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

1. Point-of-care risk assessment

1. Before each patient interaction, a point-of-care risk assessment should be performed to determine the appropriate routine practices for safe patient care. [CII]

2. Hand hygiene

1. Recommendations outlined in the PHAC infection prevention and control guideline Hand Hygiene Practices in Healthcare Settings^{Footnote 217} and specified by Accreditation Canada^{Footnote 418} should be followed.

3. Source control

The following source control measures should be applied^{Footnote 148, Footnote 430}:

1. Triage
   1. Emergency departments and acute assessment settings [CI]
      • Signs to direct patients with symptoms of acute infection (e.g., cough, fever, vomiting, diarrhea, coryza, rash, conjunctivitis) should be posted in specific waiting areas.
      • A physical barrier (e.g., plastic partition at triage desk) should be located between infectious sources (e.g., patients with symptoms of a respiratory infection) and susceptible hosts.
      • Patients with respiratory infections should be placed directly into an examining room or an airborne infection isolation room, as indicated by the respiratory infection suspected.
      • Patients with an acute diarrheal illness should be placed into a single examining room with dedicated toilet or commode whenever possible and as soon as possible.
   2. Community or outpatient settings
      • When scheduling appointments for routine clinic visits, patients with symptoms of an acute infection should be identified and asked that, if possible, they defer routine clinic visits until symptoms of the acute infection have subsided.
      • Patients who cannot defer their routine clinic visit (i.e., those who need assessment of symptoms/condition) should be informed to follow hand hygiene and/or respiratory hygiene recommendations as indicated by their symptoms. These patients should be directed into an examining room as soon as they arrive and/or schedule their appointment for a time when other patients are not present.
      • Signs at the entrance to the clinic reminding symptomatic patients to perform hand hygiene and/or respiratory hygiene as indicated by their symptoms should be posted. [CI]
2. Early diagnosis and treatment
   1. Symptomatic patients should be assessed in a timely manner and for any potential communicable infection (e.g., tuberculosis, norovirus, respiratory syncytial virus, pertussis)^{Footnote 65, Footnote 138, Footnote 210}. [CII]
3. Respiratory hygiene
   1. Respiratory hygiene should be encouraged for patients and accompanying individuals who have signs and symptoms of an acute respiratory infection, beginning at the point of initial encounter in any healthcare setting (e.g., prehospital, triage, reception and waiting areas in emergency departments, outpatient clinics and physician's offices). Respiratory hygiene should include^{Footnote 216, Footnote 368, Footnote 369, Footnote 376, Footnote 443}:
      • using tissues to contain respiratory secretions to cover the mouth and nose during coughing or sneezing, with prompt disposal into a no-touch waste receptacle
      • covering the mouth and nose during coughing or sneezing against a sleeve/shoulder if a tissue is not available.
      • wearing a mask when coughing or sneezing
      • turning the head away from others when coughing or sneezing
      • maintaining a spatial separation of two metres between patients symptomatic with an acute respiratory infection (manifested by new cough, shortness of breath and fever) and those who do not have symptoms of a respiratory infection. [BII]
4. Spatial separation
   1. A minimum two metre separation^{Footnote 122, Footnote 123, Footnote 124} should be maintained between patients who may have a respiratory infection and are symptomatic with a cough, fever or shortness of breath and those who do not have symptoms. [CII]
5. Strategies to reduce risk from aerosol generation of microorganisms [BII]
   1. Patients should be assessed for signs or symptoms of suspected or confirmed tuberculosis, severe acute respiratory syndrome or respiratory infection with an emerging pathogen for which the transmission characteristics are not yet known prior to performing an aerosol-generating medical procedure.
   2. Strategies should be applied to reduce the level of aerosol generation, as listed in Part B, Section IV, subsection iii, 1b, for aerosol-generating medical procedures performed on patients with signs and symptoms of suspected or confirmed tuberculosis, severe acute respiratory syndrome or respiratory infection with an emerging pathogen for which the transmission characteristics are not yet known^{Footnote 150, Footnote 151, Footnote 152, Footnote 153, Footnote 154, Footnote 155, Footnote 156}. Strategies to reduce aerosol generation should also be implemented when aerosol-generating medical procedures are necessary on patients with viral hemorrhagic fevers^{Footnote 161}.
   3. Routine practices are sufficient for aerosol-generating medical procedures performed on patients with no signs or symptoms of suspected or confirmed tuberculosis, severe acute respiratory syndrome or respiratory infection with an emerging pathogen for which the transmission characteristics are not yet known.

4. Patient placement and accommodation

1. Options should be determined for patient placement and room sharing if single rooms are limited, as per the point-of-care risk assessment, based on: [BII]
   1. presence or absence of known or suspected infection (i.e., need for additional precautions)^{Footnote 201, Footnote 202, Footnote 289, Footnote 290, Footnote 291, Footnote 292, Footnote 293, Footnote 294, Footnote 295, Footnote 297, Footnote 298, Footnote 299, Footnote 300, Footnote 301, Footnote 302}.
   2. route(s) of transmission of the known or suspected infectious agents:
      • contact (single room is preferred)
      • droplet (single room is preferred)
      • airborne (airborne infection isolation room needed)
   3. risk factors for transmission from the infected patient.
   4. susceptibility of other patients in the room to adverse outcome from a healthcare-associated infection.
   5. patient options for room sharing (e.g., cohorting patients infected with the same microorganism).
   6. ability of patient, roommate(s) and visitors to comply with infection prevention and control measures.
2. Patients should be prioritized for single room placement according to the potential for transmission of microorganisms^{Footnote 202, Footnote 291, Footnote 292, Footnote 294, Footnote 295, Footnote 297, Footnote 298, Footnote 299, Footnote 300}. The following patients should be given priority (in descending order)^{Footnote 289, Footnote 291, Footnote 293, Footnote 301, Footnote 302}:[BII]
   1. patients on additional precautions:
      • airborne (airborne infection isolation room needed)
      • contact (single room is preferred)
      • droplet (single room is preferred)
   2. patients who visibly soil the environment or who cannot maintain appropriate hygiene, including respiratory hygiene.
   3. patients with uncontained secretions or excretions.
   4. patients with wound drainage that cannot be contained by a dressing.
   5. patients with fecal incontinence if stools cannot be contained in incontinent products or infant diapers.

   In prehospital settings:

   1. single patient transport is preferred.
   2. if multipatient transport is necessary, consider item b (i to v), above, to determine priority for single patient transport.

5. Patient flow

1. Transfer of patients within and between facilities should be avoided unless medically indicated. [CII]

6. Aseptic technique

1. Aseptic technique should be used when performing invasive procedures and handling injectable products. Aseptic technique generally includes^{Footnote 172, Footnote 332, Footnote 425, Footnote 444}:
   1. performing hand hygiene, preferably with alcohol-based hand rub prior to opening supplies^{Footnote 217}. [AI]
   2. performing hand hygiene with antimicrobial soap and water for invasive procedures (e.g., placing central intravascular catheters, placing catheters or injecting into the spinal canal or subdural spaces) when alcohol-based hand rub is not accessible^{Footnote 217, Footnote 312, Footnote 425, Footnote 445, Footnote 446, Footnote 447, Footnote 448, Footnote 449, Footnote 450, Footnote 451}. [AI]
   3. opening tray and supplies only when ready to use to ensure a sterile field. [CII]
   4. performing hand hygiene prior to putting on single-use clean gloves, sterile gloves, sterile gown or mask, as indicated by the specific procedure^{Footnote 217}. [AI]
   5. preparing the patient's skin with an appropriate antiseptic before performing an invasive procedure^{Footnote 312, Footnote 313, Footnote 425}. [AI]
   6. using the appropriate size drape, when a drape is needed, to maintain a sterile field. [CII]
   7. not administering medications or solutions from single-dose vials, ampules or syringes to multiple patients and not combining leftover contents for later use. [BII]
   8. using single-dose medication vials, prefilled syringes and ampules in clinical settings. If the product is only available as multi-dose vial, refer to item b, below. [BII]
   9. disinfecting the stoppers or injection ports of medication vials, infusion bags, etc., with alcohol before entering the port, vial or bag. [BII]
   10. using a sterile, single-use disposable needle and syringe for each medication/fluid withdrawal from vials or ampules. [BII]
2. When a product is only available for purchase in multi-dose vials adhere to the following^{Footnote 167, Footnote 168, Footnote 170, Footnote 171, Footnote 172, Footnote 173, Footnote 332, Footnote 333, Footnote 452}:
   1. the multi-dose vial should be restricted to single patient use whenever possible.
   2. syringes from multi-dose vials should be prepared from a centralized medication preparation area (e.g., do not take multi-dose vials to the patient bedside).
   3. the multi-dose vial should be stored in such a way as to restrict access (e.g., in a secure location away from the patient bedside or in a medication room or locked cart).
   4. a sterile single-use needle and syringe should be used each time the multi-dose vial is entered.
   5. re-entering the multi-dose vial with a previously used needle or syringe should not be done.
   6. the multi-dose vial should be stored in accordance with manufacturer's recommendations.
   7. the multi-dose vial should be labeled with the date of first opening.
   8. the multi-dose vial should be discarded according to manufacturer's expiry date or organizational policy, whichever time is shorter.
   9. the multi-dose vial should be inspected for clouding or particulate contamination prior to each use and should be discarded if clouding or particulate contamination is present.
   10. the multi-dose vial should be discarded if sterility or product integrity is compromised. [BII]
3. Single patient multi-use devices (e.g., glucose sampling devices, fingerstick capillary blood sampling devices) should be used for only one patient^{Footnote 92, Footnote 131, Footnote 132}. If not feasible to assign glucometers to individual patients, they should be cleaned and disinfected before use with another patient^{Footnote 332}. [CI]
4. Aseptic technique (as outlined in Part B, Section III, 6a ) should be used, and should include the use of a mask and sterile gloves when placing a catheter or injecting material into the spinal canal or subdural space (e.g., during lumbar puncture, myelogram or spinal or epidural anesthesia) ^{Footnote 322, Footnote 326, Footnote 327, Footnote 329, Footnote 330, Footnote 331, Footnote 453, Footnote 454}. [BII]
5. Aseptic technique should be adhered to for storage, assembly and handling components of intravenous delivery systems^{Footnote 169, Footnote 171, Footnote 174, Footnote 228, Footnote 455}. [BII]
   1. Intravenous bags, tubing and connectors should be used for one patient only and disposed of appropriately after use.
   2. A syringe, needle or cannula should be considered contaminated once it has been used to enter or connect to one patient's intravenous infusion bag or administration set and should not be reused.
   3. Sterile components should not be assembled until time of need, with the exception of the emergency department, operating room, intensive care unit, and prehospital settings where it may be essential to maintain one system primed and ready for emergency use. The primed system should be stored in a clean and dry area, secure from tampering, and labeled with the date of priming. The primed system should be replaced if not used within 24 hours.
   4. Sterile intravenous equipment components should be stored in a clean, dry and secure environment.
6. Maximal aseptic barriers (as outlined in Part B, Section III, 6a) that include a cap, mask, long-sleeved sterile surgical gown, sterile gloves and a large full body sterile drape^{Footnote 228, Footnote 319, Footnote 320, Footnote 427} and skin preparation with chlorhexidine in alcohol or an equally effective alternative should be used for inserting central venous catheters and pulmonary arterial catheters^{Footnote 228, Footnote 314, Footnote 315, Footnote 316, Footnote 317}. [AI]
7. When inserting peripheral venous catheters or peripheral arterial lines, at a minimum, hand hygiene should be performed, the skin should be prepared with an antiseptic and clean disposable gloves should be worn^{Footnote 217, Footnote 312, Footnote 313}. [AII]
8. Skin antisepsis and single-use disposable needles should be used for acupuncture ^{Footnote 456} and for the use of items such as lancets and blood sampling devices. [AII]

