icg draft 10jan10

8/2/2019 ICG Draft 10jan10

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AUSTRALIANGUIDELINESFORTHE

PREVENTIONANDCONTROLOF

INFECTIONINHEALTHCARE

CONSULTATIONDRAFT

7JANUARY 2010


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CONSULTATIONDRAFTJANUARY2010

Contents

2

Contents

Summaryofrecommendations.................................................................................................................... 7

Introduction .................................................................................................................................................. 13

PART A BASICS OF INFECTION CONTROL..................................... .................................................... .......................... 19

A1 Infectioncontrolinthehealthcaresetting...................................................................................... 20

A1.1 Risksofcontractingahealthcareassociatedinfection.......................................................... 20

A1.2 Standardandtransmissionbasedprecautions...................................................................... 22

A2 Overviewofriskmanagementininfectionpreventionandcontrol ......................................... 24

A2.1 Riskmanagementbasics ....................................................... .................................................... 24

A3 Apatientcentredapproach ........................................................... .................................................... 26

A3.1 Patientcentredhealthcare ....................................................................................................... 26

A3.2 Howdoespatientcentredcarerelatetoinfectioncontrol?.................................................. 26

PART B STANDARD AND TRANSMISSION-BASED PRECA UTIONS.......... ............................................ ................. ........ 28B1 Standardprecautions.......................................................................................................................... 29

B1.1 Handhygieneandcoughetiquette ......................................................................................... 30

B1.2 Personalprotectiveequipment ................................................................................................ 36

B1.3 Handlinganddisposingofsharps........................................................................................... 47

B1.4 Routinemanagementofthephysicalenvironment .............................................................. 51

B1.5 Processingofinstrumentsandequipment .................................................................. ........... 63

B2 Transmissionbasedprecautions...................................................................................................... 69

B2.1 Applicationof

transmission

based

precautions .................................................................... 70

B2.2 Contactprecautions .................................................. ............................................................ ..... 71

B2.3 Dropletprecautions .................................................. ............................................................ ..... 74

B2.4 Airborneprecautions................................................................................................................. 77

B2.5 Puttingitintopractice ......................................................... ...................................................... 80

B3 Managementofresistantorganismsandoutbreaksituations.................................................... 89

B3.1 Managementofmultiresistantorganisms............................................................................. 90

B3.2 Outbreakinvestigationandmanagement ..................................................................... ......... 99

B3.3 Puttingit

into

practice ......................................................... .................................................... 106

B4 applyingstandardandtransmissionbasedprecautionsduringprocedures......................... 107

B4.1 Takingariskmanagementapproachtoprocedures........................................................... 108

B4.2 Therapeuticdevices .............................................................. ................................................... 110

B4.3 Surgicalprocedures ............................................................ ..................................................... 121

B4.4 Puttingitintopractice ......................................................... .................................................... 125


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PART C ORGANISATIONAL SUPPORT.......................... .................................................... .......................................... 126

C1 Managementandclinicalgovernance .................................................. ......................................... 127

C1.1 Clinicalgovernanceininfectioncontrol ...................................................................... ......... 127

C1.2 Rolesandresponsibilities........................................................................................................ 129

C1.3 Infectionpreventionandcontrolprogram .............................................................. ............. 131

C1.4 Riskmanagement..................................................................................................................... 133

C1.5 Takinganorganisationalsystemsapproachtoriskmanagement .................................... 134

C2 Staffhealthandsafety...................................................................................................................... 136

C2.1 Rolesandresponsibilities........................................................................................................ 136

C2.2 Healthstatusscreeningandimmunisation.......................................................................... 137

C2.3 Exclusionperiodsforhealthcareworkerswithacuteinfections....................................... 138

C2.4 Healthcareworkerswithspecificcircumstances................................................................. 140

C2.5 Exposureproneprocedures ................................................................................................... 141

C2.6 Occupationalhazardsforhealthcareworkers ..................................................................... 142

C3 Educationandtraining ........................................................... .......................................................... 145

C3.1 Teachingfacilities..................................................................................................................... 145

C3.2 Healthcarefacilities.................................................................................................................. 147

C3.3 Educationstrategies................................................................................................................. 148

C3.4 Exampleofeducationinpracticehandhygiene............................................................. 148

C3.5 Complianceandaccreditation................................................................................................ 150

C3.6 Patientengagement.................................................................................................................. 150

C4 Healthcareassociatedinfectionsurveillance............................................................................... 152

C4.1 RoleofsurveillanceinreducingHAI.................................................................................... 152

C4.2 Typesofsurveillanceprograms............................................................................................. 153

C4.3 Datacollectionandmanagement........................................................................................... 154

C4.4 Outbreaksurveillance ............................................................................................................. 155

C4.5 Diseasesurveillanceinofficebasedpractice ....................................................................... 155

C4.6 Notifiablediseases .......................................................... ......................................................... 156

C5 Antibioticstewardship..................................................................................................................... 157

C5.1 Background............................................................................................................................... 157

C5.2 Antibioticstewardshipprograms.......................................................................................... 158

C5.3 Antibioticstewardshipsurveillancemethods...................................................................... 159

C6 Influenceoffacilitydesignonhealthcareassociatedinfection ............................................... 161

C6.1 Facilitydesignanditsimpactoninfectioncontrol.............................................................. 161

C6.2 Mechanismsforinfluencinghealthcareassociatedinfectionthroughenvironmental

design......................................................................................................................................... 162

C6.3 Thebenefitsofsinglebedroomsforpatientisolation....................................................... 166

C6.4 Constructionandrenovation................................................................................................. 167

C6.5 Guidancedocuments............................................................................................................... 167


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PART D STANDARDS, LEGISLATION A ND OTHER RESOURCES......................... ............................................ ............. 168

D1 Generalinfectioncontrolresources........................................................................................ 169

D2 Standardprecautions................................................................................................................ 170

D3 Transmissionbasedprecautions ............................................................................................ 172

D4 Devicemanagement ................................................................ ................................................. 173

D5 Involvingpatientsintheircare ....................................................... ........................................ 174

D6 Staffhealthandsafety ............................................................. ................................................. 175

D7 Surveillance................................................................................................................................ 175

D8 Facilitydesign............................................................................................................................ 176

APPENDICES...................................................................................................................................................................177

1 MembershipandTermsofreferenceoftheWorkingCommittee............................................. 178

2 Processreport ....................................................... ........................................................... ..................... 180

3 Exposureproneprocedures(EPP) .......................................................... .......................................... 189

Glossary ............................................................... ........................................................... ............................. 194

Abbreviationsandacronyms ....................................................... ............................................................ 200

References.................................................................................................................................................... 202

List of tables and figures

Tab les

Table1: Directoryofkeyinformationintheseguidelines ......................................................... ...................... 11

Table2: Sourcesofevidencetosupportrecommendations............................................................................. 14Table3: NHMRCgradesofevidence.................................................................................................................. 16

Table4: Keytotypesofinformationhighlightedintheguidelines................................................................ 17

Table5: Topicsdiscussedintheguidelines........................................................................................................ 18

TableA1.1: Howstandardprecautionsareimplemented...................................................................................... 22

TableA1.2: Strategiesforimplementingtransmissionbasedprecautions .......................................................... 23

TableA2.1: Riskanalysismatrix .......................................................... ............................................................... ....... 24

TableB1.1: Stepsincoughetiquette.......................................................................................................................... 32

TableB1.2: Useofalcoholbasedhandrub.............................................................................................................. 33

TableB1.3: Usingsoap(includingantimicrobialsoap)andwater....................................................................... 33

TableB1.4: Characteristicsofaprons/gowns ................................................................ ........................................... 37

TableB1.5: Useoffaceandeyeprotectionaspartofstandardprecautions ....................................................... 38

TableB1.6: Propertiesofdifferenttypesofmask.................................................................................................... 38

TableB1.7: Selectionofglovetype............................................................................................................................ 41

TableB1.8: PuttingonandremovingPPE............................................................................................................... 43

Table

B1.9: Reducing

risks

if

a

sharps

injury

is

sustained ..................................................... ................................ 48TableB1.10:Characteristicsofdisinfectants.............................................................................................................. 52


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TableB1.11:Managementofbloodorbodysubstancespills.................................................................................. 55

TableB1.12 Recommendedroutinecleaningfrequenciesforclinical,patientandresidentareas.................... 56

TableB1.13:Categoriesofitemsforpatientcare .......................................................... ............................................ 63

TableB1.14:Generalcriteriaforreprocessingandstorageofequipmentandinstrumentsinhealthcaresettings...................................................................................................................................................... 66

TableB2.1: Applicationofstandardandtransmissionbasedprecautions ......................................................... 81

TableB2.2: Infectionswarrantingtransmissionbasedprecautionsbeforelaboratoryconfirmationofinfection ............................................................... .............................................................. ....................... 82

TableB2.3: Typeanddurationofprecautionsforspecificinfectionsandconditions ....................................... 83

TableB3.1 SuggestedapproachtoscreeningforMRSA....................................................................................... 93

TableB3.2 SuggestedapproachtoscreeningforVREandMRGNdependentonlocalacquisitionrates..... 94

TableB3.3: ExampleofasuccessfulstrategytopreventendemicityofMRSAinatertiaryhospitalinWA .96

TableB3.4: ExampleofasuccessfulstrategytopreventendemicityofVREinatertiaryhospitalinWA.....96

TableB3.5: Stepsinanoutbreakinvestigation...................................................................................................... 100

TableB4.1: Levelofrisktopatientsfromdifferenttypesofprocedures........................................................... 108

TableB4.2: Summaryofprocessesforappropriateuseofdevices..................................................................... 109

TableB4.3: Keyconceptsinminimisingtheriskofinfectionrelatedtotheuseofinvasivedevices ............ 110

