infection prevention & control manual

Infection Prevention & Control Manual CALVARY PUBLIC HOSPITAL BRUCE &

CALVARY BRUCE PRIVATE HOSPITAL Function: Infection Prevention & Control

Approved by: Healthcare-Associated Infection Committee Approved Date: December 2019

UNCONTROLLED WHEN PRINTED Review Date: December 2020

of 66 Continuing the Mission of the Sisters of the Little Company of Mary

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Infection Prevention & Control Manual Table of Contents 1. Purpose ................................................................................................................................................. 5

2. Scope ................................................................................................................................................. 5

3. Governance and Systems for Infection Prevention and Control .................................................................... 5

4. Infection Prevention and Control Strategies ............................................................................................... 6 4.1 Standard Precautions ......................................................................................................................................... 6 4.2 Transmission Based Precautions ........................................................................................................................ 7

4.2.1 Contact Precautions ........................................................................................................................ 7 4.2.2 Droplet Precautions ........................................................................................................................ 8 4.2.3 Airborne Precautions ...................................................................................................................... 8

4.3 Infection Control Risk Assessment .................................................................................................................... 9 4.3.1 Procedure ........................................................................................................................................ 9 4.3.2 Determination of Patient Placement .............................................................................................. 9

4.4 Hand Hygiene .................................................................................................................................................. 10 4.4.1 When to Perform Hand Hygiene..................................................................................................... 10 4.4.2 Promoting Patient, Visitor and Volunteer Hand Hygiene ............................................................. 10 4.4.3 Gloves and Hand Hygiene ............................................................................................................. 10 4.4.4 Hand Hygiene Auditing ................................................................................................................. 10 4.4.5 Hand Hygiene and Appropriate Attire for Healthcare Workers in the Healthcare Setting .......... 11 4.4.6 Skin Care Requirements ................................................................................................................ 11 4.4.7 Placement of Hand Hygiene Products .......................................................................................... 11 4.4.8 Occupational Dermatitis/Skin Breakdown Management ............................................................. 12

4.5 Personal Protective Equipment ...................................................................................................................... 13 4.5.1 Gowns ........................................................................................................................................... 13 4.5.2 Gloves ............................................................................................................................................ 14 4.5.3 Face and Eye Protection ................................................................................................................ 15 4.5.4 Masks ............................................................................................................................................ 15 4.5.4.1 Surgical Masks ............................................................................................................................ 15 4.5.4.2 P2/N95 Masks ............................................................................................................................ 16

4.6 Aseptic Non-Touch Technique .......................................................................................................................... 18 4.6.1 Use of Standard and Surgical ANTT .............................................................................................. 18

4.7 Single Use or Single Patient Use Equipment/Items .......................................................................................... 20 4.8 Notifiable Diseases............................................................................................................................................ 21

4.8.1 Procedure ...................................................................................................................................... 21 4.9 Code of Dress or Attire in Restricted/Semi Restricted Procedure Areas .......................................................... 21

4.9.1 Scrub Attire ................................................................................................................................... 22 4.9.2 Scrub Attire Outside of Restricted or Semi Restricted Area ......................................................... 22 4.9.3 Headwear ...................................................................................................................................... 22






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4.9.4 Footwear ....................................................................................................................................... 22 4.9.5 Jewellery ....................................................................................................................................... 23 4.9.6 Fingernails ..................................................................................................................................... 23 4.9.7 Surgical Masks ............................................................................................................................... 23 4.9.8 Protective Eyewear ....................................................................................................................... 24

4.10 Outbreak Management .................................................................................................................................. 24 4.10.1 Preliminary Phase ....................................................................................................................... 24 4.10.2 Control Measures ........................................................................................................................ 25 4.10.3 Evaluation ................................................................................................................................... 26 4.10.4 Outcome Measures ..................................................................................................................... 27

4.11 Infection Control and Nebuliser Use .............................................................................................................. 27 4.12 Reporting and Investigating Infection Control Breaches ................................................................................ 28

4.12.1 Procedure .................................................................................................................................... 28

5. Managing Patients with Infections or Colonisations of Pathogens ............................................................. 29 5.1 Multi-Resistant Organism (MRO) Screening and Clearance ............................................................................. 29

5.1.1 MRO Screening .............................................................................................................................. 29 5.1.2 MRO Clearance ............................................................................................................................. 29 5.1.3 Healthcare Facility Transfer Screening ......................................................................................... 30

5.2 Management of Patients with an MRO in the Acute Care Setting ................................................................... 30 5.2.1 Procedure ...................................................................................................................................... 30 5.2.2 Core Strategies .............................................................................................................................. 30

