Infection Control (English version 1/8/2003)

Infection Control Precautions in Hospitals (1/8/2003)

Precautionary Measures in Out-patient Setting (1/8/2003)

　

感染控制措施 (中文版 2003年8月1日) 



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A. Infection control precautions In hospitals (1/8/03)

　

SARS: Current Situations and Precaution Strategy

SARS: Current Situations and Precaution Strategy

　

1.

On 5 July 2003, Taiwan was removed from the WHO list of areas with recent local transmission of SARS, indicating human-to-human chain of transmission of SARS appears to be broken globally.
   

2.

Vigilance for SARS must be maintained, because resurgence of SARS is possible as experienced in Toronto, and knowledge on the origin, animal or environmental reservoir of SARS-Coronavirus is still lacking.
   

3.

A high index of suspicion, rapid detection and isolation of cases, prompt contacts tracing and isolation are the key measures for effective control of SARS outbreak.
   

4.

Effective infection control with onsite assessment of environment, patient characteristics, healthcare activities, prevailing staff awareness and practices, etc. are needed.
   

5.

Consolidate hospital infection control (IC) mechanism to ensure effective implementation of IC measures at all workplaces.
   

6.

SARS information and IC precautions should be regularly updated and promoted to all staff.
   

7.

HA Influenza Vaccination Programme  

In order to avoid the anxiety and confusions caused by influenza, this year the vaccination programme will be extended to include hospitalised mentally ill patients and all Health Care Workers with direct patient contact.

　
   

8.

Isolate / cohort SARS patients from other patients and practice barrier nursing with personal protection equipment (PPE) according to the risk of exposure.

　

　

Basic Considerations
1.

SARS-coronavirus (CoV) can be found in respiratory secretions, saliva, blood, urine and feces of SARS patients.

2.

SARS-CoV is stable in environment for up to 2 day at room temperature and longer at a lower temperature. Survival in a variety of stool suspension varies depending on the pH, consistency of stool and possibly other factors (up to 4 days in alkaline, diarrhoeal stool, 6 hours in normal stool and 3 hours in normal, acidic baby stool). The virus loses infectivity after exposure to different commonly used disinfectants (including alcohol and hypochlorite), and heating at 56°C for 15 minutes.

 

 

3.

The main modes of transmission are by droplets, aerosolized respiratory secretions and direct contact with patient’s secretion, excreta and fomites.
   

Main mode of transmission

Characteristics

Prevention Strategy

Droplets

Coughing, sneezing, talking (limited distance » 3 feet)
Splashing during procedure (could be farther)

Surgical mask for symptomatics & healthcare workers (HCW)
Protection eyewear
Space out patients ± barriers
PPE for patient care and procedure

Aerosolized respiratory secretions

Require additional contributing factors
Float in air longer & farther

Avoid nebulizer use
Limit high-risk procedures (e.g. cough inducing procedures) and consider additional precautions
Good Ventilation (increase air change, directional air flow)

Contact with patient’s secretion, excreta (direct) and fomites (indirect)

Environmental contamination
Hands as a vehicle

Frequent environment cleaning and disinfection
PPE for patient care and procedures
Hand hygiene critical
Avoid touching mask and face (eyes, nose and mouth)

 

 

 

High index of suspicion
　
1. Maintain high vigilance and practice infection control precautions in all healthcare settings according to risk of SARS. Each hospital must categorize its clinical settings by risk and implement corresponding levels of IC precaution and PPE standards.
 

Risk assessment

  • Patient-related risk (confirmed / suspected SARS, super spreading events, triage areas such as AED and triage ward, patient with fever of unknown origin, etc.)
  • Procedure-related risk (ICU, procedure room such as bronchoscopy room or XR department area serving SARS patients, dirty utility room, etc.)

 

　

Training and Enforcement
　
1. All personnel working inside a patient setting must receive documented training on infection control precautions against SARS.
2. This applies to HA employees as well as contractor staff.
3. Hospital management should maintain records of training for independent review.
4. Regular update and drills on infection control practice should be conducted.