7. Use of personal protective equipment

The technique for putting on and taking off personal protective equipment, as outlined in Appendix X, should be followed^{Footnote 216, Footnote 219, Footnote 372}.

1. Gloves (clean, single-use, non-sterile) [CII]
   1. Gloves should not be a substitute for other elements of hand hygiene. [CII]
   2. Gloves are not required for routine patient care activities in which contact is limited to a patient's intact skin; gloves should be worn for routine patient care as determined by the point-of-care risk assessment. [CII]
   3. Gloves should be worn as determined by the point-of-care risk assessment^{Footnote 337, Footnote 338, Footnote 457}:
      • for anticipated contact with blood, body fluids, secretions and excretions, mucous membranes, draining wounds or non-intact skin (including skin lesions or rash)
      • for handling items or touching surfaces visibly or potentially soiled with blood, body fluids, secretions or excretions
      • while providing direct care if the healthcare worker has an open cut or abrasions on the hands

      Appropriate glove use:

      • Hand hygiene should be performed prior to putting on gloves for tasks requiring clean, aseptic or sterile technique^{Footnote 130, Footnote 402, Footnote 408, Footnote 450, Footnote 458, Footnote 459}. [AI]
      • Gloves should be put on directly before contact with the patient or just before the task or procedure requiring gloves. [CII]
      • Gloves with fit and durability appropriate to the task (refer to Appendix IX) should be worn. Use of powder-free gloves is preferred^{Footnote 347, Footnote 460, Footnote 461}. [CII]
      • Disposable medical examination gloves or reusable utility gloves should be worn for cleaning the environment or cleaning and disinfecting patient care equipment. [CII]
      • Gloves should be removed and hand hygiene performed immediately after patient care activities that involve contact with materials that may contain microorganisms (e.g., after contact with mucous membranes, after handling an indwelling urinary catheter, after open suctioning an endotracheal tube or changing a dressing), before continuing care of that patient^{Footnote 98, Footnote 343, Footnote 345, Footnote 405, Footnote 406, Footnote 407}. If gloves are still indicated, they should be replaced with a clean pair. [AII]
      • Gloves should be removed and discarded into a no-touch waste receptacle immediately following their intended use. Single-use gloves should not be reused, cleaned with alcohol-based hand rub or washed^{Footnote 339, Footnote 353}. [BII]
      • Hand hygiene should be performed following the removal of gloves, before leaving the patient's environment and before touching clean environmental surfaces^{Footnote 337, Footnote 340, Footnote 347, Footnote 402, Footnote 406, Footnote 457}. [AI]
2. Long-sleeved gowns
   1. Routine wearing of gowns to enter high-risk units (e.g., burn unit, intensive care unit, neonatal intensive care unit, hematopoietic stem cell unit) is not required^{Footnote 354, Footnote 356, Footnote 357, Footnote 358, Footnote 359}. [BI]
   2. Long-sleeved cuffed gowns should be worn as determined by the point-of-care risk assessment^{Footnote 70, Footnote 98}; gowns should be cuffed and cover the front and back of the healthcare worker, from the neck to mid-thigh. [CI]
   3. The type of gown to be worn should be based on:
      • anticipated degree of contact with infectious material
      • potential for blood and body fluid penetration of the gown (fluid repellence when heavy liquid contamination is anticipated (e.g., operating theatre, dialysis)
      • requirement for sterility (e.g., operating theatre, central line insertion) [CI]
   4. Organizational policy should be followed regarding the laundering of scrub suits and uniforms supplied by the organization^{Footnote 363, Footnote 462}. [CII]

      Appropriate gown use: [CI]

      • Hand hygiene should be performed before gowning.
      • The gown should be long enough to cover the front and back of the healthcare worker, from the neck to mid-thigh, and the sleeves no shorter than just above the wrist.
      • The gown should be put on with the opening at the back and edges overlapping, covering as much clothing as possible.
      • The cuffs of the gown should be covered by gloves.
      • The gown should be tied at the neck and then at the waist.
      • The gown should be removed by undoing the neck and then the waist ties, without touching the clothing or agitating the gown unnecessarily, then turned inside on itself and rolled up.
      • The gown should be removed immediately after the indication for use and placed in a no-touch receptacle, followed by hand hygiene before leaving the patient's environment^{Footnote 70, Footnote 98}.
      • Wet gowns should be removed immediately to prevent a wicking action, which facilitates the passage of microorganisms through the fabric.
      • Gowns should not be reused once removed, even for repeated contacts with the same patient.
      • The same gown should not be worn between successive patients.
3. Facial protection
   1. Healthcare workers should be educated to avoid touching their faces with their hands during patient care^{Footnote 126, Footnote 463}. [CII]
   2. Facial protection (i.e., masks and eye protection, or face shields or masks with visor attachment) should be worn as determined by the point-of-care risk assessment^{Footnote 135, Footnote 365, Footnote 367, Footnote 371, Footnote 410, Footnote 411}:
      • to protect the mucous membranes of the eyes, nose and mouth during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids, secretions or excretions, including respiratory secretions [BII]
   3. Disposable eye protection or face shields should be worn only once to avoid self-contamination, and should not be positioned on the head or around the neck for later use. [CII]
   4. Eye protection or face shields should be removed immediately after use and placed promptly into a no-touch receptacle followed by hand hygiene. [CII]
   5. If eye protection or face shields are reusable, they should be cleaned and disinfected as per organizational policy before reuse. [CII]
   6. Eye protection should be worn over prescription glasses, as prescription glasses are not adequate eye protection. [CII]

      Appropriate use of facial protection:

      • Hand hygiene should be performed prior to putting facial protection on. [CII]
      • Facial protection should be worn as instructed by manufacturer.
      • Facial protection should be worn and discarded appropriately to prevent self-contamination.
      • Nose, mouth and chin should be covered when wearing a mask.
      • Self-contamination should be avoided during use and disposal by not touching facial protection on its external surface.
      • Facial protection should be removed carefully by the straps or ties.
      • Facial protection should be discarded immediately after the intended use into a no-touch receptacle (i.e., as soon as removed from the face) followed by hand hygiene.
      • Masks should not be dangled around the neck when not in use, and should not be reused.
      • The mask should be changed if it becomes wet or soiled (from the wearer's breathing or an external splash).
      • The mask should be changed if breathing becomes difficult.
      • In cohort settings, facial protection may be worn for the care of successive patients.