5.3 Management of Patients with an MRO in the Subacute Unit (Mental Health Units) ...................................... 31 5.3.1 Procedure ...................................................................................................................................... 31 5.3.2 Personal Protective Equipment (PPE) ........................................................................................... 31 5.3.3 Room Placement ........................................................................................................................... 31 5.3.4 Movement of Patients within the Unit ........................................................................................ 31 5.3.5 Visitors .......................................................................................................................................... 32 5.3.6 Transfer of Patients from Sub-Acute to an Acute Care Ward ....................................................... 32 5.3.7 Patients going for ECT ................................................................................................................... 32

5.4 Management of Patients with an MRO in Operating Theatres ....................................................................... 32 5.4.1 Preparation of Operating Theatre and Surrounding Area ............................................................ 32 5.4.2 Transport of the Patient within Perioperative Unit ...................................................................... 33 5.4.3 Management During and on Completion of Surgical Procedure .................................................. 33 5.4.5 Caring for Patients in Post Anaesthetic Care Unit that Require Infection Control Precautions ... 34

5.5 Isolation Rooms ................................................................................................................................................ 34 5.5.1 Types of Isolation Rooms .............................................................................................................. 34 5.5.2 Class S – Standard Pressure Isolation Room ................................................................................. 34 5.5.3 Class N – Negative Pressure Isolation Room ................................................................................. 34 5.5.4 The Functional Classification of Isolation Rooms ......................................................................... 35

6. Animals, Toys, Plants and Electronics in the Healthcare Setting ................................................................ 35 6.1 Animals/Pets in the Healthcare Setting .......................................................................................................... 35

6.1.1 Patients and/or their Family/Carers ............................................................................................. 36






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6.1.2 Nurse Unit Manager or Nursing Team Leader in Charge .............................................................. 36 6.1.3 Staff Working Inside the Health Care Facility ............................................................................... 37 6.1.4 Mandatory Requirements for Visiting Animals ............................................................................. 37 6.1.5 Environmental Considerations ...................................................................................................... 37 6.1.6 Reporting Incidents and Recording Patient Feedback .................................................................. 37

6.2 Toys in the Hospital ......................................................................................................................................... 38 6.2.1 Purchasing / Obtaining Toys ......................................................................................................... 38 6.2.2 Cleaning of Toys ............................................................................................................................ 38 6.2.3 Storage of Toys .............................................................................................................................. 38

6.3 Flowers and Pot Plants .................................................................................................................................... 38 6.4 Mobile Phones and Electronic Devices ........................................................................................................... 39

7. Antimicrobial Stewardship ....................................................................................................................... 39 7.1 Antimicrobial Stewardship (AMS) ................................................................................................................... 39

8. Staff Health ............................................................................................................................................. 40 8.1 Vaccination and Screening ................................................................................................................................ 40 8.2 Occupational Exposure Incident Management ................................................................................................ 40 8.3 Exclusion Periods for Healthcare Workers Exposed to or diagnosed with an Infectious Condition ................ 40

8.3.1 Procedure ...................................................................................................................................... 40

9. Reprocessing of Reusable Medical Devices ............................................................................................... 44 9.1 Reprocessing of Reusable Medical Devices .................................................................................................... 45

9.1.1 Principles of reprocessing reusable medical devices .................................................................... 45 9.1.2 Procedure ...................................................................................................................................... 45 9.1.3 Categories of RMDs ....................................................................................................................... 46

10. Cleaning ............................................................................................................................................... 46 10.1 Cleaning Procedures to Prevent the Spread of Hospital Acquired Infections .............................................. 46

10.1.1 Routine Cleaning ......................................................................................................................... 46 10.1.2 Additional Levels of Cleaning when Transmission-Based Precautions are in Place ................... 47 10.1.2.1 Daily Cleaning of the Patient Surrounding while in Hospital: .................................................. 47 10.1.2.2 Terminal Cleaning of Room on Discharge or Transfer of Patient: ........................................... 47 10.1.3 Additional Levels of Cleaning in SSU, ED and Medical Imaging .................................................. 47 10.1.4 Cleaning of Carpet in Healthcare Facilities ................................................................................. 48 10.1.5 Colour Coding of Cleaning Equipment ........................................................................................ 48 10.1.6 Cleaning Products ....................................................................................................................... 48 10.1.7 Evaluation ................................................................................................................................... 49

10.2 Environmental Services .................................................................................................................................. 49

11. Waste, Sharps and Spills Management ................................................................................................... 49 11.1 Waste Management ..................................................................................................................................... 49 11.2 Sharps Management and Disposal ................................................................................................................ 50

11.2.1 Procedure .................................................................................................................................... 50 11.3 Management of Blood and Body Fluid Spills ................................................................................................ 51

