identify • Residents with new or worsening respiratory symptoms • HCP with new-onset of respiratory symptoms in the setting of residents

with respiratory infection symptoms• Report clusters of symptomatic residents to local public health• Track suspect and confirmed respiratory infections using a line list (PDF)

(https://www.cdph.ca.gov/Programs/CHCQ/HAI/CDPH%20Document%20Library/RecommendationsForThePreventionAndControlOfInfluenzaNov2018_FINAL.pdf)

• Increase frequency of monitoring if widespread transmission is occurring in your community

Stay tuned to your local health department for updates.

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https://www.cdph.ca.gov/Programs/CHCQ/HAI/CDPH%20Document%20Library/RecommendationsForThePreventionAndControlOfInfluenzaNov2018_FINAL.pdf


Prepare to Receive and Care for Residents with Suspected or Confirmed COVID-19


Expansion of Complementary Non-Hospital-Based Care

• Long term care facilities may need to expand their role and accept additional patients who are discharged from the hospital but not yet able to go home.

• It is imperative that all health care providers, in all facility types, collaborate regionally to address any barriers to providing care and establish additional designated areas for care.


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Identify Space and Staff NOW

• Identify a separate area that can be used to cohort residents with confirmed COVID-19 infection such as on the same unit, wing, or building

• Identify a minimum number of HCP dedicated to care for residents with COVID-19 • Perform N95 respirator fit-testing for designated staff if not already

fit-tested• Educate healthcare personnel to use recommended PPE, including

proper donning and doffing PPE to avoid self contamination


Long Term Care Facilities Transfer / Readmit / Discharge Considerations

• Patients with confirmed or suspected COVID-19 should not be sent to a long term care facility via hospital discharge, inter-facility transfer, or readmission after hospitalization without first consulting the local public health department.

• As the pandemic progresses, it will be necessary to designate certain long term care facilities as receiver sites for those with confirmed or suspected COVID-19.


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Prepare Infection Control Supplies

• Increase access to hand hygiene • Place alcohol-based hand sanitizer (with >60% alcohol) in

• Resident rooms (ideally both inside and outside of room)• Care areas, such as therapy rooms • Common areas, such as just outside of dining hall

• Confirm all sinks are working and well-stocked with soap and paper towels for handwashing

• Acquire recommended personal protective equipment (PPE)• N95 respirators• Face shield or goggles for eye protection • Gowns and gloves• Facemasks


Prevent Transmission of COVID-19 Within the Facility


Patient Placement• Most SNF do not have airborne isolation rooms • Place resident with COVID-19 in single room or cohort with other

COVID-19 patients with the door closed • Cohort residents with confirmed COVID-19 infection on the same unit,

wing, or building – Patients with the same known respiratory disease/condition other

than COVID-19 may be cohorted with local IP/ID guidance.

– Patients confirmed with COVID-19 may be cohorted with local IP/ID guidance.

• Minimize the number of persons entering room

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Resident/Patient Movement

• Suspend large group activities and close communal dining areas• Restrict residents with fever or acute respiratory symptoms to their

room • When they must leave the room, such as for medical transport, the

resident should be provided with a facemask (if tolerated)• Notify facilities prior to transferring a resident with an acute

respiratory illness, including suspected or confirmed COVID-19, to a higher level of care

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Use Recommended PPE for COVID-19• Wear N95 respirator when collecting nasopharyngeal and oropharyngeal

swab specimens• For routine care, wear all recommended PPE, specifically

– Gown– Gloves– N-95 respirator whenever available* or facemask– Eye protection

*Use respirators based on availability; prioritize 1) fit-tested respirator, 2) respirator that has not been fit-tested, 3) expired respirator, 4) non-medical grade respirator. If no respirator is available, wear a facemask.CDC's PPE Optimization Strategies(https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html)

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https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html


Use Recommended PPE for COVID-19 (continued)

• Negative pressure rooms are not required for all suspect and confirmed COVID-19 patients but staff should at minimum take droplet precautions for any patients with respiratory symptoms while being evaluated and treated.

• Those escorting patients with respiratory symptoms or suspected to have COVID-19 do not need to wear a mask, if the patient is masked. If the patient is unable to wear a mask, staff must put on a mask while escorting. Staff must wear full PPE if in direct contact (touching or providing care) with patients during transport.