8. Sharps safety and prevention of exposure to bloodborne pathogens

1. Provincial/territorial regulations should be followed regarding the use of safety-engineered sharp devices. [Regulated]
2. Safety-engineered sharp devices should be used wherever possible and the safety of patients and healthcare workers should be considered when selecting safety-engineered sharp devices^{Footnote 224, Footnote 225, Footnote 229, Footnote 231}. [BII]
3. Needles should not be recapped; used needles and other used single-use sharp items should be disposed of immediately into designated puncture-resistant containers that are easily accessible at the point-of-care^{Footnote 219}. [CII]
4. Healthcare workers should cover open skin areas/lesions on hands or forearms with a dry dressing at all times while at work and should consult occupational health or designate if adherence to hand hygiene recommendations are impeded by the dressing ^{Footnote 219}. [CII]
5. Eyes, nose and mouth should be protected using facial protection when splashes with blood and/or body fluids are anticipated. [CII]
6. First aid should be performed immediately if there has been exposure to blood or body fluids. The exposure should be reported immediately to employer and immediate medical attention should be obtained ^{Footnote 219}. [CII]
   1. The site of a percutaneous injury should be thoroughly rinsed with running water, and any wound should be gently cleansed with soap and water.
   2. Mucous membranes of the eyes, nose or mouth should be flushed with running water if contaminated with blood, body fluids, secretions or excretions.
   3. Non-intact skin should be rinsed thoroughly with running water if contaminated with blood, body fluids, secretions or excretions.

9. Cleaning and disinfection of non-critical patient care equipment

1. Reusable non-critical equipment that has been in direct contact with a patient or in that patient's environment should be reprocessed with cleaning and low-level disinfection before use in the care of another patient^{Footnote 72, Footnote 108, Footnote 239, Footnote 464}. [AII]
2. Items such as toys and electronic games that have been in direct contact with a patient or in that patient's environment should be reprocessed with cleaning and low-level disinfection before use by another patient^{Footnote 93, Footnote 105, Footnote 106, Footnote 108, Footnote 109, Footnote 110, Footnote 434}. [AII]
3. Non-critical patient care equipment dedicated to an individual patient should be cleaned and disinfected according to a regular schedule. [CII]
4. Bedpans and commodes should be provided for single patient use and labeled appropriately. Bedpans and commodes should be reprocessed with cleaning and low-level disinfection before use by another patient^{Footnote 129, Footnote 130, Footnote 465} . The use of single-patient-use disposable bedpans is acceptable. [CII]
5. Manufacturer's written instructions should be followed when using products for cleaning and disinfecting.
6. Sterile and clean supplies should be stored in a designated and separate clean, dry area protected from dust. Sterile and clean supplies should not be stored under sinks and/or near plumbing, as leaks may occur^{Footnote 242} . [CII]

   In home care settings:

   • patients should be educated about the importance of environmental cleaning
   • the amount of disposable and non-disposable patient care equipment and supplies brought into the home should be limited
   • patients should be advised to purchase items such as thermometers and scissors for personal use
   • whenever possible, reusable patient care equipment should be left in the home until the patient is discharged from home care services
   • non-critical patient care equipment (e.g., stethoscope) that cannot remain in the home should be reprocessed with cleaning and low-level disinfection before taking them from the home
   • alternatively, contaminated reusable items should be in a plastic bag for transport and reprocessed with cleaning and disinfection
   • unused disposable equipment or supplies in the home should be discarded following discharge from home care services [CII]

   In prehospital care:

   • use of disposable items is preferred where practical
   • patient care equipment touched or potentially touched by patients and personnel should be cleaned and disinfected following transport [CII]

10. Environmental cleaning

1. Surfaces that are likely to be touched and/or used frequently should be cleaned and disinfected on a more frequent schedule. This includes surfaces that are in close proximity to the patient (e.g., bedrails, overbed tables, call bells) and frequently touched surfaces in the patient care environment, such as door knobs, surfaces in the patient's bathroom and shared common areas for dining, bathing, toileting^{Footnote 72, Footnote 129, Footnote 130, Footnote 239, Footnote 263, Footnote 293, Footnote 466, Footnote 467}. [AI]

   In prehospital care:

   • terminal cleaning should be performed following patient care and transport
   • response bags should be cleaned and disinfected following use and, if heavily soiled or contaminated with blood and/or body fluids, removed from service and laundered as per organizational policy [CII]

11. Handling deceased bodies

1. Routine practices properly and consistently should be used when handling deceased bodies or preparing bodies for autopsy or transfer to mortuary services. Provincial/territorial specified communicable disease regulations should be followed. [Regulated]

12. Handling of linen, waste, dishes and cutlery

1. Linen
   1. Patient bed linen should be changed regularly and when soiled, upon discontinuation of contact precautions and following patient discharge.
   2. Soiled linen from healthcare settings should be handled in the same way for all patients without regard to their infection status. Soiled linen should be placed in a no-touch receptacle at the point-of-use.
   3. Soiled linen should be handled with a minimum of agitation to avoid contamination of air, surfaces and persons^{Footnote 278, Footnote 279}.
   4. Soiled linen should be sorted and rinsed outside of patient care areas, except specialized items (e.g., antiembolic stockings) and personal clothing in specific healthcare settings.
   5. Heavily soiled linen should be rolled or folded to contain the heaviest soil in the centre of the bundle. Large amounts of solid soil (e.g., feces or blood clots) should not be removed by spraying with water. A gloved hand and toilet tissue should be used to place the solid soil into a bedpan or toilet for flushing.
   6. Hand hygiene should be performed after handling soiled linen.
   7. Clean linen should be transported and stored in a manner that prevents its contamination and ensures its cleanliness.
   8. Clean and soiled linen should be separated during transport and storage.
   9. Reusable linen bags should be washed after each use; they may be washed in the same cycle as the linen contained in them.[CII]

      In ambulatory care:

      • patient linen should be changed following every patient treatment/procedure. [CII]

      In prehospital care:

      • patient linen should be changed following every patient treatment/transport [CII]
2. Waste
   1. Biomedical waste (e.g., sponges, dressings and surgical drapes soaked with blood or secretions) should be contained in impervious waste-holding bags or double bags according to municipal/regional regulations^{Footnote 275}. [Regulated]
   2. Blood, suctioned fluids, excretions and secretions should be disposed of in a sanitary sewer or septic system according to municipal/regional regulations^{Footnote 275}. [Regulated]
   3. Used needles and other sharp instruments should be handled with care to avoid injuries during disposal. Used medical sharps should be disposed of immediately in designated puncture-resistant containers located at the point-of-use. [CII]

      In home care settings:

      • patients should be advised to dispose of medical sharps (e.g., hypodermic needles used by patients) in accordance with municipal or regional regulations
      • patients should be informed to place sharps into an impervious container. Some local pharmacies provide sharps containers [CII]
3. Dishes
   1. There are no indications for the use of disposable dishes except in the circumstance of non-functioning dishwashing equipment.[CII]

13. Education of patients, families and visitors

1. Healthcare workers should provide instructions to patients, families and visitors regarding hand hygiene and respiratory hygiene. [CII]

14. Visitor management

1. Visitors with symptoms of acute infection (e.g., cough, fever, vomiting, diarrhea, coryza, rash, conjunctivitis) should not visit unless the visit is essential (e.g., parent, guardian or primary caretaker), in which case they should be instructed and supervised in precautions to minimize transmission of infection. [CII]

Subsection i: Contact precautions for all care settings and modifications for specific healthcare settings

Routine practices properly and consistently applied should prevent transmission by the contact route. For certain situations that may result in extensive contamination of the environment or for microorganisms with a very low infectious dose, contact precautions may be indicated. Contact precautions should be used for the conditions/clinical presentations and specific etiologies listed in List 3 below. In addition to routine practices for the care of all patients in all settings, the recommendations that follow List 3 apply to the care of patients on contact precautions in all care settings. Modifications for specific healthcare settings follow. Certain diseases require public health notification; check local regulations.

List 3 - Note i

Use contact precautions:

• only for children with diarrhea who are incontinent or unable to comply with hand hygiene
• for children with skin lesions/exudates who are unable to comply with hand hygiene or appropriate handling and disposal of purulent discharges and maintaining dressings in place
• only for adults with diarrhea who are incontinent if diarrhea cannot be contained in incontinence products or for adults with poor hygiene that contaminate their environment

Return to note i referrer

1. Source control

1. A system should be developed to identify patients with known or suspected infections that warrant contact precautions.
   1. Contact precautions should be implemented empirically for patients with conditions/clinical presentations as listed in List 3. above, rather than waiting for the etiology to be determined.
   2. Refer to specific etiologies in List 3 if the etiology has been established.
   3. Note that indications for contact precautions may differ for certain children (e.g., children who are incontinent or unable to comply with hygiene) and other adult patients (e.g., incontinent or cognitively impaired adults).
   4. Note that some diseases/conditions need two precautions categories (e.g., contact and droplet).
   5. A sign should be placed at the entrance to the patient room, cubicle or designated bedspace or other visible locations to identify contact precautions.
   6. Patients on contact precautions should be restricted from participating in pet therapy programs^{Footnote 71}. [CI]
2. Contact precautions in addition to routine practices are sufficient for aerosol-generating medical procedures performed on patients on contact precautions who have no signs or symptoms of suspected or confirmed tuberculosis, severe acute respiratory syndrome or respiratory infection with an emerging pathogen for which the transmission characteristics are not yet known. (Refer to Part A, Section II, C, 2c).

2. Hand hygiene

1. Hand hygiene using soap and water, instead of alcohol-based hand rub should be used during outbreaks or in settings with high transmission of norovirus or Clostridium difficile infection^{Footnote 265, Footnote 266, Footnote 269, Footnote 270, Footnote 271}. or with suspected or documented exposure to B. anthracis-contaminated items^{Footnote 468}.