TableB4.4: Summaryofprocessesforurethralcatheterinsertionandmaintenance ...................................... 112

TableB4.5: CAUTImaintenancebundle ................................................... ........................................................... .. 113

TableB4.6: RiskfactorsforIVDrelatedBSI .......................................................................................................... 114

TableB4.7: Central

venous

catheter

decision

tree

for

adults............................................................................... 114

TableB4.8: Summaryofprocessesforinsertionandmaintenanceofintravascularaccessdevices..............117

TableB4.9: SummaryofstrategiesforpreventingVAP ...................................................................................... 119

TableB4.10:VAPcarebundle......................................... ................................................................ ........................... 119

TableB4.11:Summaryofprocessesforusingenteralfeedingtubes.................................................................... 120

TableB4.12:Summaryofprocessespresurgicalprocedure ............................................................... .................. 122

TableB4.13:Summaryofprocessesduringasurgicalprocedure ................................................................ ........ 123

TableB4.14:Summaryofprocessesfollowingasurgicalprocedure ........................................................... ........ 124

TableB4.15:Checklistofstandardprecautionsforprocedures............................................................................ 125

TableC1: Recommendedvaccinationsforallhealthcareworkers .................................................................. 138

TableC2: Staffexclusionperiodsforinfectiousillnesses.................................................................................. 139

TableC3: Categoriesofexposureproneprocedures ...................................................... ................................... 141

TableC4: Keyrequirementsofahospitalantibioticstewardshipprogram................................................... 158

TableApp2.1:Clinicalquestionsforsystematicreview......................................................................................... 183

Figures

FigureA1.1:Riskmanagementflowchart ............................................................ ...................................................... 25

FigureB1.1: Importanceofhandhygiene.................................................................................................................. 30

FigureB1.2: The5momentsofhandhygiene........................................................................................................... 31


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FigureB1.3: Processesforroutinecleaning ............................................................. .................................................. 51


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Summary of rec omme nda tions

7

SUMMARY OF RECOMMENDATIONS

Theseguidelinesproviderecommendationsthatoutlinethecriticalaspectsofinfectionpreventionand

control.TherecommendationsweredevelopedbytheInfectionControlSteeringCommittee1basedon

systematicreviewsoftheliteratureundertakenspecificallyfortheseguidelinesoronguidelinesdeveloped

byotheradvisorybodies.Theyshouldbereadinthecontextoftheevidencebase.Thisisdiscussedin

SectionsB1,B2andB3,whichalsoincludeadviceonthepracticalapplicationoftherecommendations.The

tablebelowlistsrecommendationsandthesectionoftheguidelinesinwhichtheyarediscussed.

Rec om me nda tion Refer to:

Standard preca utions

Hand hygiene

1 Routine hand hyg iene

Hand hygiene must b e p erformed before and after every episode of pa tient c ontac t.

This inc lud es:

before touching a pa tient;

before a proced ure;

a fter a p roced ure or bod y fluid exposure risk;

after touching a pa tient; and

after touching a patients surroundings.

Hand hygiene must a lso b e p erformed after rem ova l of gloves.

Sec tion B1.1.2

Page 30

2 Choice of produc t for routine hand hygiene prac tices

Alcoho l-ba sed hand rubs c onta ining at least 70% v/ v etha nol or equivalent should b e

used for all routine hand hygiene p rac tices in the hea lthcare environm ent.

Sec tion B1.1.3

Page 32

3 Choice of hand hygiene produc t when hands are visibly soiled

If hand s a re visibly soiled, hand hygiene should b e performed using soa p a nd w ater.

Sec tion B1.1.3

Page 32

Personal protective equipment

4 Wearing of ap rons/ gow ns

Ap rons or gow ns should b e a pp rop riate to the ta sk being und ertaken. They should b e

wo rn for a single p roc ed ure or episod e of p atient c are and remo ved in the area

where the ep isod e of ca re takes plac e.

Sec tion B1.2.3

Page 37

5 Use of face and eye protection for proce dures

A surgica l mask and go gg les must b e wo rn d uring p roc ed ures that ge nerate ae rosols,

sp lashes or sp rays of b lood , bo dy fluids, sec retions or excretions into the fac e a nd eyes.

Sec tion B1.2.4

Page 38

6 Wearing of gloves

Glove s must b e wo rn as a single-use item for:

each invasive procedure;

c onta c t with sterile sites and no n-inta c t skin or muc ous me mb ranes; and

any ac tivity tha t has been assessed as c arrying a risk of exposure to bloo d, bod y

fluids, secretions and excretions.

Gloves must be c hang ed be twee n pa tients and after every ep isod e of individua l

pa tient ca re.

Sec tion B1.2.5

Page 40

1 MembershipandtermsofreferenceoftheInfectionControlSteeringCommitteearegiveninAppendix1.


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7 Sterile glo ves

Sterile gloves must b e used for asep tic p roce dures and c onta c t w ith sterile sites.

Sec tion B1.2.5

Page 40

Handling and disposal of sharps

8 Safe hand ling of sharpsSharps must not b e p assed direc tly from hand to ha nd a nd ha ndling should b e kep t to

a minimum .

Need les must not be rec ap pe d, b ent, broken or d isassemb led a fter use.

Sec tion B1.3.2Page 47

9 Dispo sal of sharps

The person who has used the sha rp must b e respo nsible fo r its imme dia te safe d isposal.

Used sha rps must be disc arde d into a n ap prove d sha rps c onta iner a t the p oint-of-use.

These m ust no t b e filled abo ve the m ark that indica tes the b in is three-qua rters full.

Sec tion B1.3.3

Page 48

Routine environmental cleaning

10 Routine c leaning of surfac es

Clean freque ntly touc hed surfac es with de tergent solution a t least d aily, and whe n

visibly soiled and after eve ry known c onta mination.

Clea n ge neral surfac es and fittings whe n visibly soiled a nd imm ed iate ly a fter sp illage .

Sec tion B1.4.2

Page 51

11 Cleaning of shared c linica l equipm ent

Clean to uche d surfac es of shared c linic al eq uipment b etw een p atient uses, with

detergent solution.

Exce p tions to this should be justified by risk assessme nt.

Sec tion B1.4.2

Page 51

12 Surfac e ba rriersUse surfac e b a rriers to p rote c t c linica l surfac es (inc luding equ ipment) tha t are:

touc hed freque ntly with gloved hand s during the d elivery of pa tient ca re;

likely to bec om e c onta minated with blood o r bo dy substanc es; or

diffic ult to c lean (e.g. com pute r keyboa rds).

Exce p tions to this should be justified by risk a ssessme nt.

Sec tion B1.4.2Page 51

13 Site de c ontam ination after spills of bloo d or other po tentially infec tious ma terials

Spills of b lood or other po tentia lly infec tious ma terials should b e p romp tly c leaned as

follows:

wear utility gloves and other PPEap propriate to the ta sk;

co nfine a nd c ontain spill, clean visible ma tter with dispo sab le ab sorbe nt ma terial

and disc ard the used c leaning ma terials in the ap propriate wa ste c onta iner;

clean the sp ill area w ith a c loth or pa per towels using dete rge nt solution.

Use o f che mic al d isinfec ta nts suc h as sod ium hypo c hlorite should be based on

assessme nt of risk of transmission of infe c tious ag ents from tha t sp ill.

Sec tion B1.4.3

Page 54

Transmission- ba sed prec autions (see Sec tion B2)

Contact precautions


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14 Impleme ntation of c ontac t preca utions

In ad dition to stand ard p rec autions, imp lement c onta c t prec autions in the presenc e

of known o r suspe c ted infec tious ag ents that a re sprea d by d irec t or indirec t c onta c t

with the pa tient or the p atient s environme nt.

Sec tion B2.2.2

Page 71

15 Hand hygiene and pe rsonal protec tive equipm ent to prevent contac t transmission

When working with pa tients who req uire c onta c t p rec autions:

perform hand hygiene;

put on g loves and gow n upon entry to the pa tient ca re a rea ;

ensure that c lothing a nd skin do not c onta c t pote ntially c onta minated

environme nta l surfac es; and

remove gow n and gloves and perform ha nd hygiene before leaving the pa tient

ca re area.

Sec tion B2.2.3

Page 71

16 Hand hygiene when Clostridium difficileis suspe c ted o r known to be p resent

To fa c ilitate the m ec hanica l rem ova l of spores, meticulously wash hands with soa p

and wa ter and pa t d ry with single-use to wels.

Use o f alc oho l-ba sed hand rubs alone ma y not b e sufficient to red uc e transmission of

Clostridium difficile.

Sec tion B2.2.3

Page 71

17 Patient c are equipm ent for pa tients on contac t preca utions

Use p atient d ed ica ted eq uipment o r single-use non-critic al pa tient ca re eq uipment

(e.g. b lood p ressure c uffs).

If co mm on use of e quipm ent for multiple p atients is unavo idab le, c lean the e quipm ent

and allow it to dry before use on a nother pa tient.

Sec tion B2.2.3

Page 72

Droplet precautions

18 Impleme ntation of droplet preca utions

In a dd ition to stand ard p rec autions, imp lem ent d rop let prec autions for patients known

or suspec ted to b e infec ted with ag ents transmitted by respirato ry drop lets (ie large-

particle droplets >5 in size) that a re ge nerated by a p atient whe n co ughing,

snee zing, ta lking, o r during suc tioning.

Sec tion B2.3.2

Page 74

19 Persona l protec tive eq uipment to prevent drop let transmission

When entering the pa tient ca re e nvironme nt, put on a surgic al ma sk.

Sec tion B2.3.3

Page 74

20 Plac em ent of pa tients requiring drop let prec autions

Place pa tients who req uire d rop let prec autions in a single-patient room when

available.

