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National Infection Prevention and Control Manual

National Infection Prevention and Control Manual

Chapter 2 - Transmission Based Precautions (TBPs)

SICPs may be insufficient to prevent cross transmission of specific infectious agents. Therefore additional precautions TBPs are required to be used by staff when caring for patients with a known or suspected infection or colonisation.

Clinical judgement and decisions should be made by staff on the necessary precautions.  This must be based on the:

  • suspected or known infectious agent
  • severity of the illness caused
  • transmission route of the infectious agent
  • care setting and procedures undertaken

TBPs are categorised by the route of transmission of infectious agents (some infectious agents can be transmitted by more than one route): Appendix 11 provides details of the type of precautions, optimal patient placement, isolation requirements and respiratory precautions required.  Application of TBPs may differ depending on the setting and the known or suspected infectious agent.

Contact precautions

Used to prevent and control infections that spread via direct contact with the patient or indirectly from the patient’s immediate care environment (including care equipment). This is the most common route of cross-infection transmission.

Droplet precautions

Used to prevent and control infections spread over short distances (at least 3 feet or 1 metre) via droplets (greater than 5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Droplets penetrate the respiratory system to above the alveolar level.

Airborne precautions

Used to prevent and control infections spread without necessarily having close patient contact via aerosols (less than or equal to 5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Aerosols penetrate the respiratory system to the alveolar level.

Further information on Transmission Based Precautions can be found in the definitions of Transmission Based Precautions literature reviews.

2.1 Patient Placement/Assessment for Infection Risk

The potential for transmission of infection must be assessed at the patient’s entry to the care area.  If hospitalised or in a care home setting this should be continuously reviewed throughout the stay/period of care. The assessment should influence placement decisions in accordance with clinical/care need(s).

Patients who may present a cross-infection risk in any setting includes those:

  • With diarrhoea, vomiting, an unexplained rash, fever or respiratory symptoms.
  • Known to have been previously positive with a Multi-drug Resistant Organism (MDRO) e.g MRSA, CPE.
  • Who have been hospitalised (inpatient) outside Scotland in the last 12 months.

Isolation facilities should be prioritised depending on the known/suspected infectious agent (refer to Aide Memoire - Appendix 11).  All patient placement decisions and assessment of infection risk (including isolation requirements) must be clearly documented in the patient notes.

The clinical judgement and expertise of the staff involved in a patient's management and the Infection Prevention and Control Team (IPCT) or Health Protection Team (HPT) should be sought particularly for the application of TBPs e.g. isolation prioritisation when single rooms are in short supply. 

Hospital settings:

  • Isolation of infectious patients can be in specialised isolation facilities, single room isolation, cohorting of infectious patients where appropriate, ensuring that they are separated by at least 3 feet (1 metre) with the door closed.
  • Signage should be used on doors/areas to communicate isolation requirements and prevent entry of unnecessary visitors and non-essential staff.
  • Infectious patients should only be transferred to other departments if medically necessary.  If the patient has an infectious agent transmitted by the airborne/droplet route then if possible/tolerated the patient should wear a surgical face mask during transfer.
  • Receiving department/hospital and transporting staff must be aware of the necessary precautions.

Care home settings:

  • Residents should remain in their bedroom whilst considered infectious (as described above) and the door should remain closed (if unable to isolate this should be documented).
  • If transfer to hospital is required the ambulance service should be informed of the infectious status of the resident.
  • Advice on resident’s clinical management should be sought from GP,  and infection prevention and control management sought from the HPT.
  • Avoid unnecessary transfer of residents within/between care areas.

Staff cohorting; consider assigning a dedicated team of care staff to care for patients in isolation/cohort rooms/areas as an additional infection control measure during outbreaks/incidents. This can only be implemented if there are sufficient levels of staff available (so as not to have a negative impact on non-affected patients’ care).

Before discontinuing isolation; individual patient risk factors should be considered (e.g. there may be prolonged shedding of certain microorganisms in immunocompromised patients).

Primary care/out-patient settings:

  • Patients attending these settings with suspected/known infection/colonisation should be prioritised for assessment/treatment e.g. scheduled appointments at the start or end of the clinic session. Infectious patients should be separated from other patients whilst awaiting assessment and during care management by at least 3 feet (1m). 
  • If transfer from a primary care facility to hospital is required the ambulance service should be informed of the infectious status of the patient.