3. Patient placement and accommodation

1. Single room
   1. Patients requiring contact precautions should be placed into a single room with a private toilet (or designated commode chair), designated patient sink and a designated staff handwashing sink^{Footnote 48, Footnote 95, Footnote 201, Footnote 289, Footnote 293, Footnote 302, Footnote 469}. It may be difficult to maintain physical separation related to shared spaces and equipment (e.g., toilets, sinks) in a shared room^{Footnote 201}. [BII]
   2. The room door may remain open. [CII]
2. When single patient rooms are limited, a point-of-care risk assessment should be performed to determine patient placement and/or suitability for cohorting.
   1. Prioritize patients with conditions that may facilitate cross-transmission of microorganisms (e.g., uncontained drainage, stool incontinence, young age, and cognitive impairment) for single patient room placement. Use prioritization as in routine practices. [CI]
   2. Cohort patients who are infected or colonized with the same microorganism and are suitable roommates^{Footnote 395, Footnote 396, Footnote 470, Footnote 471}. [CI]
   3. Roommates should be selected for their ability and the ability of their visitors to comply with necessary precautions. [CII]
3. When cohorting is not feasible:
   1. Placing a patient requiring contact precautions in the same room as a patient who is at high risk for complications if infection occurs or with conditions that may facilitate transmission (e.g., those who are immunocompromised, have open wounds) should be avoided. [CII]
   2. In a shared room, a patient with diarrhea should not share a toilet with another patient. A designated toilet or commode should be assigned to the patient with diarrhea. [CII]
   3. In shared rooms, roommates and all visitors should be aware of the precautions to follow. Roommates should be selected for their ability and the ability of their visitors to comply with necessary precautions. [CII]
   4. If possible, the privacy curtain between beds should be closed to minimize opportunities for direct contact. [CII]
   5. Contact precautions should be applied in nursery settings including providing the necessary spacing between infant stations to minimize opportunities for direct contact^{Footnote 429}. If multiple infants are kept in a single room, a 1.2-2.4 metre space should be maintained between infant stations (depending on care needs)^{Footnote 472} and family members or designated visitors should comply with the necessary precautions. [CII]

4. Patient flow

1. The patient should perform hand hygiene with assistance as necessary before leaving the room. [AII]
2. The patient should be allowed out of the room as indicated in the care plan. Supervision of the patient should be provided if compliance with precautions is inadequate. [CII]
3. When transfer or movement in healthcare facilities is necessary, the patient should be provided with clean bedclothes and bedding, draining wounds should be contained with clean dressings, infected areas of the patient's body should be covered and body substances should be contained. [CII]
4. Personnel in the area to which the patient is to be transported should be informed of precautions to follow and requested to see the patient efficiently to minimize time in waiting areas and reduce time spent outside of the patient room. [CII]
5. Transfer within facilities should be avoided unless medically indicated. If a medically indicated transfer is unavoidable, the transferring service, receiving unit, or facility or home care agency should be advised of the necessary precautions. [CII]
6. Personal protective equipment should be removed and disposed of and hand hygiene should be performed, prior to transporting patients. [AII]
7. Clean personal protective equipment should be put on if necessary, to handle the patient during transport and at the transport destination. [CII]

5. Personal protective equipment

1. Personal protective equipment for contact precautions should be provided outside the patient room (or when available, in the anteroom), cubicle or patient's designated bedspace in shared rooms. [CII]
2. In addition to the use of personal protective equipment as per routine practices^{Footnote 22, Footnote 219}:
   1. Gloves
      • Gloves should be worn to enter the patient room, cubicle or patient's designated bedspace in shared rooms.
      • Gloves should be removed and discarded into a no touch waste receptacle and hand hygiene should be performed on exit from the room or patient bedspace^{Footnote 337, Footnote 339, Footnote 407}. [AII]
   2. Long-sleeved gowns
      • A long-sleeved gown should be worn if it is anticipated that clothing or forearms will be in direct contact with the patient or with environmental surfaces or objects in the patient care environment.
      • If a gown is to be worn it should be put on prior to entry into the room, cubicle or patient's designed bedspace in shared rooms^{Footnote 48, Footnote 70, Footnote 95, Footnote 473}.
      • The gown should be removed and discarded into a no touch receptacle immediately after the indication for use and hand hygiene should be performed before leaving the patient's environment^{Footnote 129, Footnote 130}. [BII]
3. The same personal protective equipment should not be worn for more than one patient. Personal protective equipment should be changed and hand hygiene performed between contacts with all patients in the same room^{Footnote 337, Footnote 339, Footnote 405, Footnote 407, Footnote 474}. [BII]

6. Cleaning and disinfection of non-critical patient care equipment

1. All equipment/supplies should be identified and stored in a manner that prevents use by or for other patients. [CII]
2. Non-critical patient-care equipment (e.g., thermometers, blood pressure cuff, pulse oximeter) should be dedicated to the use of one patient and cleaned and disinfected as per Routine Practices before reuse with another patient or a single-use device should be used and discarded in garbage after use^{Footnote 42, Footnote 70, Footnote 95, Footnote 260, Footnote 289}. [BII]
3. Toys, electronic games or personal effects should not be shared between patients. [CI]

7. Cleaning of the patient environment

1. Additional cleaning measures or frequency may be warranted in situations where continued transmission of specific infectious agents is noted (e.g., Clostridium difficile, norovirus and rotavirus)^{Footnote 475}. The efficacy of disinfectants being used should be assessed and if indicated, a more effective disinfectant should be selected^{Footnote 239, Footnote 264, Footnote 265}. All horizontal and frequently touched surfaces should be cleaned at least twice daily and when soiled^{Footnote 82, Footnote 239, Footnote 264, Footnote 476}. [BII]
2. In outbreak situations or when there is continued transmission, rooms of Clostridium difficile infection patients should be decontaminated and cleaned with chlorine-containing cleaning agents (at least 1,000 ppm) or other sporicidal agents^{Footnote 43, Footnote 266, Footnote 267, Footnote 268, Footnote 269, Footnote 270, Footnote 271}. [BII]
3. When precautions are discontinued or the patient is moved, terminal cleaning of the room/bedspace and bathroom, changing of privacy curtains and cleaning and disinfection or changing of string/cloth call bells or light cords should be done (refer to Appendix VII). [BII]

8. Education of patients, families and visitors

1. Patients, their visitors, families and their decision makers should be educated about the precautions being used, the duration of precautions, as well as the prevention of transmission of disease to others with a particular focus on hand hygiene. [CII]
2. Visitors who are participating in patient care should be instructed about the indications for and appropriate use of personal protective equipment (barriers). In the adult setting, visitors who assist with patient care should use the same personal protective equipment as healthcare workers. This may not be necessary for parents carrying out their usual care of young children. [CII]

9. Management of visitors

1. Visitors should be instructed to speak with a nurse before entering the patient room in order to evaluate the risk to the health of the visitor, and the ability of the visitor to comply with precautions. [CII]
2. The number of visitors should be minimized to essential visitors (e.g., parent, guardian or primary caretaker) only. Visitors should be restricted to visiting only one patient. If the visitor must visit more than one patient, the visitor should be instructed to use the same barriers as the healthcare workers and perform hand hygiene before going to the next patient room. [CII]

10. Duration of precautions

1. Contact precautions should be discontinued after signs and symptoms of the infection have resolved or as per the pathogen specific recommendations in Table 5. [CII]
2. The duration of precautions should be determined on a case-by-case basis when patient symptoms are prolonged or when the patient is immune suppressed^{Footnote 477, Footnote 478, Footnote 479, Footnote 480, Footnote 481, Footnote 482}. The patient with persistent symptoms should be reevaluated for underlying chronic disease. Repeated microbiological testing may be warranted. [CII]
3. Precautions should be discontinued only after the room/bedspace and bathroom has been terminally cleaned. [CII]

11. Handling deceased bodies

1. Routine practices, properly and consistently applied should be used in addition to contact precautions, for handling deceased bodies, preparing bodies for autopsy or for transfer to mortuary services. Provincial/territorial specified communicable disease regulations should be followed. [Regulated]

12. Waste, laundry, dishes and cutlery

1. No special precautions are required; routine practices are sufficient. [CII]

   Special considerations for antibiotic-resistant organisms in all healthcare settings [CII]

   • In acute-care inpatient facilities (for the purpose of this document, 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]), routine practices and contact precautions are recommended for infection or colonization (i.e., patient is asymptomatic) with microorganisms such as MRSA, vancomycin-resistant Enterococcus or other microorganisms resistant to a wide spectrum of antibiotics (as determined by the infection prevention and control service of the facility) (refer to Table 5). In addition, some facilities may choose to include precautions for persons at risk of colonization pending screening results, particularly in outbreak situations.
   • Although masks may protect the healthcare worker from nasal colonization, data are inconclusive on the need for masks, apart from their use for routine practice for persons caring for patients with MRSA^{Footnote 483}. Masks should be worn as indicated by routine practices.
   • There are insufficient data at present on which to base recommendations for discontinuation of precautions for patients colonized with antibiotic-resistant microorganisms^{Footnote 484}. Decisions should be made locally, taking into consideration the specific microorganisms, the patient population and local experience with duration of colonization. These policies should be updated as data become available.
   • Policies and practices that result in stigmatization of patients with antibiotic-resistant microorganisms (e.g., disease-specific signage) or increase the patient's sense of isolation should be avoided. Recognizing that patients on contact precautions may have fewer contacts with healthcare providers and that this may reduce their quality of care, steps should be taken to mitigate this impact on care.

