Isolation Precautions: A multi site standardization project

Transcription

1 IsolationPrecautions: Amultisitestandardizationproject InfectionPreventionandControl MayoClinic September2012 Copyright2012MayoFoundationforMedicalEducationandResearch.Allrightsreserved.

2 Keycomponents Followaclearpurpose Haveaninfrastructure Interpretationoftheguidelines Applythemconsistentlyandwith flexibility Createcommonproductsandtools Signage,policy,educationand communication Followaclearpurpose Thebestinterestofthe patientistheonlyinterestto beconsidered,andinorder thatthesickmaybenefitof advancingknowledge,unionof forces isnecessary. ~WilliamJ.Mayo,M.D.(1910)

3 Establishaninfrastructureinfrastructure CreateOversightTeamm Policy Education Communication Identifyrepsfromeachregion Establishatimelinewithdeadlines Setuponlinecollaboration(Launchpad) Defineafuturereviewschedule Roadmap:Interpretationof theguidelines Interpretationoftheguidelines Adults CDCGuidelines AppendixAp.109 StandardPrecautions CDCGuidelines AppendixAp.109 Inimmunocompromised patients,extendtheduration ofcontactprecautionsduetoprolongedshedding Respiratoryinfectious disease,acute(ifnot coveredelsewhere) CDCGuidelinesAppendixAp.109 ContactPrecautions. WearmaskaccordingtoStandardPrecautions. DCGuidelinesAppendixAp.109 Respiratorysynctial virusinfection,in infants,youngchildrenand immunocompromised adults CDCGuidelinesAppendixAp.109 Infantsandyoung children CDCGuidelinesAppendixAp.109 ContactPrecautions Alsoseesyndromesor conditionslistedintable2 CDCGuidelinesAppendixAp.109 Respiratoryinfections,particularlybronchiolitis andpneumonia,ininfantsandyoungchildren (RSV,parainfluenza,adenovirus,influenza) CDCGuidelinesTable2p.121 ContactplusDropletPrecautions. DropletPrecautionsmaybediscontinuedwhen adenovirusandinfluenzahavebeenruledout CDCGuidelinesTable2p.121

4 "...itisbettertothinkand sometimesthinkwrong thannottothinkatall." ~WilliamJ.Mayo,M.D. Stopsalongtheway: Applicationofthe guidelines Categories SignageInstructions Icons Colors Airborne Contact Droplet Neutropenic PitStop:Isolation PrecautionCategories Airborne Contact Droplet ProtectiveEnvironment* Strict Stop Modified Droplet Protective Environment Enteric Special Agent Airborne *AlsoreferencedGuidelinesforEnvironmentalInfectionControlinHealthCareFacilities,2003

5 FlexibilityfromCDC Detour1 Gasstop:Healthcareworker Instructions Handhygiene? Handhygienerequired Mask? Surgicalmaskvs.maskwithfaceshield Gownandgloves? Otherresources? Gasstop:Visitor Instructions Handhygiene? Mask? Gownandgloves? Requiredforpatientcarevs.patientcontact Restrictionsandotherinstructions?

6 Flexibilityforinstructions acrosssites Detour2 Restarea:Icons Flexibilitywithinicons Standardhandhygieneicon ModifiedContacthand hygieneicon Standardhealthcareworker maskicon Detour3 Masksuppliedforhealthcare workersatsomesites

7 CommonColors Sometimesthemostunexpected detoursarethemostmemorable eventsonaroadtrip. CommonColors Blue =DropletPrecautions Brown =ModifiedContactPrecautions Pink =AirbornePrecautions Turquoise =ProtectiveEnvironment Orange =ModifiedDropletPrecautions Yellow =ContactPrecautions Red =NegativeAirPrecautions Detour4 Ifindthegreatthinginthis worldisnotsomuchwhere westand,asinwhatdirection wearemoving. ~OliverWendellHolmes

8 Standardizedproductsand tools Policy,Education&Communication DoorCards TransportCards QuickReference Commoninfrastructure Oneisolationprecautionspolicy Tailoredproceduresforeachisolation precautionateachsite Oneeducationtemplateandquick referencesheetsforhospital, ambulatoryandlongtermcare Formalcommunicationsdraftedand sharedacrosssites CommonDoorCards