Sec tion B2.3.3

Page 75

Airborne precautions

21 Impleme ntation of airborne preca utions

In a dd ition to stand ard p rec autions, imp leme nt a irbo rne p rec autions for patients

known or suspected to be infected with infectious agents transmitted person-to-person

by the airborne route (ie airborne drop let nuc lei or pa rticles


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23 Plac em ent of pa tients requiring airborne prec autions

Pat ients on a irborne p reca utions should be pla c ed in nega tive p ressure roo ms or in a

room from which the air do es not c irc ulate to o ther area s.

Exce p tions to this should be justified by risk assessme nt.

Sec tion B2.4.3

Page 78

Multid rug resistant o rganisms (see Sec tion B3)

24 Imp leme ntation of co re strategies in the control of multi-resistant organisms (MRSA,

MRGN, VRE)

Imp lement transmission-ba sed prec autions for all pa tients c olonised or infec ted with a

multi-resistant organism, including:

putting on gloves and go wns be fore entering the pa tient ca re area;

using pa tient ded ica ted or single-use non-c ritic al pa tient ca re e quipm ent

(e.g. bloo d p ressure cuff, stethosc op e);

using a single-pa tient roo m o r, if unava ilab le, coho rting p a tients with the sam e

strain of m ulti-resista nt o rga nism in d esigna ted pa tient c are a reas; and

ensuring c onsistent c leaning and d isinfec tion o f surfac es in close p roximity to the

pa tient and tho se likely to be to uche d b y the pa tient and he althca re wo rkers.

Sec tion B3.1.2

Page 91


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11

Finding information

Theserecommendationsprovidethebasisforappropriateinfectioncontrolpracticeinthehealthcaresetting.

PracticalguidanceontheirimplementationisgiveninPartBoftheseguidelines.Thefollowingtable

providesadirectoryforthisguidance.

Tab le 1: Directo ry of key informa tion in these guid elines

WHEN YOU NEED TO KNOW READ PAGE

Infec tion control ba sics

What are standard precautions and how are they ap plied Basics p29

How are transmission-based precautions app lied Basics p70

How to help patients become involved in infection co ntrol Sec tion A3;

Patient care tips also highlighted

How to a pp ly the p roce ss of risk management Sec tion A2; Case studies pp35, 46, 50, 61,

73, 75, 79, 98, 105

Hand hygiene and c ough etiquette

When to pe rform hand hygiene Basics p30; Contac t 71; Drop let p 74; MROs p90

What hand hygiene products to use and how Basics pp 32 to 33; Ca se study p 35; MROs p90

What to d o if there are cuts or ab rasions on y our hands Basics p33

Aboutjewe llery or artificial fingernails and infec tion Basics p33

How to ca re for your hand s Basics pp33 to 34

How to p rac tice cough etiquette Basics p32

Personal p rotective e quipm ent

How to dec ide wha t PPE is need ed for a pa rtic ular situation Basics p36

What PPE to we ar for routine clinical practice Stand ard p 71;

What PPE to w ea r when there is a risk of co nta mina tion with

blood, body fluids, secretions, or excretions

Ap rons and go wns p37, fac e and e ye protection p38;

gloves p40

What PPE to w ea r when transmission-ba sed prec autions are

implemented

Contact p71; Droplet p74; Airbo rne p77;

MROs p91; Summa ry p81

When to wea r aprons and g owns Basics p37; Contac t 71

When to wea r face and e ye protection Basics p38; Airbo rne 77

When to wea r gloves Basicsp40; Contac t 71; Ca se study p 46

What is the c orrec t proc ed ure for putting on and removing PPE Basics p43

Hand ling and disposal of sharps

How to avoid sharps injuries Basics p47 ; Ca se study p 50

How to use need leless devic es Basics p49

How to safe ly dispose of sha rps Basics p48

What to do if a sharps injury is sustained Basics p48


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Environmental cleaning

What p roduc ts and proc esses to use for routine e nvironme ntal

cleaning of surface s

Basics p51, p56

When to use disinfectants Basics p52; MROs p91

How to m inimise c onta mination of c leaning implem ents and

solutions

Basics p53

What products and processes to use when there is a spill of blood

or body fluids

Basics p54; Ca se study p 61

Processing of instruments and equipment

How to clean eq uipment and instruments Metho ds p63; Agents 64

How to disinfect eq uipment and instruments Metho ds p64

How to sterilise eq uipment and instruments Metho ds p65

How to dec ide which proc essing is req uired Basics p63; 66; Ca se study p 68

When there is a suspec ted o r co nfirmed infection

What transmission-based precautions are required for a specific

infec tious ag ent

Summ ary p81, p83

When to implement transmission-ba sed prec autions Gene ral p82; Contac t p71; Droplet p74; Airborne p77

When to impleme nt the use of single-use or dedicated patient

care equipment

Contact p72; MROs p91

What to consider when transporting pa tients Contac t p73; Droplet p75; Airborne p78

Where to place p atients to avoid cross-contam ination Contac t p72; Droplet p75; Airbo rne p78;

MROs p91; Outbreak p103


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Introduction

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INTRODUCTION

Effectiveinfectioncontrolpreventingthetransmissionofinfectiousorganismsandmanaginginfectionsif

theyoccuriscentraltoprovidinghighqualityhealthcareforpatientsandasafeworkingenvironmentfor

thosethatworkinhealthcaresettings.

Healthca re-assoc iated infec tion is preventable

Therearearound200,000healthcareassociatedinfections(HAIs)inAustralianacutehealthcarefacilities

eachyear.ThismakesHAIsthemostcommoncomplicationaffectingpatientsinhospital.Aswellascausing

unnecessarypainandsufferingforpatientsandtheirfamilies,theseadverseeventsprolonghospitalstays

andarecostlytothehealthsystem.Theproblemdoesnotjustaffectpatientsandworkersinhospitals

HAIscanoccurinanyhealthcaresetting,includingofficebasedpractices(e.g.generalpracticesurgeries,

dentalclinics)andlongtermresidentialcarefacilities(seeGlossary).Anypersonworkinginorenteringa

healthcarefacilityisatrisk.However,healthcareassociatedinfectionisapotentiallypreventableadverse

eventratherthananunpredictablecomplication.ItispossibletosignificantlyreducetherateofHAIs

througheffectiveinfectioncontrol.

Infec tion control is eve rybod ys businessUnderstandingthemodesoftransmissionofinfectiousorganismsandknowinghowandwhentoapplythe

basicprinciplesofinfectioncontroliscriticaltothesuccessofaninfectioncontrolprogram.This

responsibilityappliestoeverybodyworkingandvisitingahealthcarefacility,includingadministrators,

staff,patientsandcarers.

SuccessfulapproachesforpreventingandreducingharmsarisingfromHAIsinvolveapplyingarisk

managementframeworktomanagehumanandsystemfactorsassociatedwiththetransmissionof

infectiousagents.Thisapproachensuresthatinfectiousagents,whethercommon(e.g.gastrointestinal

viruses)orevolving(e.g.influenzaormultiresistantorganisms[MROs]),canbemanagedeffectively.

Development of the guidelines

AspartoftheAustralianCommissiononSafetyandQualityinHealthCares(ACSQHC)coordinated

approachtothepreventionandcontrolofHAIs,theNationalHealthandMedicalResearchCouncil

(NHMRC)wasaskedtodevelopguidelinestoprovidenationalguidanceforthecontrolofHAIsandalsoa

foundationbywhichotherstrategiesaddressingthepriorityareaofHAIscanbeimplemented.

TheNHMRCappointedanexpertgrouptoguidethedevelopmentprocess(SteeringCommittee

membershipandtermsofreferencearegiveninAppendix1).Theguidelinesarebasedonthebestavailable

evidence.Theybuildonexistingguidelinesandreviews,aswellassystematicreviewsoftheevidence.

Aim

Byassistinghealthcareworkerstoimprovethequalityofthecaretheydeliver,theseguidelinesaimto

promote

and

facilitate

the

overall

goal

of

infection

control:

Thecreationofsafehealthcareenvironmentsthroughtheimplementationofpracticesthatminimisetheriskof

transmissionofinfectiousagents.

Scope

Thescopeoftheseguidelineswasestablishedatthestartoftheguidelinedevelopmentprocess,followinga

periodofconsultationthatincludedforumsinvolvingawiderangeofstakeholders(seeAppendix2).

Theguidelinesweredevelopedtoestablishanationallyacceptedapproachtoinfectioncontrol,focusingon

coreprinciplesforinfectioncontrolandpriorityareasforaction.Theyprovideabasisforhealthcareworkers

andhealthcarefacilitiestodevelopdetailedprotocolsandprocessesforinfectioncontrolthatapplytotheir

specificsituation.

Whiletheguidelinesfocusonacutecare,theriskapproachusedtoaddresstheprinciplesofinfectioncontrol

meanstheyareapplicabletoawiderangeofhealthcaresettings,includingofficebasedpractice,residential


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Introduction

14

carefacilities,Aboriginalmedicalservices,homeandcommunitynursingandemergencyservices.Materials

thatidentifyrelevantrisksandmakerecommendationsonorganisationalpoliciesandproceduresforother

settingswillalsobedeveloped,basedontheprinciplesoutlinedintheseguidelines.Informationforpatients

willalsobederivedfromtheseguidelines.

Theguidelinesdonotincludedetailedinformationon:

infectiousdiseases;

pandemicplanning;

thereprocessingofinstruments;

occupationalhealthandsafety;

hospitalhotelservicessuchasfoodservices,laundryservicesorwastedisposal;or

engineering/healthfacilitydesign.

TheguidelinesdonotduplicateinformationprovidedinexistingAustralianStandardsbutrefertospecific

standardswhereverrelevant.