Modifications for contact precautions in specific healthcare settings

Modification of contact precautions for long-term care

1. Routine practices (as per Part B, Section III) and contact precautions should be followed for all healthcare settings (as per Part B, Section IV, subsection i), and modified as noted below:
   1. Patient placement, accommodation and activities
      • A point-of-care risk assessment to determine patient placement, removal from a shared room or participation in group activities should be performed on a case-by-case basis, balancing infection risks to other patients in the room, the presence of risk factors that increase the likelihood of transmission and the potential adverse psychological impact on the symptomatic patient.
      • Participation in group activities should not be restricted if wound drainage or diarrhea is contained.
      • Patients should perform hand hygiene and be assisted as necessary before participation with group activities. [CII]
   2. Use of personal protective equipment
      • Gloves should be worn if direct personal care contact with the patient is necessary or if direct contact with frequently touched environmental surfaces is anticipated. [BII]
   3. Cleaning of patient environment
      • In outbreaks, consideration should be given to more frequent cleaning and/or cleaning with disinfectants. This includes bathing and toileting facilities, recreational equipment and horizontal surfaces in the patient room and, in particular, areas/items that are frequently touched (e.g., hand and bedrails, light cords). [BII]

Special considerations for the care of patients with antibiotic-resistant microorganisms in long-term care settings

In addition to routine practices (as per Part B, Section III) and contact precautions for all care settings (as per Part B, Section IV, subsection i) and modifications for contact precautions in LTC mentioned above, the following apply to antibiotic-resistant microorganisms in the LTC setting:

• Policies for managing antibiotic-resistant microorganisms, including initiation and discontinuation of precautions, should be in place, reflect the local experience with particular antibiotic-resistant microorganisms and should be flexible enough to accommodate the various characteristics of different antibiotic-resistant microorganisms^{Footnote 484}. It is important to collaborate with other local healthcare organizations to design a comprehensive control program.
• Management strategies should take into consideration the risk and benefits of both the patient and the facility, based on the point-of-care risk assessment^{Footnote 484}.Controlling transmission is primarily the responsibility of direct caregivers through hand hygiene and appropriate use of gloves^{Footnote 484}. Ability to maintain hygiene by the patient and caregivers, individualized activity restrictions, selection of low-risk roommate, and environmental cleanliness are also factors that need consideration. [CII]

Modifications of contact precautions for ambulatory care

1. Routine practices (as per Part B, Section III) and contact precautions should be followed for all healthcare settings (as per Part B, Section IV, subsection i), and modified as noted below:
   1. Source control

      Triage

      • Contact between symptomatic patients and others should be avoided by minimizing time spent in waiting rooms.
      • Symptomatic patients should be scheduled at a time when they are less likely to encounter other patients.
      • Placement in a separate room should be done as soon as possible. [CII]
   2. Cleaning and disinfection of non-critical patient care equipment and patient environment
      • Equipment and surfaces in direct contact with the patient or infective material (e.g., respiratory secretions, stool or skin exudates) should be cleaned and disinfected before the room is used for another patient. Contaminated reusable non-critical patient care equipment should be cleaned and disinfected before use with another patient.
      • All horizontal surfaces and frequently touched surfaces in the room should be cleaned and disinfected if the patient is likely to cause extensive environmental contamination (diarrhea or fecal incontinence not contained by incontinence products or infant diapers, copious wound drainage, copious uncontrolled respiratory secretions or sputum) prior to use by another patient. [BII]

Special considerations for the care of patients with antibiotic-resistant microorganisms in ambulatory care settings

• Contact precautions should not be used for asymptomatic carriers (i.e., colonized only) of antibiotic-resistant microorganisms; routine practices, properly and consistently applied, are sufficient.
• Requiring proof of screening for antibiotic-resistant microorganisms before care is provided is not advised. Communicating (preferably with infection control personnel) when referring a patient known to have an antibiotic-resistant microorganism to a healthcare facility should be done to ensure appropriate precautions are implemented.
• Collaboration with local or regional public health departments and infection control professionals should be done to design a comprehensive infection and prevention control program. [CII]

Modifications of contact precautions for home care

1. Routine practices (as per Part B, Section III) and contact precautions should be followed for all healthcare settings (as per Part B, Section IV, subsection i) and modified as noted below:
   1. Accommodation

      Symptomatic patients should be advised to:

      • rest away from others, in a separate room, if available
      • use a designated bathroom, whenever possible
      • clean the bathroom frequently, especially frequently touched surfaces
      • not share towels or other personal items [CII]
   2. Patient flow
      • Asymptomatic patients should not be excluded from group/social activities.
      • Symptomatic patients should be advised on how to contain secretions/excretions to minimize the risk of transmission to others (e.g., contain draining wounds with an intact dressing) and to perform hand hygiene prior to group activities.
      • Symptomatic patients should be advised to exclude themselves from group/social activities when experiencing acute symptoms and when secretions/excretions cannot be contained.
      • Care and services (e.g., appointments at foot care clinics, volunteer visiting and volunteer transportation) that are not medically necessary should be postponed until patients are asymptomatic. [CII]
   3. Personal protective equipment
      • Gloves and gowns should be worn when direct contact is anticipated with a symptomatic patient or equipment and environmental surfaces in the patient's immediate environment. [BII]
   4. Duration of precautions
      • Precautions should be discontinued when the patient is asymptomatic. [CII]

Special considerations for the care of patients with antibiotic-resistant microorganisms in home care

• Requiring proof of screening for antibiotic-resistant microorganisms before care is provided is not advised. Communicating (preferably with infection control personnel) when referring a patient known to have an antibiotic-resistant microorganism to a healthcare facility should be done to ensure appropriate precautions are implemented.
• Contact precautions should not be used for patients who are asymptomatic, including asymptomatic carriers of antibiotic-resistant organisms; routine practices, properly and consistently applied, are sufficient.
• Collaboration with local or regional public health departments and infection control professionals should be done to design a comprehensive infection prevention and control program. In some jurisdictions, such collaboration may be appropriate with the local funder of home care services. [CII]

Modifications of contact precautions for prehospital care

1. Routine practices (as per Part B, Section III) and contact precautions should be followed for all healthcare settings (as per Part B, Section IV, subsection i), and modified as noted below:
   1. The number of personnel attending the patient should be limited, when possible.
   2. Gloves/gowns should be put on at the point-of-care.
   3. Gloves/gown should be removed when patient care is completed, immediately discarded, and hand hygiene should be performed.
   4. When transfer to healthcare facilities is necessary, the patient should be provided with clean bedclothes and bedding, draining wounds should be contained with clean dressings, infected areas of the patient's body should be covered and body substances should be contained.
   5. Single patient transport is preferred.
   6. A point-of-care risk assessment should be done when considering multi-transport; conditions, as listed in routine practices, for priority for single transport should be considered.
   7. The receiving hospital/facility should be notified if precautions are indicated.
   8. Equipment and surfaces should be cleaned and disinfected and linen should be changed after every patient. [CII]

Special considerations for the care of patients with antibiotic-resistant microorganisms in prehospital care

• Modifications of contact precautions for prehospital care in the box above should be followed.
• Contact precautions for patients who are asymptomatic, including asymptomatic carriers of antibiotic-resistant microorganisms, should not be used; routine practices, properly and consistently applied, are sufficient. [CII]

Subsection ii: Droplet precautions in all care settings and modifications for specific healthcare settings

Droplet precautions should be used for the conditions/clinical presentations and specific etiologies listed in List 4. In addition to routine practices applied properly and consistently for the care of all patients in all settings, the recommendations that follow List 4 apply to the care of patients on droplet precautions in all care settings. Modifications for specific healthcare settings follow. Certain diseases require public health notification; check local regulations.

1. Source control

1. A system to identify patients with known or suspected acute infections that warrant droplet precautions should be developed.
   1. Droplet precautions should be implemented empirically for patients with conditions/clinical presentations listed in List 4, rather than waiting for the etiology to be determined.
   2. Refer to specific etiologies in List 4 if the etiology has been established. (Note: some indications for droplet precautions may differ for certain children [e.g., epiglottitis or cellulitis in children <5 years, scarlet fever] and adult patients.).
   3. Note: Some conditions/specific infections warrant two categories of precautions: contact and droplet.
   4. Patients should be instructed to adhere to respiratory hygiene. When a mask is worn, the patient can remove the mask once accommodated in the room.
   5. Patients with acute respiratory symptoms should be directed to a separate waiting area or placed into a single room; in a multi-bed room, the privacy curtain should be pulled (refer to Part B, Section IV, subsection ii, 3).
   6. A sign should be placed at the entrance to the patient room or other visible locations to identify droplet precautions. [CI]
2. Droplet precautions in addition to routine practices are sufficient for aerosol-generating medical procedures performed on patients on droplet precautions who have no signs or symptoms of suspected or confirmed tuberculosis, severe acute respiratory syndrome or respiratory infection with an emerging pathogen for which transmission characteristics are not yet known.