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11 CommonTransportCards

12 Common referencetools InfectionswithIsolationPrecautions Hospitalquickreference Ambulatoryquickreference Longtermcarequickreference InfectionswithIsolationPrecautions Expectations StandardPrecautionsarefollowedforallpatients,regardlessofisolationstatus *Indicatesdiseasesthatarevaccinepreventable.Individualswhoarenotimmune(eitherbyvaccinationorpriorinfection)shouldnotenterthe roomorcareforthepatient.thisalsoappliestolocalizedzosterforwhichstandardprecautionsarerecommended. Inanoutbreaksituation,InfectionPreventionandControlmaymodifytherecommendationsbelow AirbornePrecautions Tuberculosis(suspectedorconfirmedpulmonaryorlaryngeal) ExtrapulmonaryTB(onlywhenperformingaerosolizingproceduresatthesiteofinfection) ContactPrecautions ModifiedContactPrecautions Skinorwoundinfection Uncontaineddrainage Resistantgrampositivebacteria MRSA(Methicillinresistant Staphylococcusaureus) VRE(Vancomycinresistant Enterococcus) Epidemiologicallysignificant resistantgramnegativebacteria (GNB) Acinetobacter E.coli Enterobacter Klebsiella Proteus Pseudomonasaeruginosa Stenotrophomonas DropletPrecautions ModifiedDropletPrecautions Respiratorysymptoms Suspectedinfectiousetiology untildiagnosismadeand conditionrequiringdroplet Precautionshasbeenruledout Suspectedorconfirmedinfection withoneofthefollowingin fecallyincontinentpatients Campylobacter Cholera(Vibriocholerae) Cryptosporidium Enteroviruses E.coli(0157:H7andothershiga toxinproducingstrains) Giardialamblia HepatitisA HepatitisE Salmonella Shigella Staphylococcusaureus (enterocolitis) Vibrioparahaemolyticus Yersiniaenterocolitica Meningitisuntil24hrsof effectivetherapy Haemophilusinfluenzae Neisseriameningitidis Pneumoniauntil24hrsof effectivetherapy Haemophilusinfluenzae (infantsandyoungchildren) Neisseriameningitidis Streptococcus(GroupA) Otherpathogensandconditions Burkholderiacepacia (incysticfibrosispatients) Congenitalrubella Conjunctivitis (acuteviralhemorrhagic) Diphtheria(cutaneous) Herpessimplex(disseminatedor severemucocutaneous,or neonatalinfection) Impetigo Lice Parainfluenza (infantsandyoungchildren) Poliomyelitis Scabies Scaldedskinsyndrome Otherpathogensandconditions Diphtheria(pharyngeal) Epiglottitis (infantsandyoungchildren) Influenza,seasonal(adults) Mumps* Mycoplasma ParvovirusB19 Pertussis Plague(pneumonic) Rubella(Germanmeasles)* Streptococcus(GroupA) - Pharyngitis (infantsandyoungchildren) - Pneumonia - Scarletfever (infantsandyoungchildren) Novelinfluenza Respiratoryinfectionoutbreaks (asdirectedbyinfection PreventionandControl) Recommendationsabovearebasedonthe2007CDCGuidelineforIsolationPrecautions.Exceptionsincludemeasles(ContactPrecautionsaddedto CDCrecommendations)andRSV(DropletPrecautionsaddedtoCDCrecommendations) Clostridiumdifficile Norovirus Rotavirus Contact+NegativeAir Herpeszoster,disseminated (shingles)* Measles(Rubeola)* Varicellazoster(chickenpox)* Contact+DropletPrecautions Adenoviruspneumonia Bronchiolitis,bronchitis,croup (infantsandyoungchildren) Influenza,seasonal (infantsandyoungchildren) RSV Streptococcus,GroupA (extensiveskininfection) Refertodiseaseindexfordefinitionofresistanceforeachorganism AirbornePrecautionsareanacceptablealternativetoNegativeAirPrecautionsifstaffing/suppliesallow