　

Personal Protection Equipment
　
1. All persons coming into contact with a probable or suspected SARS patient or the immediate environment must practice IC precautions according to the risk of exposure as judged by patient- and procedure-related risks. 
2. The hospital IC team should establish PPE standards making reference to the recommended minimal standards by the HA and other factors pertaining to the hospital.
3. Recommended standards of PPE by the Hospital Authority:
 
I.   High-risk patient areas (Fever triage wards/cubicles, cohort wards, SARS screening areas)
a. No direct patient contact

  • surgical mask

  • A linen or or disposable gown

The following are optional:

  • Eye shield/Full-face shield, Disposable cap
   
b. Direct patient contact or activities with risk of exposure to blood, body fluids, secretions, excreta and contaminated items
 

  • N95/surgical mask

  • A linen or or disposable gown

  • Full-face shield or eye shield

  • Latex gloves (only for procedures with exposure to blood and body fluid, secretion, excreta, and contaminated items)

The following are optional:

  • Disposable cap, Goggles
   
c. Procedures with high risk of generating aerosols (e.g. resuscitation, high flow oxygen) and requiring prolonged very close contact with affected patients
 
  • N95 respirator 
  • A linen gown if no uniform / working clothes 
  • Disposable gown
  • Latex gloves
  • Full-face shield
  • Goggles 

The following are optional:

  • Disposable cap
II.  Other patient areas
a. No direct patient contact
 

  • surgical mask

The following are optional:

  • A linen or or disposable gown
b. Direct patient contact or activities with risk of exposure to blood, body fluids, secretions, excreta and contaminated items

  • surgical mask

The following are required for procedures with exposure to blood, body fluids, secretion , excreta and contaminated items:

  • A linen or or disposable gown

  • Latex gloves
  • Full-face shield or eye shield
c. Procedures with high risk of generating aerosols (e.g. resuscitation, high flow oxygen) and requiring prolonged very close contact with affected patients
  • N95/surgical mask
  • A linen or disposable gown
  • Latex gloves
  • Full-face shield

The following are optional:

  • Disposable cap, Goggles
III. Other non-patient areas (office, corridors & etc)
  • surgical mask is optional

Note:

  • N95 respirator should be fit checked every time when used.

  • Barrier-man suit is not designed for infection control purposes. Great care must be exercised in the undressing process to avoid contamination.

  • Management should ensure that the standard PPE and any optional items are available upon request. PPE is only effective if used correctly and does not replace basic hygiene measures.

  • PPE is not meant to be foolproof and healthcare workers are advised to wash liberally without delay if get contaminated.
   
4. General advice in using PPE
 

General advice in using PPE

  • Latex gloves provide protection against gross contamination of patient’s secretions, body fluid and excretions during procedure or contact with the immediate environment and equipment used by a high-risk patient
  • To avoid cross infecting other patients and contaminating the environment, healthcare workers must change gloves after procedure and in between patients. They must wash hands or use hand rub before putting on a pair of new gloves
  • Gloves do not replace hand washing. Washing gloves for continual use is not allowed and double gloving is not recommended
  • When the supply of N95 respirator is tight (especially small size models), reuse may be necessary despite an increased potential of contamination. This risk should be balanced against the benefit of ensuing supply of N95 respirator to healthcare workers. In reusing a N95 respirator, all of the following conditions must be fulfilled:
    • The N95 respirator (i) is always protected by an overlying surgical mask or full-face shield, (ii) has not been exposed to gross contamination, (iii) is not wet, (iv) has no visible soiling, and (v) is not deformed.
    • Used N95 respirator should be stored in a single use clean paper bag labeled with the user name
    • After wearing a used N95 respirator, user must wash hands thoroughly

  • Remove / change PPE when moving from a high to a low risk area as defined in your hospital
  • Careful gowning down is crucial in avoiding contamination. Do not gown down together in close proximity to another person
  • Used PPE should be treated as contaminated and should not be taken out of the workplace into non-clinical areas except in brief transit and adequately protected
  • Reusable PPE must be properly maintained and disinfected after use
  • Wearing of PPE except surgical masks outside clinical area is not allowed
  • Full face shield is used for situation where there is a chance of splashing during the procedure, otherwise eye shield is adequate.

 

　

Standard Precautions

　

Use Standard Precautions for the care of all patients:
1. Handwashing
  a) Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments.
b) Use a plain  or antimicrobial soap for routine handwashing.
c) Use an antimicrobial agent or a waterless antiseptic agent for specific circumstances (e.g., control of outbreaks or hyperendemic infections), as defined by the infection control program.
2. Gloves
a) Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body fluids, secretions, excretions, and contaminated item.
b) Put on clean gloves just before touching mucous membranes and nonintact skin.
c) Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.
d) Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments.
3. Mask, Eye Protection, Face Shield
a) Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions.
 