Target audienc e

Theguidelines

are

for

use

by

all

those

working

in

healthcare

this

includes

healthcare

workers,

managementandsupportstaff.

Evidence base

Theseguidelinesarebasedonthebestavailableevidenceandknowledgeofthepracticalitiesofclinical

procedures.Theydrawfromotherworkinthisarea,includingthetwopreviousnationalinfectioncontrol

guidelines,2internationalinfectioncontrolguidelines,systematicliteraturereviewsconductedtoinformthe

developmentoftheseguidelines,workonHAIpreventionfromACSQHC,andAustralianStandards

relevanttoinfectioncontrol.Australiandataareusedwhereveravailable.

Tab le 2: Source s of evidenc e to supp ort reco mm endations

Systematic ally de velope d international guidelines3

World Health Organization

Guidelines on ha nd hygiene in hea lth ca re (2009)

United States Centers for Disea se C ontrol a nd Prevention

Workbo ok for d esigning, imp lementing a nd eva luating a sharps injury p revention prog ram (2009)

Guideline for isola tion p recautions: preventing tra nsmission of infec tious age nts in hea lthca re setting s (2007)

Management of multidrug-resistant organisms in healthcare settings (2006)

Guidelines for infection control in the dental setting (2003)

Guidelines for environmental infection control in health-care facilities (2003)

United Kingdom National Institute for Health and Clinical Excellence

Surgica l site infect ion prevention a nd t rea tme nt of surgica l site infect ion (2008)

Prevention of hea lthcare-assoc iated infection in prima ry and c omm unity care (2003)

UK Dep artme nt of Health

Epic 2: Nat ional evidenc e-b ased g uide lines for preve nting hea lthca re-assoc iated infec tions in NHS hospitals inEngla nd (2007)

British Soc iety for Antimicrob ial Chem otherapy

Guidelines for UK practice for the diagnosis and management of methicillin-resistant Stap hyloc oc cus aureus

(MRSA) infec tions presenting in the c om mun ity

Guidelines for the m ana ge ment of ho spital-ac quired pne umonia in the UK: Rep ort of the Working Party on

Hospita l-Ac qu ired Pneum onia o f the British Soc iety for Antimic rob ial Che mo the rap y

2 CDNA(2004)InfectionControlGuidelinesforthePreventionofTransmissionofInfectiousDiseaseintheHealthCareSetting.

CommunicableDiseasesNetworkofAustralia.

NHMRC(1996)InfectionControlintheHealthcareSetting.GuidelinesforthePreventionofTransmissionofInfectious

Diseases.NationalHealthandMedicalresearchCouncil.Rescinded.3 TheseguidelineswereselectedbasedonanalysisusingtheAGREEtool,whichensuresthatguidelineshavebeen

developedinarigorous,transparentandrobustmanner.ThisprocessisdiscussedindetailinAppendix2.


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Introduction

15

Canad ian Critica l Care Trials Group

Com prehensive evidenc e-ba sed clinic al prac tice g uidelines for ventilator-assoc iated pne umonia: p revention

(2008)

Europe an Assoc iation o f Urology

Europea n and Asian guidelines on ma nag em ent an d p revention of ca thete r-assoc iated urinary tract infec tions

Sepa rate systema tic reviews of pub lished scientific and med ica l literature for areas of co ntroversy a nd c linica l

variation4

Alcohol products and other agents for hand hygiene

Infec tion co ntrol mea sures relate d to the use o f intrava sc ular device s

Positive p ressure room s in red uc ing risk for imm unoc om prom ised pa tients

Sta ff exclusion p olicies relat ing to norov irus ga stroen teritis

Persona l protec tive eq uipment in reduc ing the t ransmission of multi-resistant organ isms

Isolation m ea sures for p atients infec ted with va nco myc in-resistant enteroc oc ci or multi-resistant Gram neg ative

bacteria

Education interventions for the prevention of HAIs

Limitations of the grad ing proc ess as it applies to the prac tice of infec tion co ntrol

TherecommendationsintheseguidelineswereformulatedbytheInfectionControlSteeringCommittee5

throughaprocessofconsensus.Recommendationsaregivenwhenanactionisdeemedcriticaltopreventing

ormanaginginfection.RecommendationsaregradedaccordingtotherevisedNHMRCgradingsfor

assessingevidence,withtheadditionofgoodpracticepoints,whichoutlineactionsthatareessentialto

infectionpreventionandcontrolbutwhereevidencegradescannotbeapplied.

Inmanyareasofinfectioncontrol,theevidencemaybelimitedbytheinabilitytoconductcertainstudy

designsthataredifficulttoimplementinrealpractice.Thishasimplicationsforthelevelofgradingthatis

assignedtotherecommendations,sincegradingsystemswilltendtofavourstudydesignsthatare

sometimesnotfeasibleorunethicaltoconductininfectioncontrolsettingssuchasrandomisedcontrolled

trials.Forexample,itisunethicaltocomparetheincidenceofinfectionrelatedtosurgicalinstrumentsby

allocatingonepatientgrouptohavesterilisedinstrumentsusedonthemandonepatientgrouptohavenon

sterileinstruments

used

on

them.

This

may

result

in

alower

grading

due

to

the

available

evidence

but

sterilisationofsurgicalinstrumentsisuniversallydeemedcriticaltoinfectioncontrol.

Giventhatthereislimitedevidenceavailabletosupportmanyroutinepracticesintendedtoreduceinfection

risk,practiceisbasedondecisionsmadeonscientificprinciples.Someactivities,suchaspractisinghand

hygienebetweenadministeringcaretosuccessivepatients,haveacrediblehistorytosupporttheirroutine

applicationinpreventingcrossinfection.Others,suchassomeuniformandclothingrequirements,have

moretodowiththeethosofqualitycareandworkplaceculturethanwithaprovenreductionofcross

infection.

Itisnotacceptabletodiscontinuepracticesforwhichthereisasolidscientificbasis,evenifthelevelof

evidenceisnothigh.Rather,routinepracticesshouldcontinueunlessthereissufficientevidencetosupport

alternativeprocedures.

Continuing

research

is

needed

to

keep

evaluating

practice,

to

identify

evidence

gaps

andpromoteresearchintheseareas,andensurethatpoorpracticesdonotcontinue.

4 Duetoapaucityofevidenceorlowqualityevidencesomesystematicreviewswerenotusedtodraftrecommendations.

5 MembershipoftheInfectionControlSteeringCommitteeisgiveninAppendix1.


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Introduction

16

Tab le 3: NHMRC grad es of evid enc e

Grade Description

A Body of evidenc e c an b e trusted to guide p rac tice

B Bod y of evidenc e c an b e trusted to guide prac tice in most situations

C Bod y of evidenc e p rovide s some supp ort for reco mm end ation(s) but c are should b e ta ken in

its ap plication

D Body o f evidence is wea k and reco mmend ation must be ap plied with caution

TheICGSteeringCommitteealsoassignedanadditionalgradereferredtoasgoodpracticepoints(GPPs):

GPP Bod y of evidenc e is wea k or non-existent. Rec omm end ation for be st prac tice b ased on

clinical experience and expert opinion

Struc ture of the guidelines

Theseguidelinesarebasedaroundthefollowingcoreprinciples:

anunderstandingofthemodesoftransmissionofinfectiousagentsandanoverviewofriskmanagement;

effectiveworkpracticesthatminimisetheriskofselectionandtransmissionofinfectiousagents;

governancestructures

that

support

the

implementation,

monitoring

and

reporting

of

infection

control

workpractices;and

compliancewithlegislation,regulationsandstandardsrelevanttoinfectioncontrol.

ThePartsofthedocumentarebasedonthesecoreprinciplesandareorganisedaccordingtothelikely

readership.

PartApresentsbackgroundinformationthatshouldbereadbyeveryoneworkinginhealthcare(for

exampleasorientationoraspartofannualreview)thisincludesimportantbasicsofinfectioncontrol,

suchasthemainmodesoftransmissionofinfectiousagentsandtheapplicationofriskmanagement

principles.Thispartoftheguidelinesdoesnotincluderecommendations.

PartBisspecifictothepracticeofhealthcareworkersandsupportstaff,andoutlineseffectivework

practicesthatminimisetheriskofselectionortransmissionofinfectiousagents.RecommendationsaregiveninSectionsB1toB3.Eachsectionincludesadviceonputtingtherecommendationsintopracticeandarisk

managementcasestudy.

SectionB1describesstandardprecautionsusedatalltimestominimisetheriskoftransmissionof

infectiousagents;

SectionB2outlinestransmissionbasedprecautionstoguidestaffinthepresenceofsuspectedorknown

infectiousagentsthatrepresentanincreasedriskoftransmission;

SectionB3outlinesapproachestothemanagementofmultiresistantorganisms(MROs)oroutbreak

situations;and

SectionB4outlinesprocessesforriskidentificationandtheapplicationofstandardandtransmission

basedprecautions

for

certain

procedures.

PartCdescribestheresponsibilitiesofmanagementofhealthcarefacilities,includinggovernance

structuresthatsupporttheimplementation,monitoringandreportingofeffectiveworkpractices.The

chaptersoutlinethemaincomponentsofasystemsapproachtofacilitywideinfectioncontrol,giving

guidanceonmanagementandstaffresponsibilities,protectionofhealthcareworkers,requirementsfor

educationandtrainingofallstaff,considerationsforfacilitydesignandrenovation,andotherimportant

activitiessuchassurveillanceandantibioticstewardship.

PartDprovidesexamplesofrelevantstandards,legislationandresources.

Theappendicesprovideadditionalinformationontheguidelinedevelopmentprocess,andsometoolsto

assistinapplyingtherecommendations.

Keyinformationishighlightedintheguidelinesasfollows.