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Environmental/ Equipment Cleaning

• Limit the number of staff entering the room of resident with COVID-19 – Consider assigning staff nurse to do daily high-touch surface

cleaning• Follow routine environmental infection control procedures such as

waste management, laundry, food service, and environmental cleaning• Use dedicated medical equipment for patient care• For non-disposable medical equipment, clean and disinfect according

to manufacturer’s instructions, including contact times• All EPA-registered hospital-grade disinfectants can be used for COVID-

19

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Use Recommended PPE for Environmental Cleaning• Environmental services (EVS) should follow at minimum droplet and contact

precautions with eye protection while performing daily and discharge protocols for cleaning of rooms occupied by patients suspected or confirmed to have COVID-19.

• In general, rooms of discharged patients suspected or confirmed to have COVID- 19 on droplet precautions need not be closed for 1 hour prior to cleaning. The exception is negative pressure rooms used by patients suspected or confirmed to have COVID-19 on airborne precautions due to aerosol-generating procedures; these must be closed for at least 1 hour prior to cleaning. However, the room may be cleaned without waiting for 1 hour if EVS staff wear a properly fitted N95 respirator.

AFL 20-23: COVID-19 Health Care System Mitigation Playbookhttps://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-23.aspx

131



Resources

• For more information, see CDC guidance for nursing homes(https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-

facilities.html) March 10, 2020• For the most up-to-date infection control guidance for healthcare

facilities, visit CDC coronavirus website at (https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/index.html)

• See CDC for general long term care infection control training resources, (https://www.cdc.gov/longtermcare/)

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https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-facilities.html

https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/index.html

https://www.cdc.gov/longtermcare/


ONSITE ASSESSMENT: OVERVIEW & ADHERENCE MONITORING

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Periodic Onsite Infection Prevention Assessment

• 3 total; every 6-8 months

• Conducted at your facility alongside an HAI Program Liaison Infection Preventionist (IP) with participation of local public health and key staff from the participating vSNF

• The initial assessment will focus on IP program infrastructure and adherence monitoring of core infection prevention practices.

• Subsequent assessments will track progress from the previous assessment.

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Adherence Monitoring Tool: Hand Hygiene

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Adherence Monitoring Tool: EnvironmentalCleaning andDisinfection

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Adherence Monitoring Tool: FluorescentMarker Assessment

137


Adherence Monitoring Tool: Environmental Cleaning and DisinfectionResponsibilityAssessment

138


Adherence Monitoring Tool: Contact Precautions

139


Adherence Monitoring Program Checklist Initiate meeting for ongoing participation and supportInclude chief-level executives and multidisciplinary team members

Establish as a facility program Develop the facility Adherence Monitoring Program policyInclude all patient care departmentsDecide where and how often to be performedCompile adherence monitoring tools to be usedDecide how feedback of results will be delivered to staff

Develop formal training for staff performing adherence monitoring Hold a kick-off event to inform staff of program Develop a plan for feedback and remediation of identified practice gaps Develop a plan to celebrate successes

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QUALITY IMPROVEMENT PROJECT: WORKBOOK, MATERIALS, AND TOOLS

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QI Project Workbook

• Instructions and materials to plan and implement a QI project within your facility

• Guidance on how to measure outcomes

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Tools for Implementing a Quality Improvement Project

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Timeline (Sample)

Plan and track completion of each activity.

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Training and Education:Hand Hygiene Poster

145


Training and Education:Hand Hygiene Posters

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Training and Education: Staff Training Slides / Flipchart

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Providing Feedback

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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM149

Providing Feedback

HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM150

Providing Feedback, cont’d


Next Steps

Complete the post-workshop evaluation online

Ensure leadership approvals to participate

Schedule your onsite baseline assessment (Goal: complete by June 30, 2020)

Form team / identify key staff to help you implement your QI project

Access resources on vSNF Workgroup Webpage(https://www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/vSNF.aspx)

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https://www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/vSNF.aspx


Questions?

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CDPH HAI Program• Assessments/IP support: Zenith Khwaja, [email protected]• Assessments/IP support: Hosniyeh Bagheri, [email protected]• Project information: Erin Garcia, [email protected]

Local Health Department Partners• Long Beach: Nick LeFranc, [email protected]• Orange County: Kathryn O'Donnell, [email protected]• Riverside: Barbara Cole, [email protected]• San Bernardino: Erin Gustafson, [email protected]• San Diego: Grace Kang, [email protected]

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