Updated : 11/01/15 17:02

2.2 Safe Management of Patient Care Equipment in an Isolation Room/Cohort Area

  • Use single-use items if possible.
  • Reusable non-invasive care equipment should be dedicated to the isolation room/cohort area and decontaminated prior to use on another patient Section 1.5. Safe Management of Care Equipment
  • An increased frequency of decontamination should be considered for reusable non-invasive care equipment when used in isolation/cohort areas.

For how to decontaminate non-invasive reusable equipment see Appendix 7.

Note: Scottish Ambulance Service (SAS) and Scottish National Blood Transfusion Service adopt practices that differ from those stated in the National Infection Prevention and Control Manual.

Updated : 11/01/15 17:03

2.3 Safe Management of the Care Environment

Routine environmental decontamination

Hospital/Care home setting:

Patient isolation/cohort rooms/area must be decontaminated at least daily, this may be increased on the advice of IPCTs/HPTs. These areas must be decontaminated using either:

  • a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available chlorine (ppm available chlorine (av.cl.)); or
  • a general purpose neutral detergent in a solution of warm water followed by disinfection solution of 1,000ppm av.cl.

Manufacturers’ guidance and recommended product "contact time" must be followed for all cleaning/disinfection solutions .

Increased frequency of decontamination/cleaning schedules should be incorporated into the environmental decontamination schedules for areas where there may be higher environmental contamination rates e.g.

  • toilets/commodes particularly if patients have diarrhoea; and
  • “frequently touched” surfaces such as door/toilet handles and locker tops, over bed tables and bed rails.

Vacated rooms should also be decontaminated following an AGP. Clearance of infectious particles after an AGP is dependent on the ventilation and air change within the room. This is a minimum of 20 minutes in hospital settings where the majority of these procedures occur. Advice should be sought from IPCT.

Patient rooms must be terminally cleaned following resolution of symptoms, discharge or transfer. This includes removal and laundering of all curtains and bed screens.

Primary care/Out-patient settings:

The extent of decontamination between patients will depend on the duration of the consultation/assessment, the patients presenting symptoms and any visible environmental contamination. 

Equipment used for environmental decontamination must be either single-use or dedicated to the affected area then decontaminated or disposed of following use e.g. cloths, mop heads.

Terminal decontamination

Following patient transfer, discharge, or once the patient is no longer considered infectious:

Remove from the vacated isolation room/cohort area, all:

  • healthcare waste and any other disposable items (bagged before removal from the room);
  • bedding/bed screens/curtains and manage as infectious linen (bagged before removal from the room); and
  • reusable non-invasive care equipment (decontaminated in the room prior to removal) Appendix 7.

The room should be decontaminated using either:

  • a combined detergent disinfectant solution at a dilution (1,000ppm av.cl.); or
  • a general purpose neutral detergent clean in a solution of warm water followed by disinfection solution of 1,000ppm av.cl..

The room must be cleaned from the highest to lowest point and from the least to most contaminated point.

Manufacturers’ guidance and recommended product "contact time" must be followed for all cleaning/disinfection solutions .

Unless instructed otherwise by the IPCT there is no requirement for a terminal clean of an outpatient area or theatre recovery.

Note: Scottish Ambulance Service (SAS) and Scottish National Blood Transfusion Service adopt practices that differ from those stated in the National Infection Prevention and Control Manual.

Updated : 11/01/15 17:04

2.4 Personal Protective Equipment (PPE): Respiratory Protective Equipment (RPE)

PPE must still be used in accordance with SICPs when using Respiratory Protective Equipment. See Chapter 1.4 for PPE use for SICPs. 

Further information on best practice for PPE use for TBPs can be found in Appendix 16.

Where it is not reasonably practicable to prevent exposure to a substance hazardous to health (as may be the case where healthcare workers are caring for patients with suspected or known airborne micro-organisms) the hazard must be adequately controlled by applying protection measures appropriate to the activity and consistent with the assessment of risk. If the hazard is unknown the clinical judgement and expertise of IPC/HP staff is crucial and the precautionary principle should apply.

Respiratory Protective Equipment (RPE) i.e. FFP3 and facial protection, must be considered when a patient is admitted with a known/suspected infectious agent/disease spread wholly by the airborne or droplet route and when carrying out aerosol generating procedures (AGPs) on patients with a known/suspected infectious agent spread wholly or partly by the airborne or droplet route.