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Introduction

17

Tab le 4: Key to type s of informa tion highlighted in the guidelines

Summaries provide key information from ea c h sec tion of the g uidelines

Rec omm enda tions (Sec tions B1, B2 and B3) outline the c ritica l aspe c ts of infec tion p reve ntion a nd c ontrol

Patient c are tips highlight pa tient c onsiderations in the a pp lic ation o f infec tion c ontrol principles

Casestudiesillustratetheapplicationofriskmanagementprinciples(SectionsB1,B2andB3)andmeasuresto

supportgoodpractice(PartC)

Thefollowingtablesummarisesthekeytopicsdiscussedinthedocument.


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PART A BASICS OF INFECTION CONTROL

Hea lthca re-assoc iated infec tions (HAIs) ca n oc c ur in any hea lthca re setting . While the spec ific risks ma y

differ, the b asic principles of infec tion c ontrol ap ply reg ardless of the setting .

In orde r to p revent HAIs, it is impo rta nt to unde rsta nd ho w infec tions oc c ur in healthc a re sett ings and then

institute wa ys to p revent the m. Risk manage me nt is integral to this ap p roa ch.

If effec tively imp lemented , the two -tiered a pp roa c h of stand ard a nd transmission-ba sed prec autions

rec om mend ed in these guidelines provides high-level protec tion to pa tients, hea lthc are w orkers and

other pe op le in healthca re settings.

Infec tion control is integral to c linica l c a re a nd the way in which it is provided . It is not a n ad d itiona l set of

practices.

Involving p a tients is essential to suc c essful c linica l ca re. This inc lude s ensuring tha t pa tients rights a re

respe c ted at all times, that they a re involved in dec ision-ma king ab out the ir c are, and they a re suffic ientlyinformed to b e a b le to p articipa te in red uc ing the risk of transmission of infec tious ag ents.

The informat ion presente d in this Pa rt is releva nt to e verybo dy emp loyed b y a hea lthca re fa c ility, including

ma nag em ent, hea lthca re w orkers and supp ort servic e staff.


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Sec tion A1 Infec tion c ontrol in the hea lthcare setting

21

otherfactorsthatincreasetheriskoftransmissionofinfection(e.g.undergoingsurgery,requiringan

indwellingdevicesuchasacatheter,orremaininginhospitalforlengthyperiods).

Inhealthcaresettings,themostcommonsusceptiblehostsarepatientsandhealthcareworkers:

Patientsmaybeexposedtoinfectiousagentsfromthemselves(endogenousinfection)orfromother

people,instrumentsandequipment,ortheenvironment(exogenousinfection).Thelevelofriskrelatesto

thehealthcaresetting(specifically,thepresenceorabsenceofinfectiousagents),thetypeofhealthcare

proceduresperformedandthesusceptibilityofthepatient.

Healthcareworkersmaybeexposedtoinfectiousagentsfrominfectedorcolonisedpatients,instruments

andequipment,ortheenvironment.Thelevelofriskrelatestothetypeofclinicalcontacthealthcare

workershavewithpotentiallyinfectedorcolonisedpatientgroups,instrumentsorenvironments,andthe

healthstatusofthehealthcareworker(e.g.immunisedorimmunocompromised).

Inhealthcaresettings,themainmodesoftransmissionofinfectiousagentsarecontact(including

bloodborne),dropletandairborne.Themodesoftransmissionvarybytypeoforganism.Insomecasesthe

sameorganismmaybetransmittedbymorethanoneroute(e.g.norovirus,influenzaandrespiratory

syncytialvirus[RSV]canbetransmittedbycontactanddropletroutes).

A1.1.1 Routes of transmission

Conta c t transmission

Contactisthemostcommonmodeoftransmission,andusuallyinvolvestransmissionbyhandorviacontact

withbloodorbodysubstances.Contactmaybedirectorindirect.

Directtransmissionoccurswheninfectiousagentsaretransferredfromonepersontoanotherfor

example,apatientsbloodenteringahealthcareworkersbodythroughanunprotectedcutintheskin.

Indirecttransmissioninvolvesthetransferofaninfectiousagentthroughacontaminatedintermediate

objectorpersonforexample,ahealthcareworkershandstransmittinginfectiousagentsaftertouching

aninfectedbodysiteononepatientandnotperforminghandhygienebeforetouchinganotherpatient,or

ahealthcareworkercomingintocontactwithfomites(e.g.bedding)orfaecesandthenwithapatient.

Examplesof

infectious

agents

transmitted

by

contact

include

multi

resistant

organisms

(MROs),

Clostridiumdifficile,norovirusandhighlycontagiousskininfections/infestations(e.g.impetigo,scabies).

Drop let transmission

Droplettransmissioncanoccurwhenaninfectedpersoncoughs,sneezesortalks,andduringcertain

proceduressuchassuctioning.Dropletsareinfectiousparticleslargerthan5micronsinsize.Respiratory

dropletstransmitinfectionwhentheytraveldirectlyfromtherespiratorytractoftheinfectedpersonto

susceptiblemucosalsurfaces(nasal,conjunctivaeororal)ofanotherperson,generallyovershortdistances.

Dropletdistributionislimitedbytheforceofexpulsionandgravityandisusually1metreorless.However,

dropletscanalsobetransmittedindirectlytomucosalsurfaces(e.g.viahands).

Examplesofinfectiousagentsthataretransmittedviadropletsincludeinfluenzavirusandmeningococcus.

Airborne transmission

Airbornedisseminationmayoccurviaaerosols(smallairbornedropletslessthan5insize)containing

infectiousagentsthatremaininfectiveovertimeanddistance.Aerosolscanbegeneratedbycoughingand

sneezingandcertainprocedures,particularlythosethatinducecoughing,canpromoteairborne

transmission.Theseincludeproceduressuchasdiagnosticsputuminduction,bronchoscopy,airway

suctioning,endotrachealintubation,positivepressureventilationviafacemaskandhighfrequency

oscillatoryventilation.Aerosolscontaininginfectiousagentscanbedispersedoverlongdistancesbyair

currents(e.g.ventilationorairconditioningsystems)andinhaledbysusceptibleindividualswhohavenot

hadanycontactwiththeinfectiousperson.Thesesmallparticlescantransmitinfectionintosmallairwaysof

therespiratorytract.

Examplesofinfectiousagentsthataretransmittedviatheairbornerouteincludemeasles(rubeola)virus,

varicellavirusandM.tuberculosis.


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Part A Basics of infec tion c ont rol

22

Other modes of transmission

Transmissionofinfectioncanalsooccurviacommonsourcessuchascontaminatedfood,water,

medications,devicesorequipment.

A1.2 STANDARD AND TRANSMISSION-BASED PRECAUTIONS

Successfulinfectioncontrolinvolvesimplementingworkpracticesthatpreventthetransmissionof

infectiousagentsthroughatwotieredapproachincluding:

routinelyapplyingbasicinfectioncontrolstrategiestominimiserisktobothpatientsandhealthcare

workers,suchashandhygiene,personalprotectiveequipment,cleaningandappropriatehandlingand

disposalofsharps(standardprecautions);and

effectivelymanaginginfectiousagentswherestandardprecautionsmaynotbesufficientontheirown.

Thesespecificinterventionscontrolinfectionbyinterruptingthemodeoftransmission(transmissionbased

precautions;formerlyreferredtoasadditionalprecautions).

Ifsuccessfullyimplemented,standardandtransmissionbasedprecautionspreventanytypeofinfectious

agentfrombeingtransmitted.

A1.2.1 Standard prec autions

Allpeoplepotentiallyharbourinfectiousagents.Workpracticestoensureabasiclevelofinfectioncontrol,

coveredbythetermstandardprecautions,areappliedtoeveryone,regardlessoftheirperceivedor

confirmedinfectiousstatus.Implementingstandardprecautionsasafirstlineapproachtoinfectioncontrol

inthehealthcareenvironmentminimisestheriskoftransmissionofinfectiousagentsfrompersontoperson,

eveninhighrisksituations.

Standardprecautionsareusedbyhealthcareworkerstopreventorreducethelikelihoodoftransmissionof

infectiousagentsfromonepersonorplacetoanother,andtorenderandmaintainobjectsandareasasfree

aspossiblefrominfectiousagents.

GuidanceonhowtoimplementstandardprecautionsisgiveninSectionB1.

Tab le A1.1: How stand ard prec autions are implem ented

Personal hygiene practices, particularly hand hygiene and cough etiquette, aim to reduce the risk of c ross-transmission a nd

c ross-infec tion o f infec tious agents (see Sec tion B1.1).

The use of personal protective equipment, which may include gloves, gowns, plastic aprons, masks/face-shields and eye

protec tion, aims to p revent expo sure of the hea lthcare wo rker to infectious ag ents (see Sec tion B1.2).

Appropriate hand ling a nd d isposal of sharps assist in preventing transmission of bloo d -bo rne d isea ses to hea lthca re wo rkers

(see Sec tion B1.3).

Environmental controls, inc luding c leaning a nd sp ills ma na ge me nt, assist in preve nting t ransmission of infec tious ag ents from

the e nvironment to p a tients (see Sec tion B1.4).

Appropriate reproce ssing of reusable eq uipment a nd instruments, including appropriate use of disinfectants, aims to

p revent p a tient-to -pa tient transmission of infec tious age nts (see Sec tion B1.5).

The a pp ropriate use o f aseptic and sterile techniques prevents conta mination of wound s and other susc ep tible sites by

infec tious agents (see Glossary).


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Sec tion A1 Infec tion c ontrol in the hea lthcare setting

23

A1.2.2 Transmission-ba sed prec autions

Anyinfectioncontrolstrategyshouldbebasedontheuseofstandardprecautionsasaminimumlevelof

control.Transmissionbasedprecautionsarerecommendedasextraworkpracticesinsituationswhere

standardprecautionsalonemaybeinsufficienttopreventtransmission.Transmissionbasedprecautionsare

alsousedintheeventofanoutbreak(e.g.gastroenteritis),toassistincontainingtheoutbreakand

preventingfurtherinfection.