11.3.1 Management of Blood or Body Substance Spills ........................................................................ 51






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12. Food Safety – Food Brought into the Hospital for Patient Consumption .................................................. 52 12.1 Food Safety – Management of Food for Patient Consumption .................................................................... 52 12.2 Monitoring Patient Food Refrigerators ......................................................................................................... 52

12.2.1 Daily Monitoring Process ............................................................................................................ 52 12.3 Contracted Patient Food Services ................................................................................................................... 53

13. Linen & Privacy Curtains ........................................................................................................................ 53 13.1 Laundering Practices ..................................................................................................................................... 53

13.1.1 Machines and Dryers.................................................................................................................. 53 13.1.2 Laundry Powder .......................................................................................................................... 53 13.1.3 Laundry Areas ............................................................................................................................. 54 13.1.4 Staff ............................................................................................................................................. 54 13.1.5 Washing Patient Clothing ............................................................................................................ 54

13.2 Schedule for the Cleaning of Reusable Curtains and the Replacement of Disposable Curtains .................. 54 13.2.1 Instructions for the Laundering of Reusable Curtains ................................................................ 54 13.2.2 Instructions for the use of Disposable Curtains .......................................................................... 55

13.3 Contracted Linen Services .............................................................................................................................. 55

14. Facilities Management ........................................................................................................................... 55 14.1 Maintenance and Engineering Services .......................................................................................................... 55 14.2 Infection Control during Construction, Renovation and Maintenance ........................................................ 55

14.2.1 Preliminary Considerations ......................................................................................................... 56 14.2.2 Construction and Renovation Risk Assessment .......................................................................... 56 Construction Project Type ....................................................................................................................... 57 14.2.3 Infection Prevention, Control and Staff Health Department Role .............................................. 59 14.2.4 Engineering Staff Role ................................................................................................................. 60

15. Communication with Patients and Carers ............................................................................................... 60 15.1 Patient Information Pamphlets ..................................................................................................................... 60

16. Caring for the Deceased and Infection, Prevention and Control ............................................................... 60 16.1 Management of Deceased Person with a Confirmed or Suspected Infectious Disease ............................... 60

16.1.1 Instructions for use of the BioSeal System 5 Containment System ............................................ 62 16.1.2 Autopsy Request for Deceased with Suspected CJD................................................................... 62

17. Implementation..................................................................................................................................... 62

18. Related Guidelines and Legislation ......................................................................................................... 63 18.1 National Guidelines ........................................................................................................................ 63 18.2 Legislation ...................................................................................................................................... 63

19. References ............................................................................................................................................ 63

20. Search Terms ......................................................................................................................................... 65






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1. Purpose The purpose of the Infection Prevention & Control Manual is to promote and facilitate the overall goal of preventing hospital acquired infections. It aims to do so by creating safe healthcare environments through the implementation of evidence-based practices that minimise the risk of transmission of infectious agents. The Infection Prevention & Control Manual is a combination of all healthcare associated infection related procedures and has been aligned with the National Safety and Quality Health Service Standards and the Australian Guidelines for the Prevention and Control of Infection in Healthcare. The manual aims to provide basic infection prevention and control guidelines without providing the rationale or evidence in support of the guidelines. Please refer to the Australian Guidelines for the Prevention & Control of Infection in Healthcare (2019) for additional information in support of the guidelines provided within this manual.

2. Scope This manual applies to all Calvary Public Hospital Bruce (CPHB) and Calvary Bruce Private Hospital (CBPH) staff, volunteers, students and trainees undertaking clinical placement and all contracted staff working on CPHB & CBPH premises. The above mentioned groupings are all referred to and grouped together in this manual as Healthcare Workers (HCWs).

3. Governance and Systems for Infection Prevention and Control The CPHB Infection Prevention, Control and Staff Health Department will:

• Set up and implement governance structures for healthcare-associated infections and antimicrobial stewardship

• Provide promotion, education, support and assistance to staff to promote high quality patient care and customer service

• Assist divisions and branches within CPHB & CBPH to develop and maintain current best practice procedures specific to their field of expertise

• Assist staff members to identify major infection risks in accordance with legislative requirements • Ensure any responsibilities relating to notification of diseases are met • Ensure staff members are educated in and understand their infection prevention and control

responsibilities through initial orientation training and other in-service education as appropriate • Liaise with internal and external divisions to ensure contracted service providers, carers, volunteers,

students and visitors comply with the organisation's infection prevention and control requirements • Conduct authorised surveillance and data collection for the purpose of identifying trends in infection

rates by: - Investigating and instigating corrective processes to reduce infection rates - Investigating and implementing changes to equipment or procedures to reduce infection rates - Conducting or coordinating education programs associated with infection prevention and control

practice change. • Conduct or supervise authorised audits of CPHB & CBPH workplaces, such as clinical spaces, staff rooms,

and/or storage areas

https://www.nhmrc.gov.au/sites/default/files/documents/attachments/publications/infections-control-guidelines.pdf

https://www.nhmrc.gov.au/sites/default/files/documents/attachments/publications/infections-control-guidelines.pdf