2. Personnel restrictions

1. Healthcare workers, to prevent self-contamination, should avoid touching the mucous membranes of their eyes, nose and mouth with their hands. [CII]
2. Healthcare workers who are not immune to mumps or rubella should not provide direct care for patients with these infections^{Footnote 219}. [CII]

3. Patient placement and accommodation

1. In inpatient facilities, a single room with in-room designated toilet and sink is preferable, as it may be difficult to maintain the recommended spatial separation of two metres between patients^{Footnote 122, Footnote 123, Footnote 124}.
   1. The room door may remain open.
   2. When single patient rooms are limited, a point-of-care risk assessment should be performed to determine suitability for patient placement.
   3. Patients who cannot be confined to their bed or bed area should be prioritized for single patient room placement. [CI]
2. When sufficient single rooms are not available, patients should be cohorted if they are known to be infected with the same pathogen and if they are suitable roommates^{Footnote 385, Footnote 391, Footnote 392, Footnote 393, Footnote 401, Footnote 485}. [CI]
3. When a room must be shared and cohorting patients with the same pathogen is not possible:
   1. Avoid placing patients on droplet precautions in the same room with patients who, if they were to become infected, would be at high risk for complications or who may facilitate transmission (e.g., elderly, patients with cardiopulmonary disease, immunocompromised).
   2. Roommates and all visitors should be aware of the precautions to be followed.
   3. Roommates should be selected for their ability and that of their visitors to comply with precautions.
   4. Patients should be physically separated (i.e., at least two metres apart) from each other. The privacy curtain between beds should be drawn to minimize opportunities for droplet spread.
   5. Droplet precautions should be applied in nursery settings, including the necessary spacing between infant stations to minimize opportunities for droplet contact^{Footnote 429}. Family members and/or designated visitors should comply with the necessary precautions. [CII]

4. Patient flow

1. The patient should perform hand hygiene (with assistance as necessary) before leaving the room. [AII]
2. The patient should be allowed out of the room as indicated in their care plan. Supervision of the patient should be provided if compliance with precautions is inadequate.
   1. The patient should wear a mask^{Footnote 368, Footnote 369, Footnote 373, Footnote 374, Footnote 375, Footnote 376} if tolerated and follow respiratory hygiene during transport. [CI]
   2. Personnel in the area to which the patient is to be transported should be aware of the status of the patient and of the precautions to follow. [CII]

5. Personal protective equipment

1. Personal protective equipment for droplet precautions should be provided outside the room or in the anteroom. [CII]
2. Transport personnel should wear facial protection if the patient cannot follow respiratory hygiene. [CII]
3. Facial protection should be worn and discarded as outlined in routine practices to prevent self-contamination. [BII]
4. In addition to the use of personal protective equipment as per routine practices:
   1. Facial protection (i.e., masks and eye protection, or face shields, or masks with visor attachment)^{Footnote 410, Footnote 411} should be worn:
      • for care of patients with symptoms of acute respiratory viral infection,
      • when within two metres of patient who is coughing at the time of interaction, or
      • if performing procedures that may result in coughing^{Footnote 122, Footnote 123, Footnote 219}
   2. For care of patients with rubella or mumps, facial protection is not needed if the healthcare worker is immune. Non-immune personnel (rubella, mumps) should not enter the room unless it is essential, at which time facial protection should be worn. [CI]
5. In a cohort where patients have the same microorganisms, facial protection may be used for successive patients (gloves should be changed and hand hygiene performed between patients). [CII]

6. Cleaning and disinfection of patient care equipment

1. As per routine practices unless contact precautions are also in use, then as per contact precautions.

7. Cleaning of patient environment

1. As per routine practices unless contact precautions are also in use, then as per contact precautions.

8. Education of patient and family

1. Patients, their visitors, families and their decision makers should be educated about the precautions being used, the duration of precautions, as well as the prevention of transmission of disease to others, with a particular focus on hand hygiene. [CII]
2. Visitors who are participating in patient care should be instructed about the indications for and appropriate use of personal protective equipment (barriers). In the adult setting, visitors who assist with patient care should use the same personal protective equipment as healthcare workers. This may not be necessary for parents carrying out their usual care of young children. [CII]

9. Management of visitors

1. The number of visitors should be kept to a minimum. Visitors should be instructed to speak with a nurse before entering the patient room. In the case of acute viral respiratory infection, household members need not wear facial protection (as they may have already been exposed). On a case-by-case basis, other visitors should be instructed in the appropriate use of a mask and other precautions. [CII]
2. Exceptions to the need for facial protection include the following:
   1. for patients with suspected or confirmed Haemophilus influenzae type B infection, visitors should wear facial protection only if they will have extensive close contact with children <5 years of age.
   2. for patients with rubella or mumps, facial protection is not needed if the visitor is immune. Non-immune visitors should only enter the room when it is absolutely necessary; if they enter the room, they should wear facial protection. [CII]

10. Duration of precautions

1. Droplet precautions should be discontinued after signs and symptoms of the infection have resolved or as per the disease-specific recommendations in Table 5. [CII]
2. The duration of precautions should be determined on a case-by-case basis when patient symptoms are prolonged or when the patient is immune suppressed. The patient with persistent symptoms should be re-evaluated for underlying chronic disease. Repeat microbiological testing may sometimes be warranted. [CII]

11. Handling deceased bodies

1. Routine practices, properly and consistently applied, should be used for handling deceased bodies and preparing bodies for autopsy or transfer to mortuary services. Droplet precautions are not necessary. Adhere to provincial/territorial specified communicable disease regulations. [Regulated]

12. Waste, laundry, dishes and cutlery

1. No special precautions; routine practices are sufficient.

Modifications for droplet precautions in specific healthcare settings

Modifications of droplet precautions in long-term care

1. Routine practices (as per Part B, Section III) and droplet precautions should be followed for all healthcare settings (as per Part B, Section IV, subsection ii) and modified as noted below:
   1. In long-term care and other residential settings, a point-of-care risk assessment should be performed to determine patient placement. Infection risks to other patients in the room and available alternatives should be considered.
   2. Participation in group activities may need to be restricted while the patient is symptomatic.
   3. During an outbreak in a facility, restriction to social activities in wards/units/areas should be considered.
   4. Restriction of visitors should be considered during community or facility outbreaks of respiratory infections. [CII]

Modifications of droplet precautions in ambulatory care

1. Routine practices (as per Part B, Section III) and droplet precautions should be followed for all healthcare settings (as per Part B, Section IV, subsection ii) and modified as noted below:
   1. Patients should be placed directly into single rooms, especially if he or she has known or suspected influenza, meningococcal infection, rubella, mumps or pertussis. If this is not possible, patients should be placed in an area of the waiting room separated from other patients by at least two metres, and the time spent in waiting room should be minimized.
   2. Consider separate waiting rooms or areas for well-child visits and for children with acute respiratory infection, especially during community outbreaks. [CII]

Modifications of droplet precautions in home care

1. Routine practices (as per Part B, Section III) and droplet precautions should be followed for all healthcare settings (as per Part B, Section IV, subsection ii) and modified as noted below:
   1. Patients should be instructed to self-screen for acute respiratory illness and to inform the home care agency prior to the healthcare worker visit, scheduled appointment or attendance at a group program.
   2. Patients should be advised to exclude themselves from group programs when experiencing acute symptoms of respiratory illness.
   3. Healthcare workers should screen patients for febrile illness by phone, prior to the homecare visits, whenever possible. Healthcare workers should screen patients upon entry into clinics or group programs and for home visits if advance telephone screening is not possible.
   4. Medically necessary care should be provided. Care (e.g., foot care clinics) and services (e.g., volunteer visitors and volunteer transportation) that are not medically necessary should be deferred when patients are experiencing acute respiratory symptoms. [CII]

Modifications of droplet precautions in prehospital care

1. Routine practices (as per Part B, Section III) and droplet precautions should be followed for all healthcare settings (as per Part B, Section IV, subsection ii) and modified as noted below:
   1. A system should be developed to identify patients with known or suspected infections that warrant droplet precautions.
   2. The number of personnel attending to the patient should be limited.
   3. Single patient transport is preferred.
   4. A mask should be placed on the patient if the patient is able to tolerate it.
   5. The receiving facility should be notified of precautions indicated.
   6. If the disease is known to be of droplet transmission, then a procedure/surgical mask should be used. However, if on assessment disease caused by airborne transmission cannot be ruled out, then airborne precautions should be used. [CII]

Subsection iii: Airborne precautions in all care settings and modifications for specific healthcare settings

Airborne precautions should be used for the conditions/clinical presentations and specific etiologies listed in List 5. In addition to routine practices for the care of all patients in all settings, the recommendations that follow List 5 apply to the care of patients on airborne precautions in all care settings. Modifications for specific healthcare settings follow. Certain diseases require public health notification; check local regulations.