Transmissionbasedprecautionsshouldbetailoredtotheparticularinfectiousagentinvolvedanditsmode

oftransmission.Thismayinvolveacombinationofpractices.

GuidanceonwhenandhowtoimplementtransmissionbasedprecautionsisgiveninSectionsB2andB3

andAppendices3and4.

Tab le A1.2: Strategies for implem enting transmission-b ased p reca utions

Transmission-based prec autions may include one or any c om bination o f the following:

alloca ting a single room to a n infected pa tient (isolation);

plac ing pa tients c olonised or infec ted with the sam e infectious ag ent in a room tog ether (co horting);

wearing specific personal protective equipment;

providing dedica ted pa tient equipment;

using d isinfecta nts effec tive a ga inst the spe cific infectious ag ent;

providing a d edica ted to ilet;

use o f spe cific air hand ling tec hniques; and

restricting m ovem ent b oth o f pa tients and hea lthcare w orkers.

Contact p recautions are used w hen there is known or suspe c ted risk of transmission of infec tious age nts by d irec t or indirect

contac t (see Sec tion B2.2).

Droplet prec autions are used for pa tients known o r suspe ct ed to b e infecte d w ith age nts transmitted by respiratory droplets

(see Sec tion B2.3).

Airborne precautions are used for pa tients known o r suspe c ted to b e infect ed with ag ents transmitted pe rson-to-pe rson b y

the airbo rne route (see Sec tion B2.4).


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24

A2 OVERVIEW OF RISK MANAGEMENT IN INFECTION PREVENTION AND CONTROL

Summary

Identifying and ana lysing risks assoc iated with health c a re is an integ ra l pa rt of suc cessful infec tion c ontrol.

Ad op ting a risk ma nage me nt a pp roa c h a t a ll levels of the fac ility is nec essa ry. This task req uires the full

supp ort of the fac ilitys ma nag eme nt as well as c oop eration betw een ma nag eme nt, hea lthca re wo rkersand support staff.

A2.1 RISK MANAGEMENT BASICS

Inthecontextoftheseguidelines,riskisdefinedasthepossibilityofcolonisationorinfectionofpatientsor

healthcareworkersarisingfromactivitieswithinahealthcarefacility.Riskmanagementisthebasisfor

preventingandreducingharmsarisingfromhealthcareassociatedinfection.Asuccessfulapproachtorisk

managementoccursonmanylevelswithinahealthcarefacility:

facilitywideforexampleprovidingsupportforeffectiveriskmanagementthroughanorganisational

riskmanagementpolicy,stafftrainingandmonitoringandreporting;

wardordepartmentbasedforexampleembeddingriskmanagementintoallpoliciessothatrisksare

consideredineverysituation;

individualforexampleconsideringtherisksinvolvedincarryingoutaspecificprocedureand

questioningthenecessityoftheprocedureaspartofclinicaldecisionmaking,attendingeducation

sessions(e.g.handhygieneormaskfittraining).

TheAustralian/NewZealandStandardonRiskManagementAS/NZS4360:2004outlinesastepwise

approachtoriskmanagementthatallowscontinuousqualityimprovementandinvolves:

establishingcontextidentifyingthebasicparametersinwhichriskmustbemanaged(e.g.thetypeof

healthfacility,theextentofandsupportforthefacilitysinfectioncontrolprogram);

avoidingriskestablishingwhetherthereisariskandwhetherpotentialriskcanbeaverted(e.g.by

questioningwhetheraprocedureisnecessary);

identifyingrisksasystematicandcomprehensiveprocessthatensuresthatnopotentialriskisexcluded

fromfurtheranalysisandtreatment(e.g.usingrootcauseanalysis);

analysingrisksconsideringthesourcesofrisk,theirconsequences,thelikelihoodthatthose

consequencesmayoccur,andfactorsthataffectconsequencesandlikelihood(e.g.existingcontrols)(see

riskanalysismatrixbelow);

evaluatingriskscomparingthelevelofriskfoundduringtheanalysisprocesswithpreviously

establishedriskcriteria,resultinginaprioritisedlistofrisksforfurtheraction;and

treatingrisksselectingandimplementingappropriatemanagementoptionsfordealingwithidentified

risk(e.g.modifyingprocedures,protocolsorworkpractices;providingeducation;andmonitoring

compliancewith

infection

control

procedures).

Table A2.1: Risk ana lysis matrix

ConsequencesLikelihood

Negligible Minor Mod erate Major Extrem e

Rare Low Low Low Medium High

Unlikely Low Med ium Med ium High Very high

Possible Low Medium High Very high Very high

Likely Med ium High Very high Very high Extrem e

Almost certain Med ium Very high Very high Extrem e Extrem e

Low risk Mana ge by routine p rocedures.

Medium risk Manage by specific monitoring or audit procedures.

High risk

Very hig h risk

This is serious and must be add ressed imme d iate ly.

The ma gnitude o f the co nseq uenc es of an eve nt, should it occ ur, and the likelihood of that e vent


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A2 Overview of risk mana ge ment in infec tion prevention and c ontrol

25

Extrem e risk oc curring, are a ssessed in the c ontext of the effe c tiveness of existing strate gies and c ont rols.

Monitoringandreviewisanessentialcomponentoftheriskmanagementprocess.Thisensuresthat:

newrisksareidentified;

analysisofriskisverifiedagainstrealdata,ifpossible;and

risk

treatment

is

implemented

effectively.

Communicationandconsultationarealsokeyelementsofclinicalriskmanagement.Aninteractiveexchange

ofinformationbetweenmanagement,healthcareworkers,patientsandotherstakeholdersprovidesthebasis

forincreasedawarenessoftheimportanceofinfectionpreventionandcontrol,identificationofrisksbefore

theyariseandpromptmanagementofrisksastheyoccur.

Thefollowingflowchartoutlineskeyconsiderationsduringtheprocessofriskmanagementinthecontextof

infectioncontrolinthehealthcaresetting.Casestudiesgivingexamplesofhowtousethisprocess,including

relevantconsiderationsinspecificsituations,areincludedinPartB.

Figure A1.1: Risk ma nage me nt flowc ha rt

Avoid riskAre there alte rna tive proc esses

or proce dures that wo uld

eliminate the risk?

If a risk c annot be eliminated then

it must be ma nage d

Identify risks

What infec tious age nt is involved?

How is it transmitted?

Who is at risk (patient and/or healthcare

worker)?

Treat risks

What will be do ne to a dd ress

risk?

Who ta kes responsibility?

How will c hang e be m onitored

and reviewed ?

Analyse risks

Why c an it happ en (ac tivities,

proc esses)?

How often could it happ en?

What are likely consequences?

Communicatea

ndconsult

Eva luate risks

What ca n be done to reduce o r

elimina te the risk?

How c ould this be ap plied in this

situa tion (sta ff, resource s)?

Monit

orandreview


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26

A3 A PATIENT-CENTRED APPROACH

Summary

A p atient-centred hea lth system is known to be assoc iated with safer a nd higher quality ca re.

A two -way a pp roa c h tha t enc ourage s pa tient pa rticipation is essential to suc c essful infec tion p revention

and co ntrol.

A3.1 PATIENT-CENTRED HEALTH CARE

Peoplereceivinghealthcareincreasinglyexpecttobegiveninformationabouttheirconditionandtreatment

optionsandthisextendstotheirrightsandresponsibilitiesasusersofhealthcareservices.Althoughpatient

satisfactionwithhealthservicesinAustraliaisgenerallyhigh,patientsexperiencesarenotalwaysvalued

andtheirexpectationsarenotalwaysmet.Whilethisdoesnotnecessarilyleadtopooroutcomesforthe

individualsconcerned,thebestpossibleoutcomesaremorelikelywherepatientcentredhealthcareisa

priorityofthehealthcarefacilityandastrongandconsistenteffortismadetorespectpatientsrightsand

expectations.

TheACSQHChasdevelopedanAustralianCharterofHealthcareRights,6whichrecognisesthatpeople

receivingcareandpeopleprovidingcareallhaveimportantpartstoplayinachievinghealthcarerights.The

Charterallowspatients,families,carersandservicesprovidinghealthcaretoshareanunderstandingofthe

rightsofpeoplereceivinghealthcare.TheCharterstipulatesthatallAustralianshavetherightto:

accessservicesthataddresstheirhealthcareneeds;

receivesafeandhighqualityhealthservices,providedwithprofessionalcare,skillandcompetence;

receivecarethatshowsrespecttothemandtheirculture,beliefs,valuesandpersonalcharacteristics;

receiveopen,timelyandappropriatecommunicationabouttheirhealthcareinawaytheycan

understand;

joininmakingdecisionsandchoicesabouttheircareandabouthealthserviceplanning; havetheirpersonalprivacyandpersonalhealthandotherinformationproperlyhandled;and

commentonorcomplainabouttheircareandhavetheirconcernsdealtwithproperlyandpromptly.

Patientcentredcarecannotjustbeaddedontousualcare.Therights,experiencesandviewsofpatients

shouldbeatthecentreofthecareprocessanddrivethewayinwhichcareisdelivered.Inmosthealthcare

facilities,asignificantculturechangeisnecessarytoembedpatientcentredcareprinciplesintothe

philosophyandpracticesoftheorganisation.Healthcareworkersandorganisationsneedtoacknowledge

andunderstandtheCharterofHealthcareRightsandworktoensurethatpatientsrightsareintegraltothe

careprocess.

A3.2 HOW DO ES PATIENT-CENTRED CARE RELATE TO INFECTION CONTROL?