4. Gown
a) Wear a gown (a clean, nonsterile gown is adequate) to protect skin and to prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.
b) Select a gown that is appropriate for the activity and amount of fluid likely to be encountered.
c) Remove a soiled gown as promptly as possible, and wash hands to avoid transfer of microorganisms to other patients or environments.
5. Patient-Care Equipment
a) Handle used patient-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. Ensure that single-use items are discarded properly.
6. Environmental Control
a) Ensure that the hospital has adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces, and ensure that these procedures are being followed.
7. Linen
a) Handle, transport, and process used linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures and contamination of clothing, and that avoids transfer of microorganisms to other patients and environments.
8. Occupational health and Bloodborne Pathogens
a) Take care to prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments; and when disposing of used needles.  
b) Never recap used needles, or otherwise manipulate them using both hands, or use any other technique that involves directing the point of a needle toward any part of the body.
c) Do not remove used needles from disposable syringes by hand, and do not bend, break, or otherwise manipulate used needles by hand.  
d) Place used disposable syringes and needles, scalpel blades, and other sharp items in SHARPS box.
9. Patient Placement
a) Place a patient who contaminates the environment or who does not (or cannot be expected to) assist in maintaining appropriate hygiene or environmental control in an isolation room.

　

Practices
　
1.  Hand hygiene:

  • Hand washing is the single most important measure against transmission of infection that spreads through contact

  • Always wash hands after any patient contact, and whenever after removing gloves

  • Use alcohol-based hand rub as alternative only when hands are not visibly soiled

  • Management should ensure adequate provision of hand washing facilities and/or alcohol based hand rub to encourage hand hygiene in wards and clinics

  • Do not touch mask or face (esp. the eyes, nose and mouth) without first washing hands thoroughly

2. Uniform / working clothes: it is advisable for healthcare personnel to have uniform / working clothes and working shoes.
3. Staff working in high-risk areas should take a shower before leaving hospital or on returning home if possible.
4. Reporting fever and symptoms:

  • Adequate number of thermometers are distributed to allow each staff to have one thermometers for their own use

  • Staff are encouraged to conduct daily body temperature check as a simple & un-intrusive way of monitoring one’s health

  • It is important for staff to report fever and symptom to hospital management immediately and seek medical advice (e.g. staff clinic or AED Department)

　

　

Environmental Control
　
1. Cohorting

a) 

 All patients suspected of SARS and patients with respiratory symptoms should be given a mask to wear to avoid spreading the disease to others;
b)  Designated areas for gowning and degowning should be established in the ward areas for the care of suspected SARS patients;
c)  Suspected cases of SARS should be isolated promptly;
d)  Adequate hand washing facilities and alcohol based hand rub to encourage hand hygiene should be provided;
e)  When singles rooms are fully occupied, patients should be cohorted in cubicles and maintaining adequate separation from each other to allow barrier nursing;
f)  SARS patients with supporting laboratory evidence could be isolated by cohorting, but they should not be nursed in the same cubicle with suspected cases;
g)  To allow prompt isolation of potential cases of SARS presenting with non-specific symptoms, specialty wards should arrange side rooms for such purpose.
2. Environment hygiene and waste management
a) Clean and disinfect the environment, furniture and facilities at least once daily or more frequently depending on risk.
b) Procedure rooms should be disinfected after use by a high-risk patient. (Click here for Guidance Notes on Disinfection and Cleansing of Environment and Equipment)
 
  • Use 1:49 dilution hypochlorite for non-metallic and 70% alcohol for metallic items
  • Facilities contaminated with blood must be immediately disinfected with 1:4 dilution hypochlorite before cleaning, and 1:49 dilution hypochlorite for others contamination
  • Bedpans and urinals used by patients should be handled with care, preferably with cover during transport to the dirty utility room
  • If a bedpan washer is used, there is no need to empty the bedpan first. Just put it into the bedpan washer unless it contains waste that could block the drainage outlet
  • Urinals and urine measuring jugs should be emptied before disinfection, either by the bedpan washer or rinsing with water and then immerse in 1:49 hypochloride for 30 minutes
3. Equipment management
a) For items that cannot be readily disinfected, reserve for dedicated patient use if possible.  
b) If sharing is unavoidable, they must be cleaned and disinfected before using on other patients, e.g. by 1:49 dilution hypochlorite or 70% alcohol.  
c) Reusable respiratory equipment should undergo high-level disinfection by CSSD between patients.
4. Ventilation
a) Consult hospital engineer if ventilation of the workplace requires improvement.  
b) A negative pressure in relation to surrounding areas could create isolation effect.  Airflow should preferably be from areas of lower to higher risk.  Air discharge to outside of building should be away from air intake duct.  
c) To avoid airflow disturbances, pneumatic tubes should not be used in SARS cohort areas.
5. Portering high risk patients:
a) Attendants should wear protective apparels.  
b) Transport vehicles should be protected with disposable sheets or disinfected after use.