List 5: Conditions and/or clinical presentations and specific etiologies requiring airborne precautions

• 5a. Conditions and/or clinical presentation
  (Refer to Table 4 for details)
  • Cough, fever, pulmonary infiltrate in person at risk for TB (pleuropulmonary or laryngeal TB)
  • Rash, maculopapular with fever and one of coryza, conjunctivitis or cough
  • Rash, vesicular with fever
• 5b. Specific etiologies
  (Refer to Table 5 for details)
  • Measles (rubeola)
  • Monkeypox
  • Tuberculosis (pleuropulmonary or laryngeal)
    • nonpulmonary lesions, during procedures that may aerosolize tuberculi bacilli
  • Smallpox
  • Varicella zoster virus
    • varicella (chicken pox)
    • zoster, disseminated
    • zoster in immunocompromised patient
    • zoster in immunocompetent patient that cannot be contained

1. Source control

1. A system should be developed to identify patients with known or suspected infection that warrant airborne precautions (i.e., infectious tuberculosis, measles, varicella and disseminated zoster).
   1. Airborne precautions should be implemented empirically for patients with suspected airborne conditions/clinical presentations, as listed in List 5. above; do not wait for the etiology to be determined.
   2. Refer to specific etiologies in List 5 if etiology has been established.
   3. Note that some airborne diseases/infections warrant two precaution categories: airborne and contact.
   4. Patients should be directed to put on a mask, if tolerated (not a respirator), when not in an airborne infection isolation room^{Footnote 209, Footnote 368, Footnote 486}.
   5. Patients known or suspected to have an airborne infection should be placed directly into an airborne infection isolation room with the door closed^{Footnote 21, Footnote 72, Footnote 138, Footnote 207, Footnote 210, Footnote 437} and with exhaust vented to the outside or filtered through a high-efficiency particulate filter if recirculated^{Footnote 72, Footnote 146, Footnote 207, Footnote 486}.
   6. The patient should be allowed to remove the mask once in an airborne infection isolation room (refer to Part B, Section IV, subsection iii, 2)^{Footnote 207, Footnote 486}.
   7. The patient should be placed into a single room if an airborne infection isolation room is unavailable; the patient should be instructed to keep the mask on and the door should remain closed.
   8. When airborne isolation rooms are unavailable, the patient should be transferred to a facility with an available airborne infection isolation room as soon as medically stable for transport^{Footnote 21, Footnote 207, Footnote 486}.
   9. A sign should be placed at the entrance to the patient room or other visible location to identify airborne precautions. [CI]
2. The following strategies should be applied to reduce the level of aerosol generation when performing aerosol-generating medical procedures for patients with suspected or confirmed tuberculosis, severe acute respiratory syndrome and an emerging pathogen for which transmission characteristics are not yet known^{Footnote 150, Footnote 151, Footnote 152, Footnote 153, Footnote 154, Footnote 156, Footnote 157}. Strategies to reduce aerosol generation should also be implemented when aerosol-generating medical procedures are necessary on patients with viral hemorrhagic fevers^{Footnote 161}. [BII]
   1. Aerosol-generating medical procedures should be limited to those that are medically necessary.
   2. Aerosol-generating medical procedures should be anticipated and planned for.
   3. Appropriate patient sedation should be used.
   4. The number of personnel in the room should be limited to those required to perform the aerosol-generating medical procedure.
   5. Aerosol-generating medical procedures should be performed in airborne infection isolation rooms whenever feasible.
   6. Appropriate ventilation (e.g., level of air filtration and direction of air flow) should be maintained.
   7. Single rooms (with the door closed and away from high-risk patients), should be used in settings where airborne infection isolation rooms are unavailable.
   8. Respirators should be worn by all personnel in the room during the procedure.
   9. Closed endotracheal suction systems should be used wherever possible.

   Note: When responding to a code (cardiac arrest) on a patient with an airborne infection who is not in an airborne infection isolation room, and if transfer to a single room or airborne infection isolation room is not feasible, the privacy curtain should be pulled and all personnel in the room or within the privacy curtain area should wear appropriate personal protective equipment. Visitors and other patients should be removed from the room/area (if feasible).

3. Intubated and ventilated patients^{Footnote 437}: [CII]
   1. An appropriate bacterial filter should be placed on the endotracheal tube to prevent contamination of the ventilator and the ambient air.
   2. Endotracheal suctioning should be performed using a closed suction apparatus, where possible.

2. Patient placement and accommodation (refer to Part B, Section IV, subsection iii, 1a)

1. The airborne infection isolation room should have an in-room toilet, sink and bathing facility for the patient, and a designated handwashing sink for healthcare workers^{Footnote 201, Footnote 202, Footnote 209, Footnote 289, Footnote 290, Footnote 291, Footnote 292, Footnote 293, Footnote 294, Footnote 295, Footnote 296, Footnote 297, Footnote 298, Footnote 299, Footnote 300, Footnote 301, Footnote 302}. [BII]
2. Patients known to be infected with the same virus (measles or varicella) may share a room. [CII]
3. Patients with tuberculosis should not share rooms, as strains and levels of infectivity may be different. [CII]
4. Monitoring^{Footnote 72, Footnote 207, Footnote 487, Footnote 488} [CI]
   1. The pressure differential should be checked prior to placing a patient requiring airborne isolation in an airborne infection isolation room, using visual indicators (smoke tubes or flutter strips) or portable manometers.
   2. Visual indicators or portable manometers should be rechecked regularly, preferably daily, when airborne infection isolation rooms are in use, regardless of the presence of continuous differential pressure sensing devices.
   3. The results of monitoring should be documented.
   4. Visual or audible alarms should not be inactivated.

3. Patient flow

1. Patients should be restricted to their room, unless leaving the room for medically essential procedures. The patient should be accompanied by a healthcare worker whenever outside the room^{Footnote 209}. [CII]
2. A mask (not a respirator) should be placed on the patient (if tolerated) when the patient leaves the room^{Footnote 207, Footnote 213, Footnote 373, Footnote 374, Footnote 375}. If patient cannot wear a mask, refer to c and d, below. [CII]
3. If the patient needs transport for medically essential purposes and cannot wear a mask, transport should be planned to limit the exposure of other individuals (e.g., no waiting in the reception areas) and it should be communicated to receiving personnel that consistent precautions need to be ensured. If transport is in a confined space (e.g., ambulance), the transport personnel should wear a respirator during transport. [CI]
4. For other conditions (i.e., measles, varicella), immune transport personnel will not need a respirator. [CII]
5. Skin lesions due to varicella or smallpox, or nonrespiratory draining lesions due to Mycobacterium tuberculosis should be covered with a clean sheet to prevent aerosolization of the infectious agent if the patient leaves the room^{Footnote 138, Footnote 207, Footnote 489, Footnote 490, Footnote 491}. [CII]

4. Personnel^{Footnote 219, Footnote 419}

1. Healthcare workers and other individuals (e.g., transport personnel) should be aware of their immune status to measles and varicella. [CII]
2. All healthcare workers should be immune to measles and varicella. A healthcare worker who is not immune should not provide care for a patient with measles, varicella or zoster, or for a susceptible exposed patient who is in the infectious stage/period. [CII]
3. Non-immune healthcare workers should not enter the rooms of patients known or suspected to have measles, varicella or disseminated zoster, or the room of a susceptible exposed patient in the infectious period/stage for these conditions. In circumstances where this is unavoidable, a respirator should be worn (refer to 7, below, Personal protective equipment). (Note: Gloves should be worn by non-immune healthcare workers caring for patients with varicella or disseminated zoster.) [CII]
4. Immune healthcare workers do not need respirators when caring for patients known or suspected to have measles (rubeola), varicella (chickenpox) or disseminated zoster. [CII]

5. Management of patients with airborne infections

1. For varicella:
   • The patient should remain in the room until all lesions have crusted.
   • Susceptible personnel and visitors should not enter the room. If exceptional circumstances make this necessary, they should wear a respirator and gloves.
   • The patient should leave the room for medically essential purposes only, unless it is established that all other patients and all healthcare workers are immune to varicella.
   • The patient should wear a mask, have skin lesions covered and clean bedclothes and bedding (as needed) when out of the room. [CII]
2. For measles:
   • The patient should remain in the room until four days after onset of rash or for the duration of illness, if immunocompromised.
   • Susceptible personnel and visitors should not enter the room. If exceptional circumstances make this necessary, a respirator should be worn.
   • The patient should leave the room for medically essential purposes only, unless it is established that all other patients and all healthcare workers are immune to measles. The patient should wear a mask when out of the room. [CII]

6. Management of exposed susceptible roommates and other close contacts

1. For varicella:
   • The immune status of exposed roommates and other close contacts should be determined.
   • Exposed susceptible contacts should be placed in single airborne infection isolation room from seven days after the first possible exposure until 21 days after the last exposure.
   • The most recent National Advisory Committee on Immunization recommendations should be used to determine whether varicella zoster immune globulin or varicella vaccination is recommended for exposed susceptible contacts at risk of severe disease; if given, precautions should be extended to 28 days after exposure^{Footnote 419}.
   • Varicella vaccine should be offered to exposed susceptible individuals (with no known contraindications) within 72 hours of first contact.
   • Precautions for exposed individuals should be followed, regardless of the administration of varicella zoster immune globulin or varicella vaccine. [CII]
2. For measles:
   • The immune status of exposed roommates and other close contacts should be determined.
   • Susceptible contacts should be provided with prophylaxis (i.e., measles vaccine or immunoglobulin, as per the most recent National Advisory Committee on Immunization recommendations)^{Footnote 419}.
   • Exposed susceptible contacts should be placed in single airborne infection isolation rooms from five days after the first possible exposure until 21 days after the last exposure, regardless of vaccine administration^{Footnote 15, Footnote 492} [CII]