13 Hospital Quick Reference Card for Isolation Precautions ExpectationsforIsolationPrecautions StandardPrecautionsarefollowedforallpatients,regardlessofisolationstatus Handhygieneisrequiredusingalcoholbasedhandruborsoapandwater(followsitespecificprocedures) PersonalProtectiveEquipment(PPE)iswornforroomentryandremovedbeforeexitingthepatientroom Usededicatedpatientcareequipmentanddisinfectanyequipment usedbetweenpatientsorremovedfromanisolationroom Inanoutbreaksituation,InfectionPreventionandControlmaymodifytherecommendationsbelow Type DiseaseRequiringIsolation (thisisnotanexhaustivelist) RoomType Gloves Gown Maskor Respirator Environmental Services PatientRequirements Airborne Tuberculosis Negativeair Doorto remainclosed atalltimes No No FittestedN95 respiratororpapr Doortoremainclosed for60minutespriorto standardterminal roomcleaning Limittransporttoessentialpurposesonly Patientsarediscouragedfromambulatingoutof theirroom Patientmustperformhandhygieneand wearasurgicalmaskbeforeleavingroom Contact MRSA,VRE,RSV*,resistantgram negatives,scabies,diarrhea Private Doormay remainopen Yes Yes No Routinedailyand terminalroom cleaning Patientmustperformhandhygiene,wearaclean gownandhavecleandressingsbeforeleavingroom foressentialpurposesoratherapeuticwalk Modified Contact Suspectedorconfirmed C.difficile ornorovirus infections Private Doormay remainopen Yes Yes No Routinedailyand terminalroom cleaningwithbleach wipes Patientmustperformhandhygiene,wearaclean gownandhavecleandressingsbeforeleavingroom foressentialpurposesoratherapeuticwalk Droplet Pertussis,RSV*,parvovirus, influenza(seasonal),neisseria meningitidis,mumps^,rubella^ Private Doormay remainopen Yes No Mask Routinedailyand terminalroom cleaning Patientmustperformhandhygieneandweara surgicalmaskbeforeleavingroomforessential purposesoratherapeuticwalk Modified Droplet Novelinfluenza,respiratory infectionoutbreaks(asdirected byinfectionpreventionand Control) Private Doorto remainclosed duringaerosol generating procedures and60 minutesafter Yes Yes Maskwitheye protection PAPR(orfittested N95respiratorplus eyeprotection)for aerosolgenerating procedures Routinedailyand terminalroom cleaning Limittransporttoessentialpurposesonly Patientsarediscouragedfromambulatingoutof theirroom Patientmustperformhandhygiene, wearacleangownandsurgicalmaskbeforeleaving room Note:PatientactivitiesmaybelimitedbyInfection PreventionandControlbasedonseverityofillness Protective Environment Absoluteneutrophil count<500 cells/dl,poststemcelltransplant Private Doorto remainclosed atalltimes No No No Routinedailyand terminalroom cleaning PatientmustwearasurgicalmaskorN95respirator whenoutofroom,andwhenroomisbeingcleaned andfor30minutesaftercleaning NegativeAir # (mustbe orderedwith Contact Precautions) Disseminatedzoster^, chickenpox^,measles^ Negativeair Doorto remainclosed atalltimes Yes Yes No Doortoremainclosed for60minutespriorto standardterminal roomcleaning * Some respiratory diseases require both Droplet and Contact Precautions (e.g. RSV) ^ Non-immune staff and visitors should not enter this room # Airborne Precautions are an acceptable alternative to Negative Air Precautions if staffing/supplies allow Limittransporttoessentialpurposesonly Patientsarediscouragedfromambulatingoutof theirroom Patientmustwearasurgicalmask beforeleavingroom Ambulatory Quick Reference for Outpatients with selected Infectious Agents Category Chickenpox [Varicella] or DisseminatedHerpes Zoster[Shingles] LocalizedHerpes Zoster[Shingles] ForhospitalpatientsonIsolationPrecautionsseeninambulatoryareas,followinstructionsonTransportCard StandardPrecautionstobeusedforallpatientsatalltimes,includinghandhygiene Room Requirements Promptlyroompatient Wearsurgicalmaskatdesk UseNegativeAirroom checkin,duringtransport, (ifavailable) andwheninpublic Promptlyroompatient PatientRequirements StaffPPERequirements SpecialInstructions Coverlesionswhengoing betweenappointments Glovesforcontactwithlesions Glovesforcontactwithlesions Nonimmunestaffshouldnotentertheroom Closeexamroomfor60minutesfollowing appointment