Staff in primary care/outpatient settings or care homes would not normally be required to wear an FFP3 unless an AGP is being performed when staff should wear a single use FFP3 respirator.

The decision to wear an FFP3 respirator/hood should be based on clinical risk assessment e.g task being undertaken, the presenting symptoms, the infectious state of the patient, risk of acquisition and the availability of treatment.

For a list of organisms spread wholly or partly by the airborne (aerosol) or droplet routes see Appendix 11.

The following risk categorisation is the minimum requirement for staff groups that require FFP3 fit testing. NHS Boards can add to this for example where high risk units are present. This categorisation is inclusive of out of hours services.

National Priority Risk Categorisation for fit testing with FFP3

Level 1 – Preparedness for business as usual

Staff in clinical areas most likely to provide care to patients who present at healthcare facilities with an infectious pathogen spread by the airborne route; and/or undertake aerosol generating procedures i.e. A&E, ICU, paediatrics, respiratory, infectious diseases, anaesthesia, theatres, Chest physiotherapists, Special Operations Response Team (Ambulance), A&E Ambulance Staff, Bronchoscopy Staff, Resuscitation teams, mortuary staff.

Level 2 – Preparedness in the event of emerging threat

Staff in clinical setting likely to provide care to patients admitted to hospital in the event of an emerging threat e.g. Medical receiving, Surgical, Midwifery and Speciality wards, all other ambulance transport staff.

In the event of an ‘Epidemic/Pandemic’ Local Board Assessment as per their preparedness plans will apply.

All tight fitting RPE i.e FFP3 respirators must be:

  • Single use (disposable) and fluid repellent.
  • Fit tested on all healthcare staff who may be required to wear a respirator to ensure an adequate seal/fit according to the manufacturers’ guidance.
  • Fit checked (according to the manufacturers’ guidance) every time a respirator is donned to ensure an adequate seal has been achieved.
  • Compatible with other facial protection used i.e. protective eyewear so that this does not interfere with the seal of the respiratory protection. Regular corrective spectacles are not considered adequate eye protection.

In the absence of an anteroom/lobby remove FFP3 respirators in a safe area (e.g. outside the isolation/cohort room/area).

All other PPE should be removed in the patient care area.

Further information regarding fitting and fit checking of respirators can be found on the Health and Safety Executive website.

Powered respirator hoods are an alternative to FFP3 respirators for example when fit testing cannot be achieved.

FFP3 respirator or powered respirator hood:

  • may be considered for use by visitors if there has been no previous exposure to the infected person or infectious agent; but
  • must never be worn by an infectious patient(s) due to the nature of the respirator filtration of incoming air not expelled air.

Powered hoods must be:

  • single use (disposable) and fluid resistant;
  • the filter must be enclosed with the exterior and the belt able to withstand disinfection with 10,000ppm av.cl.

Further information can be found in the Respiratory Protective Equipment (RPE) literature review and the Personal Protective Equipment (PPE) for Infectious Diseases of High Consequence (IDHC) literature review.

Frameworks to support the assessing and recording of staff competency in PPE for IDHC are available in the resources section of the NIPCM.

Updated : 09/07/18 12:24

2.5 Infection Prevention and Control during care of the deceased

The principles of SICPs and TBPs continue to apply whilst deceased individuals remain in the care environment. This is due to the ongoing risk of infectious transmission via contact although the risk is usually lower than for living patients.

Washing and/or dressing of the deceased should be avoided if the deceased is known or suspected to have an invasive streptococcal infection, viral haemorrhagic fevers or other Group 4 infectious agents. See Appendix 12. Mandatory - Application of transmission based precautions to key infections in the deceased.

Staff should advise relatives of the precautions following viewing and/or physical contact with the deceased and also when this should be avoided.

Deceased individuals known or suspected to have a Group 4 infectious agent should be placed in a sealed double plastic body bag with absorbent material placed between each bag. The surface of the outer bag should then be disinfected with 1000ppm av.cl before being placed in a robust sealed coffin.

Post mortem examination should not be performed on a deceased individual known or suspected to have Group 4 infectious agents.  See Appendix 12. Mandatory - Application of transmission based precautions to key infections in the deceased”. Blood sampling can be undertaken in the mortuary by a competent person to confirm or exclude this diagnosis.  Refer to Section 2.4 for suitable PPE. 

 

References