7. Personal protective equipment

1. Healthcare workers should wear respirators when caring for a patient with suspected or confirmed respiratory tuberculosis. Healthcare workers should wear respirators when infectious tuberculosis skin lesions are present and procedures that would aerosolize viable tubercle bacilli organisms (e.g., irrigation) are performed^{Footnote 162, Footnote 163, Footnote 164}. [CII]
2. Healthcare workers should wear respirators when caring for a patient with vaccine preventable airborne infections (i.e., varicella, measles) to which they are not immune. [CII]
3. Healthcare workers should wear respirators when performing or assisting with aerosol-generating medical procedures (as per Part B, Section IV, subsection iii, 1b) on patients with signs and symptoms of severe acute respiratory syndrome or with a respiratory pathogen for which transmission characteristics are not yet known^{Footnote 150, Footnote 151, Footnote 152, Footnote 153, Footnote 154, Footnote 155, Footnote 156}. Strategies to reduce aerosol generation should also be implemented when aerosol-generating medical procedures are necessary on patients with hemorrhagic fevers^{Footnote 161}. For novel influenza viruses or emergence of new pathogens, refer to the PHAC website for specific guidance documents (http://www.phac-aspc.gc.ca/nois-sinp/guide/pubs-eng.php). [BII]
4. Healthcare workers should wear respirators when caring for a patient with suspect or confirmed monkeypox or smallpox. [CII]
5. Healthcare workers should adhere to policies and procedures related to the organization's respiratory protection program [Regulated]
6. Healthcare workers should remain clean shaven in the area of the respirator seal to ensure facial seal. [CII]

   Appropriate respirator use [CII]

   • Hand hygiene should be performed prior to putting on a respirator.
   • A seal check should be performed.
   • Self-contamination should be avoided by not touching the respirator on its external surface during use and disposal.
   • Respirators should be carefully removed by the straps.
   • A respirator should not dangle around the neck when not in use.
   • The respirator should be changed if it becomes wet or soiled (from the wearer's breathing or an external splash).
   • The respirator should be changed if breathing becomes difficult.
   • The respirator should be discarded immediately after its use (i.e., dispose of when removed from the face) into a no-touch waste receptacle, followed by hand hygiene.
   • In cohort settings, respirators may be used for successive patients.

8. Management of patient care equipment

1. As per routine practices unless contact precautions are also in use, then as per contact precautions.

9. Cleaning of patient environment

1. As per routine practices unless contact precautions are also in use, then as per contact precautions.

10. Education of patient, family and visitors

1. Patients, their visitors, families and their caretakers should be educated about the precautions being used, the duration of the precautions and the prevention of transmission of disease to others. [CII]
2. Patients with known or suspected airborne infections should be instructed to wear a mask and to cover skin lesions (due to varicella or smallpox or nonrespiratory draining lesions due to Mycobacterium tuberculosis) with a dry dressing if, for medical reasons, they have to leave their airborne infection isolation room^{Footnote 207, Footnote 213, Footnote 219, Footnote 373, Footnote 374}. [CII]
3. Visitors who are participating in patient care should be instructed about the indications for and appropriate use of personal protective equipment. In the adult setting, visitors who assist with patient care should use the same personal protective equipment as healthcare workers, unless determined to already have had prolonged exposure to that patient or if immune to the specific disease/condition the patient is on precautions for. Visitors should be instructed to perform a seal check if wearing a respirator. [CII]

11. Management of visitors

1. For tuberculosis:
   • Visitors should be restricted to immediate family or guardian.
   • Close contact visitors (e.g., household members, those who routinely have visited the patient's home) should be screened for the presence of cough. Coughing visitors should be sent for tuberculosis assessment as soon as possible and until assessed, they should visit only if it is essential and should wear a mask while in the facility. [CII]
2. For other airborne infections (varicella, measles):
   • Visitors should be instructed to speak with a nurse before entering the patient room.
   • Visitors should be restricted from visiting, unless confirmed to be immune to the specific infection for which the patient is on precautions for, or unless for compassionate reasons (contact, droplet) or the visit is essential (e.g., parent, guardian or primary caretaker).
   • If visit is essential, non-immune visitors may visit if appropriate personal protective equipment is worn. [CII]

12. Duration of precautions

1. Airborne precautions should be discontinued after signs and symptoms of the infection have resolved or as per the disease-specific recommendations in Table 5. [CII]

13. Handling deceased bodies

1. Routine practices, properly and consistently applied, in addition to airborne precautions, should be used for handling deceased bodies and preparing bodies for autopsy or transfer to mortuary services. Airborne precautions should be continued for the handling of a patient with infectious respiratory tuberculosis, measles or varicella until appropriate time has elapsed to remove airborne contaminants in the room (refer to Appendix VIII). Adhere to provincial/territorial specified communicable disease regulations. [Regulated]

14. Upon discharge or discontinuation of airborne precautions

1. Sufficient time should be allowed for the air to be free of aerosolized droplet nuclei (refer to Appendix VIII) before housekeeping performs terminal cleaning, or the housekeeper should wear a respirator. [CII]

Modifications for airborne precautions in specific healthcare settings

Modifications of airborne precautions for long-term care

1. Routine practices (as per Part B, Section III) and airborne precautions should be followed for all healthcare settings , including long term care (as per Part B, Section IV, subsection iii), and modified as noted below:
   1. Tuberculosis (infectious, respiratory [pleuropulmonary or laryngeal])^{Footnote 21, Footnote 437, Footnote 493, Footnote 494, Footnote 495, Footnote 496}
      1. The tuberculosis infection status of patients in residential facilities should be determined at the time of admission. [CII]
      2. If an airborne infection isolation room is not available in the long-term care setting, transfer to a facility with airborne infection isolation rooms should be arranged. If transfer is delayed:
         • place the patient in a single room with the door closed, preferably without recirculation of air from the room and as far away from the rooms of other patients as possible
         • limit the number of people entering the room (e.g., no non-essential visitors) [CII]
   2. Varicella or disseminated herpes zoster or localized herpes zoster that cannot be kept covered, or measles:
      1. The immune status (measles, varicella) of patients in residential facilities should be determined at the time of admission and immunization offered, if appropriate. [CII]
      2. If an airborne infection isolation room is not available in the long-term care setting, transfer to a facility with airborne infection isolation rooms should be arranged. If transfer is delayed:
         • place the patient in a single room with the door closed, preferably without recirculation of air from the room and as far away from the rooms of other patients as possible
         • limit the number of people entering the room (e.g., no non-essential visitors) [CII]

         If all personnel and all other residents in the facility are immune and if non-immune visitors can be excluded, transfer to a facility with an airborne infection isolation room may not be essential. [CII]

      3. Infectious patients should not be placed on units where there are susceptible immunocompromised patients. [CII]

Modifications of airborne precautions for ambulatory care

1. Routine practices (as per Part B, Section III) and airborne precautions should be followed for all healthcare settings , including long term care (as per Part B, Section IV, subsection iii), and modified as noted below: [CII]
   1. A system should be developed to identify patients with known or suspected infection that warrant airborne precautions (i.e., infectious tuberculosis, measles, varicella or disseminated zoster).
   2. A system (e.g., triage, signage) should be developed at entry to ambulatory settings or when making telephone appointments to identify patients with known or suspected infection that warrants airborne precautions (i.e., infectious tuberculosis, measles, varicella or disseminated zoster). If feasible, the visit should be scheduled at a time to minimize exposure of other patients, such as at the end of the day.
   3. Patients with suspected airborne infection should be directed to put a mask on upon entry to the facility.
   4. Patients known or suspected to have airborne infection should be placed directly into an airborne infection isolation room.
   5. The patient may remove the mask once in an airborne infection isolation room.
   6. Patients should be placed into a single room if an airborne infection isolation room is unavailable; the patient should wear a mask and the door should remain closed.
   7. Recommendations for personnel, patient flow and personal protective equipment should be followed, as per recommendations for all care facilities.
   8. Upon discharge, sufficient time should be allowed for the air to be free of aerosolized droplet nuclei before using the room for another patient (tuberculosis) or for a non-immune patient (measles or varicella). The duration will depend on the rate of air exchange in the room (refer to Appendix VIII). [CII]

Modifications of airborne precautions for home care

1. Routine practices (as per Part B, Section III) and airborne precautions should be followed for all healthcare settings , including long term care (as per Part B, Section IV, subsection iii), and modified as noted below:
   1. A system to screen patients prior to appointments should be developed to identify patients with known or suspected infection that warrants airborne precautions (i.e., infectious tuberculosis, measles, varicella or disseminated zoster).
   2. Home care agencies should consult with public health to determine if the patient is infectious for respiratory tuberculosis and needs airborne precautions. [CII]

Modifications of airborne precautions for prehospital care

1. Routine practices (as per Part B, Section III) and airborne precautions should be followed for all healthcare settings , including long term care (as per Part B, Section IV, subsection iii), and modified as noted below:
   1. A system to identify patients with known or suspected infection that warrant airborne precautions (i.e., infectious tuberculosis, measles, varicella or disseminated zoster) should be developed.
   2. Whenever possible, first responders should perform a point-of-care risk assessment and put on personal protective equipment, as needed, prior to entering the home or location of the patient.
   3. Where available, vehicle ventilation systems should be used to create a negative pressure environment; where not available, natural ventilation (e.g., open vehicle windows) should be used.
   4. Patient should wear a mask during transport, if tolerated. If the patient needs oxygen, a filtered oxygen mask should be used. [CII]