Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings

Introduction

Overview

The objective of this guideline is to identify and promote infection prevention and control (IPC) practices and precautions for preventing the transmission of microorganisms in healthcare settings, with the exception of bone marrow transplant settings. Specifications for a protective environment in bone marrow transplant units are outlined in the United States Healthcare Infection Control Practices Advisory Committee 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Infection control guidelines for classic Creutzfeldt-Jakob disease in Canada are provided in separate Public Health Agency of Canada (formerly Health Canada) publications.

For the purposes of this document, healthcare settings are any location where healthcare is provided, including emergency care, prehospital care, hospital, long-term care (LTC), home care, ambulatory care and facilities and locations in the community where care is provided (e.g., infirmaries in schools, residential facilities or correctional facilities). It should be noted that definitions of settings overlap, as some settings provide a variety of care (e.g., chronic care or ambulatory care provided in acute care facilities, complex care provided in LTC facilities). Acute care includes ambulatory care settings, such as hospital emergency departments, and free-standing or facility-associated ambulatory (day) surgery or other invasive day procedures (e.g., endoscopy units, hemodialysis, ambulatory wound clinics). Healthcare workers (HCWs) are individuals who provide health care or support services, such as nurses, physicians, dentists, nurse practitioners, paramedics and sometimes emergency first responders, allied health professionals, unregulated healthcare providers, clinical instructors and students, volunteers and housekeeping staff. Healthcare workers have varying degrees of responsibility related to the health care they provide, depending on their level of education and their specific job/responsibilities.

This guideline is designed for use by infection control professionals (ICPs). It is recommended that individuals who lack IPC expertise seek the expertise of ICPs in their organization or region for assistance. This guideline can be used to develop specific recommendations for local use, taking into consideration local conditions, such as the type of facilities available, risk of acquisition of infection, type of healthcare setting, type of care and level of education and awareness of the HCWs providing the care.

For the purposes of this document, the term "patient" will be used to include those receiving health care who are traditionally/routinely referred to as patients, clients or residents. Included in this document are the principles necessary to prevent transmission of microorganisms from patient to patient, patient to HCW and HCW to patient across the continuum of care. Principles of transmission, as well as routine practices and additional precautions, are outlined for acute care, LTC, ambulatory care, prehospital care and home care settings.

This revision promotes the consistent application of routine practices across the continuum of care and outlines modifications in the application of additional precautions for settings outside of acute care. Routine practices should be incorporated into everyday patient care. Organizational policy should provide: i) education of HCWs in the principles of routine practices and additional precautions; ii) adequate equipment and supplies to implement them and iii) a means by which compliance can be monitored, encouraged and supported.

The application of routine practices and additional precautions is based on a point-of-care risk assessment (PCRA). Each HCW has a responsibility to perform a PCRA before every interaction with every patient and/or the patient's environment, and to ensure that appropriate control measures (i.e., routine practices and, if necessary, additional precautions) are in place to prevent transmission of microorganisms.

This document replaces the 1999 version of Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care. The following developments or events have occurred since the 1999 document was written:

• Expecting HCWs to use alcohol-based hand rub (ABHR) at the point-of-care as the preferred method of hand hygienein all healthcare settingsunless exceptions apply (i.e., when hands are visibly soiled with organic material, if exposure to norovirus and potential spore-forming pathogens such as Clostridium difficile is strongly suspected or proven, including outbreaks involving these organisms).
• Preferring single inpatient rooms rather than multipatient rooms, with designated private toilets and patient sinks and accessible designated staff handwashing sinks.
• Implementing respiratory hygiene, a strategy involving a combination of measures designed to minimize the transmission of respiratory pathogens across the continuum of care.
• Changing the recommendation for spatial separation between a patient with a suspected or confirmed droplet transmissible respiratory infection who is coughing (infected source) and another patient without that infection (susceptible host) from one metre to two metres. When using a risk assessment, one metre may be sufficient for young children and others whose cough is not forceful enough to propel the droplets as far as two metres.
• Changing the recommendation that adult patients with known or suspected viral respiratory infections be placed on contact and droplet precautions (which is the current practice in pediatrics).
• Implementing strategies to reduce aerosol generation when performing aerosol-generating medical procedures (AGMPs) on patients with signs and symptoms of suspected or confirmed tuberculosis (TB), severe acute respiratory syndrome (SARS) or respiratory infection with an emerging respiratory pathogen. Strategies to reduce aerosol generation should also be implemented when AGMPs are necessary for patients with viral hemorrhagic fevers. Routine practices and contact and/or droplet precautions, as indicated, should be used for AGMPs on other patients.
• Reaffirming the need for HCWs to follow aseptic technique for invasive procedures and in the handling and delivery of parenteral medications and intravenous systems.
• An expectation that healthcare organizations should perform an organizational risk assessment (ORA) — that is, evaluating the healthcare environment to identify the risk of exposure to microorganisms and implementing appropriate control measures (e.g., healthcare facility design and cleaning, disinfection and sterilization of patient care equipment).
• Emphasizing the expectation that HCWs should perform a PCRA prior to each patient interaction, taking into consideration the patient, patient environment and nature of the interaction.
• There are four main sections to this document, Part A to C, with the appendices provided in Part D.