Infectioncontrolisultimatelyaboutpeople.Effectiveinfectioncontroliscentraltoprovidinghighquality,

patientcentredhealthcare.

Puttingpatientsatthecentreofinfectioncontrolandenablingthemtoparticipateinthecareprocessisnot

justaboutexplainingtherisksoftreatments,butinvolvesconsideringpatientsneedsateverylevel.This

rangesfromdesigningthefacilitytomaximisepatientcomfortandsafetytohavingarangeofprocessesto

engagepatientsintheircareandlistenandactontheirfeedbackaswellasprovidingthepatientwith

educationandsupportsothattheycanbeinvolvedinlookingafterthemselves.

6 Availableat:http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/compubs_ACHR

roles/$File/17537charter.pdf


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A3 A pa tient-centred a pp roach

27

Tosupportatwowayapproachtoinfectionpreventionandcontrolandencouragethepatientparticipation

requiredtopreventinfectionandminimisecrossinfection,itisimportantto:

takepatientsperspectivesintoaccountwhendevelopingpoliciesandprograms;

familiarisepatientswiththeinfectionpreventionandcontrolstrategiesthatareemployedinhealthcare

facilitiestoprotectthem,thepeoplecaringforthemandthehealthcareenvironment,andproceduresfor

dealingwithinfectioncontrolbreaches;

discusswithpatientsthespecificrisksassociatedwiththeirmedicaland/orsurgicaltreatment;

encouragepatientstodisclosetheirhealthorriskstatusifthereisapotentialriskorsourceofinfectionto

healthcareworkersorotherswithinthehealthcarefacility;

provideopportunitiesforpatientstoidentifyandcommunicaterisksandencouragethemtouse

feedbackproceduresforanyconcernsthattheyhaveaboutinfectionpreventionandcontrolprocedures;

provideeducationalmaterialsaboutinfectionpreventionandcontrolusingavarietyofmedia,including

postersinwaitingrooms,printedmaterialandeducationalvideos;and

informpatientsabouttheprotocolsforprotectingtheirprivacyandconfidentiality.

Specificguidanceonprovidingpatientcentredcareishighlightedthroughouttheguidelines,intextboxes,

inthePuttingitintopracticesectionattheendofeachchapterinPartB,andineachchapterofPartC.

Resourcesonhealthcarerights,culturalcompetence,andlinkstotoolsthataimtoassistdeliveryofpatient

centredcare,arelistedinPartD.


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PART B STANDARD AND TRANSMISSION-BASED PRECAUTIONS

The use of sta ndard p rec au tions is the primary strategy for minimising the transmission o f healthc a re-associated infections.

Transmission-ba sed p rec au tions are used in ad d ition to sta ndard p reca utions, where the suspec ted or

known presence of infectious agents represents an increased risk of transmission.

The ap p lic at ion o f transmission-ba sed prec autions is pa rtic ularly imp ortan t in c onta ining multi-resistant

organisms (MROs) and in outbreak m ana ge ment.

Med ica l and denta l proced ures increa se the risk of transmission of infec tious ag ents. Effec tive wo rk

prac tice s to m inimise risk of transmission of infec tion related to proc ed ures req uire c onsiderat ion of t he

spe c ific situation, as we ll as app rop ria te use o f sta ndard and t ransmission-ba sed p rec autions.

Ap prop riate use o f asep tic t ec hnique a lso low ers the risk of infec tion risk by m inimising the numb er of

infec tious ag ents to whic h p atients are exposed . This c omp rises c lean te c hnique (stand ard prec autions

such as hand hyg iene, rep roc essing of e quipm ent b etw een pa tients, environme ntal c leaning) as a

minimum, as well as sterile technique to prevent infectious agents from entering a patients bloodstream

(e.g . use o f sterile instrume nts, d ressing m a teria ls and g love s, skin ant isep sis, and c rea tion o f a sterile field

within which to op erate).

The informa tion p resente d in this Part is pa rticula rly releva nt t o hea lthca re wo rkers and suppo rt sta ff. It outlines

effec tive w ork prac tice s tha t m inimise t he risk of transmission o f infec tious ag ents.

In a pp lying stand ard a nd transmission-ba sed infec tion c ontrols as part of d ay-to-da y p rac tice, hea lthc are

wo rkers should e nsure tha t their pa tients understand why c ertain prac tices are b eing und ertaken, and that

these p rac tices are in plac e to protec t eve ryone from infection. In this wa y, patients c an ta ke pa rt inminimising risks and question aspects of their care if necessary.


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B1.1 Hand hygiene

29

B1 STANDARD PRECAUTIONS

Summary

It is essentia l tha t stand ard prec autions a re ap plied a t a ll time s. This is be c ause:

pe op le ma y be plac ed at risk of infec tion from others who c arry infec tious ag ents;

pe op le ma y be infec tious be fore signs or sympto ms of d isea se a re rec og nised or dete c ted , or before

labo rato ry tests are c onfirmed in time to c ontribute to c are;

pe op le ma y be a t risk from infec tious ag ents present in the surrounding environment includ ing

environmental surfaces or from equipment; and

there ma y be an inc reased risk of transmission assoc iated w ith spec ific proc ed ures and p rac tice s.

Sta ndard prec autions c onsist of the ap prop riate use o f four distinct interventions:

hand hygiene and coug h etiquette;

the use o f pe rsona l protec tive equipm ent;

the sa fe use and disposa l of sha rps; and

routine environme ntal c leaning.Hand hygiene p rac tice s are rec omm ended before and after every episode of pa tient c ontac t. Stand ard

prec autions should b e used in the hand ling o f:

blood (including dried blood);

all other bo dy fluids, sec retions and e xcretions (exclud ing swe a t), reg ardless of w hethe r they c ontain

visible bloo d ;

non-intac t skin; and

muc ous mem branes.

Ap prop riate d ispo sa l of hazardous ma terials (i.e. waste a nd linen) is a further imp ortant a spec t of infec tion

c ontrol. This is outside the sc op e o f these g uidelines and prac tice in these a rea s should ad here to releva nt

Australian standards.

Evidenc e supporting prac tice

Themajorityoftherecommendationsinthissectionhavebeenadaptedfrom:7

GraysonL,RussoP,RyanKetal(2009)HandHygieneAustraliaManual.AustralianCommissionforSafety

andQualityinHealthcareandWorldHealthOrganization;

UnitedStatesCentersforDiseaseControlandPrevention(CDC)GuidelineforIsolationPrecautions:

PreventingTransmissionofInfectiousAgentsinHealthcareSettings(2007);

Prattetal(2007)Epic2:NationalEvidenceBasedGuidelinesforPreventingHealthcareAssociatedInfectionsin

NHSHospitalsinEngland;and

WorldHealthOrganization(2009)GuidelinesonHandHygieneinHealth.

Furtherreviewoftheevidenceelicitedgoodqualityevidenceontheuseofalcoholbasedhandrubsin

reducingtransmissionofinfectiousagents.8

7 TheseguidelineswereselectedbasedonanalysisusingtheAGREEtool,whichensuresthatguidelineshavebeendevelopedinarigorous,transparentandrobustmanner.ThisprocessisdiscussedindetailinAppendix2.

8 ThereportofthisreviewisavailablefromtheNHMRCuponrequest.


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B1 Stand ard prec aut ions

30

B1.1 HAND HYGIENE AND COUGH ETIQUETTE

B1.1.1 What are the risks?

Anyinfectiousagenttransmittedbythecontactordropletroutecanpotentiallybetransmittedbytouch.

Microorganismsareeitherpresentonthehandsmostofthetime(residentflora)oracquiredduring

activitiessuchashealthcare(transientflora).Handscanalsobecomecontaminatedthroughcontactwith

respiratorysecretions

when

coughing

or

sneezing.

Contaminated

hands

can

lead

to

cross

transmission

of

infectiousagentsinnonoutbreaksituations(Prattetal2001;CDC2002;Prattetal2007)andcontributeto

outbreaksinvolvingorganismssuchasmethicillinresistantStaphylococcusaureus(MRSA),vancomycin

resistantenterococci(VRE)andmultiresistantGramnegative(MRGN)microorganisms,suchas

Acinetobacterspp(Prattetal2001).

Figure B1.1: Imp ortanc e of hand hygiene

Theseimagesillustratethecriticalimportanceofhandhygieneincaringforpatients,includingthosenotknownto

carryantibioticresistantorganisms.Animprintofahealthcareworkersunglovedhandwasobtainedafterroutine

abdominalexaminationofapatientwithnohistoryofMRSAinfectionbutfoundonroutinesurveillancetohave

MRSAcolonisation.TheresultantcultureshowsMRSAcolonies(imageonleft).Anotherhandimprintobtainedafter

theworkershandhadbeencleanedwithalcoholbasedhandrubwasnegativeforMRSA(imageonright).

Source: DonskeyCJ&EcksteinBC(2009)Imagesinclinicalmedicine.Thehandsgiveitaway.NEnglJMed360(3):e3.

Improvedhandhygienepracticeshavebeenassociatedwith:

sustaineddecreasesintheincidenceofinfectionscausedbyMRSAandVRE(Websteretal1994;Zafaret

al1995;Maliketal1999;Larsonetal2000a;Pittetetal2000;Pittet&Boyce2001);

reductionsinhealthcareassociatedinfectionsofupto45%inarangeofhealthcaresettings(Fendleretal

2002;Pittetetal2000;Ryanetal2001);and

greaterthan50%reductionintheratesofnosocomialdiseaseassociatedwithMRSAandothermulti

resistantorganisms,after12years(Graysonetal2008;Johnsonetal2005).

Handhygienepracticesalonearenotsufficienttopreventandcontrolinfectionandneedtobeusedaspart

ofamultifactorialapproachtoinfectioncontrol.