Nonimmunestaffshouldnotentertheroom Generalexamroomturnover Liceor Scabies Promptlyroompatient None Glovesforpatientcontact Vacuumupholsteredfurniture Delayfurtherappointmentsuntilscabies/lice treated,ifpossible.ifthisisnotfeasible,notify receivingareasaboutpatient sstatus. Measles MultiDrugResistant Organisms Promptlyroompatient UseNegativeAirroom (ifavailable) Promptlyroompatient Wearsurgicalmaskatdesk checkin,duringtransport, andwheninpublic Coveropenwoundswhen goingbetweenappointments Mumps Promptlyroompatient Wearsurgicalmaskatdesk checkin,duringtransport, andwheninpublic Glovesforcontactwith respiratorysecretions Standardprecautions Glovesforcontactwith respiratorysecretions Nonimmunestaffshouldnotentertheroom ImmediatelynotifyInfectionPreventionand Control Closeexamroomfor60minutesfollowing appointment Generalexamroomturnover Nonimmunestaffshouldnotentertheroom ImmediatelynotifyInfectionPreventionand Control Generalexamroomturnover Pulmonary Mycobacterium Tuberculosis[TB] Promptlyroompatient UseNegativeAirroom (ifavailable) Wearsurgicalmaskatdesk checkin,duringtransport, andwheninpublic FittestedN95respiratoror PAPRifpatientcannottolerate asurgicalmask Notifyreceivingarea(s)ofpatient'sTBstatus Closeexamroomfor60minutesfollowing patientappointment UpperRespiratory Infections [e.g.pertussis, Influenza,RSV] Promptlyroompatient Wearsurgicalmaskatdesk checkin,duringtransport, andwheninpublic Glovesforcontactwith respiratorysecretions Maskifpatient smaskis removed(e.g.duringculturing) Generalexamroomturnover Long Term Care Quick Reference Card for Infectious Agents Standard Precautions to be used for all residents at all times Category Conjunctivitis Clostridium difficile (C. diff) Herpes Zoster (Shingles) Disseminated OR Localized in immunocompromised patient until disseminated infection ruled out (if lesions have not spread in past 24 hours consider localized zoster) Herpes Zoster localized [Shingles] in patient with intact immune systems Room Requirements No special room requirements Single resident room Use Negative Air room (if available) Close Door Not required Not required Yes Not required Transmission Route Contact with eye drainage Fecal to oral Contact with surfaces or items that are contaminated Contact with fluid from lesions Contact with articles soiled with discharge from vesicles or mucous membranes Contact with fluid from lesions. Contact with articles soiled with discharge from vesicles or mucous membranes. Resident Requirements Instruct resident to perform frequent hand hygiene Avoid sharing personal items Instruct resident to perform frequent hand hygiene Cover lesions (when localized) until dry and crusted Wear surgical mask when out of room Cover lesions until lesions dry and crusted Staff PPE & Hand Hygiene Requirements Gloves for contact with eye drainage or contaminated items Perform hand hygiene Gloves for all contact Gown for contact if incontinent or diapered Gloves for skin contact with lesions Perform hand hygiene Gloves for skin contact with lesions Perform hand hygiene Special Instructions Avoid use of multi-dose medication vials Disinfect patient care equipment after each use General room cleaning Wipe down contaminated equipment and surfaces with hospital grade disinfectant Wipe down contaminated surfaces with bleach during daily cleaning Disinfect all patient care equipment after each use (check manufactures guidelines prior to use of bleach) Susceptible staff should not enter the room General room cleaning Wipe down contaminated equipment and surfaces with hospital grade disinfectant Susceptible staff should not enter the room General room cleaning Wipe down contaminated equipment and surfaces with hospital grade disinfectant

14 MakingtheMayoexperience thesameregardlessofwhere thepatientreceivesmayo Cliniccare. Otherconsiderations Challenges Computerissues Standardizationdrift StandardPrecautionseducation Aimforstandardization,butallowfor flexibilityanddeviations,asneeded Tripsummary Copyright2012MayoFoundationforMedicalEducationandResearch.Allrightsreserved.