　

Control Access by Visitors
　
1. High-risk areas: (Fever triage wards / cubicle, cohort wards, SARS screening wards)
a) "No Visiting" rule applies unless on compassionate ground.  
b) Visitors must register (i.e., in case contact tracing is required) and be kept to minimal.  
c) Other means, such as mobile phone, video-phone, video-conferencing could be measures to facilitate communication between patients and family members.
d) Educate visitors to adopt the standards of IC precautions and PPE.  
2. Other patient areas:
a) Limit visitors to no more than 2 per patient per day, and no more than 3 hours per day for acute and convalescent wards, and no more than 6 hours per day for infirmary wards.
b) Exceptions can be made for special situations such as paediatrics wards.  
c) Visitors must register ( in case contact tracing is required). (click here for visitor's record)
d) Health advice and information on proper infection control precautions should be available to visitors. (click English / Chinese for an sample of Notes to Visitors)

3. General Advice:
a) Children under 12 are generally not permitted in patient care area (unless with prior approval).
b) Pregnant women are strongly discouraged from visiting the hospital.
c) Volunteers activities within hospital patient care area should be restricted to a minimum till further assessment at a later stage.

　

Additional Precautions in High-risk Procedures/Activities
　
1. Nebuliserrs:

  • Should not use in high risk patient areas.

  • Can be considered in other patient areas if it is strongly indicated and should be carried out under aerosol removal device or inside negative pressure single room. 
2. Nasopharyngeal aspiration, BiPAP & CPAP :

  • In high risk patient areas, these procedures should be carried out in strongly indicated cases under aerosol removal device or inside a negative pressure room. 

  • In other patient areas, the risks and indications of these procedures as well as the need for additional precautions as in high risk patients should be assessed on a case-by-case basis.

 
High-risk Procedures
  • Limit indication (only if deemed medically essential, e.g. avoid use of nebulizer whenever possible)
  • Limit extent of procedure (e.g. autopsy)
  • Limit number of persons involved
  • Use appropriate PPE
   
3. Extensive nursing cares for dependent, confused or uncooperative patients could be a risk to infection, precautions should be considered, e.g., bed-bath rather than formal bath, water resistant gowns. It is also important to schedule work assignment to enhance staff’s attention span during high-risk activities. There should be sufficient instruction and supervision on supporting staff, especially in handling patient’s excreta and cleaning toilet areas.
   
4. Open manipulation of fresh SARS specimens should be conducted in class 1 safety cabinet or other physical containment devices within the containment module. No work in open vessels is allowed on the open bench. e.g., preparing cytology smears from fresh respiratory specimens like sputum and bronchial aspirates and handling of fresh specimens in the microbiology laboratory. If centrifugation is required, it should be carried out using sealed centrifuge cups or rotors that are loaded and unloaded in a biological safety cabinet. (Click here for “Interim Guidelines on Handling of Clinical Specimens during SARS Outbreak in the Laboratory”)

　

　

B. PRECAUTIONARY measures IN OUT-PATIENT SETTING (1/8/2003) 
　
1. To avoid overcrowding in the patient waiting areas, schedule patient appointment and remind patients to adhere to it.
2. Require all patients and accompanying persons to wear surgical masks if they have respiratory symptoms.
3. Request patients and accompanying persons to notify staff when they have fever and arrange medical assessment accordingly.
4. Clean and disinfect the environment at least once daily or more frequently as indicated (for places such as for patient lavatories).

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Disclaimer: This set of information is produced by the Hospital Authority to update our staff on issues relating to severe acute respiratory syndrome (SARS). They are listed under the topics above and will be updated as new information becomes available. Users should realise that SARS is a new disease and knowledge on its etiology, pathologenesis and treatment is limited and continuously evolving. Recommendations contained in this webpage are derived from consensus and must be regarded as provisional