B1.1.2 When should hand hyg iene be pe rformed ?

Handscanbecomecontaminatedwithinfectiousagentsthroughcontactwithapatient,patient

surroundings,the

environment,

or

other

healthcare

workers.

Cross

contamination

can

occur

from

one

site

to

anotherinthesamepatient,betweenhealthcareworkerandpatient,betweenpatientorhealthcareworker

andtheenvironment,orbetweenhealthcareworkers.Practicinghandhygienebeforeeveryepisodeofpatient
http://content.nejm.org/content/vol360/issue3/images/large/12f1.jpeghttp://content.nejm.org/content/vol360/issue3/images/large/12f1.jpeg


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B1.1 Hand hygiene

31

contact(includingbetweencaringfordifferentpatientsandbetweendifferentcareactivitiesforthesame

patient)andafteranyactivityorcontactthatpotentiallyresultsinhandsbecomingcontaminated(including

removalofgloves)reducestheriskofcrosscontamination.

The 5 mo me nts of hand hyg iene

The5momentsofhandhygienedevelopedbytheWorldHealthOrganizationandadoptedbyHand

HygieneAustralia

(Grayson

et

al

2009):

protectpatientsagainstacquiringinfectiousagentsfromthehandsofthehealthcareworker;

helptoprotectpatientsfrominfectiousagents(includingtheirown)enteringtheirbodiesduring

procedures;and

protecthealthcareworkersandthehealthcaresurroundingsfromacquiringpatientsinfectiousagents.

Figure B1.2: The 5 mom ents of ha nd hyg iene

Note: Handhygieneisalsoperformedaftertheremovalofgloves.

Source: Graysonetal2009.

RECOMMENDATION

1 Routine hand hyg iene Grade

Hand hygiene must be p erformed b efore and afte r eve ry episod e of pa tient co ntac t. Thisincludes:

before touching a pa tient;

before a proced ure;

after a p roc ed ure or bod y fluid expo sure risk;

after touching a pa tient; and

after touching a patients surroundings.

Hand hyg iene is also p erformed afte r the remo va l of g loves.

B

Cough e tiquette

Coveringsneezes

and

coughs

prevents

infected

persons

from

dispersing

respiratory

secretions

into

the

air.

Practisinghandhygieneaftercontactwithrespiratorysecretionsandcontaminatedobjectsormaterialsisan

essentialelementofcoughetiquette.


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B1 Stand ard prec aut ions

32

Coughetiquetteisparticularlyimportantforpatientsondropletprecautions(seeSectionB2.3).

Tab le B1.1: Step s in c oug h etiq uette

Anyone with signs and symptoms of a respiratory infection, regardless of the cause, should follow or be instructed to follow

co ugh etiquette a s follows:

Cove r the nose/ mo uth when c oug hing or sneezing

Use tissues to c onta in respiratory sec retions

Dispo se o f tissues in the nea rest waste rec ep ta c le a fter use

If no tissues are a vailable, co ugh or sneeze into the inner elbow rather than the ha nd

Practice hand hygiene after contact with respiratory secretions and contaminated objects/materials

B1.1.3 What prod uc t should be used ?

Recentsystematicreviewsandexistingguidelines(Boyce&Pittet2002;Picheansathian2004;Prattetal2007;

CanadaStandardsandGuidelineCoreCommittee2008;Larmeretal2008;PIDAC2008;Graysonetal2009)

andother

available

review

articles

(Pittet

&

Boyce

2001;

Rotter

2004;

Nicolay

2006)

agree

that

hand

hygiene

usingalcoholbasedhandrubsismoreeffectiveagainstthemajorityofcommoninfectiousagentsonhands

thanhandhygienewithplainorantisepticsoapandwater.

Alcoholbasedhandrubs(liquidorgel)areeasilyaccessibleatpointofcareandhave(Graysonetal2009):

excellentantimicrobialactivityagainstGrampositiveandGramnegativevegetativebacteria,

Mycobacteriumtuberculosisandawiderangeoffungi;

generallygoodantimicrobialactivityagainstenvelopedviruses;

lesserand/orvariableantimicrobialactivityagainstnonenvelopedviruses(suchasnorovirus);and

noactivityagainstprotozoanoocystsandbacterialspores(suchasC.difficile)(seeSectionB2.2).

Therangeofantimicrobialactivityinalcoholbasedhandrubsvarieswiththealcoholcompound(ethanol,

isopropanolornpropanol)used.Alcoholbasedhandrubsthathave70%byvolume(v/v)ethanolor

equivalenthavesignificantlygreaterantimicrobialactivityagainstcommoninfectiousagentsthanthose

below70%v/vethanol(Picheansathian2004;CanadaStandardsandGuidelineCoreCommittee2008;

PIDAC2008).Theadditionofalowconcentrationofchlorhexidinetoanalcoholbasedhandrubenhances

residualactivity(Rotter2004;Graysonetal2009)buthasbeenassociatedwithskinsensitivity.

Alcoholbasedhandrubsdonotremovedirtorotherorganicmaterial,andcontinuedusemayleadto

productbuildupthatleavesaresidue,requiringhandhygienewithliquidsoapandwater.

Plainsoapsactbymechanicalremovalofmicroorganismsandhavenoantimicrobialactivity.Theyare

sufficientforgeneralsocialcontactandforcleansingofvisiblysoiledhands.Thereisatendencyfor

antimicrobialsoapstobemoreeffectivethanplainsoaps,althoughtheevidencearoundthisisinconsistent.

Antimicrobialsoapisassociatedwithskincareissuesanditisnotnecessaryforuseineverydayclinical

practice(Prattetal2001;CDC2002;Prattetal2007.)

RECOMMENDATIONS

2 Choice of produc t for routine hand hygiene prac tices Grade

Alcoho l-ba sed hand rubs conta ining at least 70% v/ v etha nol or eq uivalent should b e

used for all routine hand hygiene p rac tices in the hea lthcare environme nt.B

3 Choice of hand hygiene produc t when hands are visibly soiled

If hand s a re visibly soiled, hand hyg iene should be performed using soa p a nd wa ter. B


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B1.1 Hand hygiene

33

Tec hnique

Effectivehandhygienereliesonappropriatetechniqueasmuchasonselectionofthecorrectproduct.Key

factorsineffectivehandhygieneandmaintainingskinintegrityinclude(CDC2002):

thedurationofhandhygienemeasures;

theexposureofallsurfacesofhandsandwriststothepreparationused(Widmer&Dangel2004);

theuseofvigorousrubbingtocreatefriction;and ensuringthathandsarecompletelydry.

Tab le B1.2: Use of alco hol-b ased hand rub

App ly the amo unt of alcohol-ba sed hand rub recom mend ed b y the manufac turer to dry hands.

Rub ha nds vigorously tog ether so tha t the solution c om es into co ntac t with all surfac es of the hand , pa ying p articular

atte ntion to the tips of the finge rs, the thumb s and the a reas be twe en the fingers.

Continue rubbing until the solution ha s eva po rated and the ha nds are d ry.

Tab le B1.3: Using soa p (includ ing antimic robial soap) and wa ter

Wet hands under tepid running w ater and ap ply the reco mmend ed amo unt of liquid soap .

Rub hand s vigorously toget her for a minimum of 15 sec ond s so tha t the solution c om es into c onta ct with a ll surfac es of

the ha nd, pa ying p articular attention to the tips of the fingers, the thumb s and the a reas be twe en the finge rs.

Rinse ha nds tho rough ly under running wa ter, then p a t d ry with single-use to we ls.

B1.1.4 Other aspec ts of hand hyg iene

Asintactskinisanaturaldefenceagainstinfection,cutsandabrasionsreducetheeffectivenessofhand

hygienepractices.Breaksorlesionsoftheskinarepossiblesourcesofentryforinfectiousagents(Larson

1996)andmayalsobeasourceofthem.Toreducetheriskofcrosstransmissionofinfectiousagents,cuts

andabrasionsshouldbecoveredwithwaterproofdressings.

Thetypeandlengthoffingernailscanhaveanimpactontheeffectivenessofhandhygiene(CDC2002;Lin

etal2003).Artificialnailshavebeenassociatedwithhigherlevelsofinfectiousagents,especiallyGram

negativebacilliandyeasts,thannaturalnails(Pottingeretal1989;Passaroetal1997;Focaetal2000;

Hedderwicketal2000;Moolenaaretal2000;Parryetal2001;CDC2002;Guptaetal2004;Boszczowskietal

2005).Fingernailsshouldthereforebekeptshortandcleanandartificialfingernailsshouldnotbeworn.

Althoughthereislessevidenceconcerningtheimpactofjewelleryontheeffectivenessofhandhygiene,

ringscaninterferewiththetechniqueusedtoperformhandhygieneresultinginhighertotalbacterialcounts

(CDC2002).Handcontaminationwithinfectiousagentsisincreasedwithringwearing(CDC2002;Tricket

al2003),althoughnostudieshaverelatedthispracticetohealthcareworkertopatienttransmission.

Wearingofjewelleryinclinicalareasshouldthereforebelimitedtoaplainband(e.g.weddingring)andthis

shouldbemovedaboutonthefingerduringhandhygienepractices.Inhighrisksettingssuchasoperating

suites/roomsthewearingofanyjewellery,evenaplainband,isnotrecommended.

B1.1.5 Hand care

Themaintypeofskinreactionassociatedwithhandhygiene,irritantcontactdermatitis,includessymptoms

suchasdryness,irritation,itchingandsometimescrackingandbleeding.Allergiccontactdermatitisisrare

andrepresentsanallergy,whichmaybetosomeingredientinahandhygieneproduct.

Generally,alcoholbasedhandrubscausesignificantlylessskindamagethanhandhygienewithplainor

antisepticsoaps(Pittet&Boyce2001).


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