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• Evaluate changes to ensure they are effective in addressing identified specific infection prevention and control issues

• Create policies/procedure/guidelines based on the best available evidence as required • Audit and investigate breaches to infection prevention and control best practice (e.g. workplace

audits/Riskman). CPHB & CBPH Department Managers will:

• Ensure those who report to them are familiar with the content of the Infection Prevention & Control Manual

• Incorporate infection prevention and control into: - Workplace specific orientation - All team meeting agendas - Staff credentialing and clinical practice assessment - Patient care planning and service provision.

• Monitor compliance with the given guidelines in their areas of responsibility. CPHB & CBPH HCWs will:

• Ensure they are immunised according to the Occupational Assessment, Screening and Vaccination Policy • Ensure that their immunisation record is provided to the Infection Prevention, Control and Staff Health

Department • Undertake orientation training • Complete annual infection prevention and control education by utilising:

- Face to face educational opportunities - On-line learning packages through eLearning.

• Ensure that they understand and comply with procedures relating to: - Work practices - Patient safety.

• Report any breaches of infection prevention and control practice or exposure to an infectious agent via Riskman

• Ensure hand hygiene, use of personal protective equipment (PPE) and transmission-based precautions are complied with.

4. Infection Prevention and Control Strategies 4.1 Standard Precautions

Relevant resources for this section: • Standard & Transmission Based Precautions Flyer – A Guide for Staff

Standard precautions are practices that are required to maintain the basic level of infection prevention and control. Standard precautions must be used for the treatment and care of all patients, regardless of their known or perceived infectious status. Standard precautions include:

• Performing hand hygiene as per the 5 moments of hand hygiene • Using PPE when there is a risk of body fluid exposure • Using and disposing of sharps safely

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• Performing routine environmental cleaning • Cleaning and reprocessing shared patient equipment • Following respiratory hygiene and cough etiquette • Using aseptic technique • Handling and disposing of waste and used linen safely.

4.2 Transmission Based Precautions

Relevant resources for this section: • Standard & Transmission Based Precautions Flyer – A Guide for Staff • Infection Control Risk Assessment Flow Chart • Quick Reference Guide to Transmission Based Precautions • Contact Precautions Poster • Droplet Precautions Poster • Airborne Precautions Poster

Transmission based precautions must be used in addition to standard precautions when standard precautions alone are insufficient to interrupt the transmission of a known or suspected pathogen. There are three main types of transmission based precautions:

• Contact Precautions • Droplet Precautions • Airborne Precautions.

4.2.1 Contact Precautions Contact precautions are used to interrupt contact transmission. Contact transmission occurs via direct or indirect contact with a colonised or infected individual or via contaminated surfaces. Management of Contact Precautions:

• PPE including gowns, gloves and mask (if infection is in the sputum) must be worn during patient contact • Display contact precaution signage to ensure all staff and visitors are aware of the precaution

requirements • Isolate patient in a single room with ensuite • If a single room is not available, consider cohorting infected/colonised persons with others who have the

same organism or with those in whom the infection is a low risk. Discuss this option with the Infection Prevention, Control & Staff Health Department or refer to the Infection Control Risk Assessment Flow Chart to guide the cohort decision making process

• Shared equipment must be cleaned between patient uses, using the green Clinell disinfectant wipes • Environmental cleaning and discharge cleaning needs to be performed as per section 10.1.2 of this

manual • The patient should be encouraged to remain within their room, however they are allowed to leave if

they would like to (e.g. to attend the main café or to go outside). They must comply with hand hygiene and minimise time spent in shared patient areas (e.g. patient kitchenettes)

• The patient does not need to wear PPE if they leave their room (unless a mask is required), however staff must comply with PPE requirements when transferring the patient to another clinical area or for a procedure (e.g. Medical Imaging).

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4.2.2 Droplet Precautions Droplet precautions are used to interrupt droplet transmission. Droplet transmission occurs via large expelled droplets that travel short distances in the air before settling on environmental surfaces. Droplet transmission requires close proximity between the infectious host and other susceptible people. Management of Droplet Precautions:

• PPE including a surgical mask must be worn during patient contact • Display droplet precaution signage to ensure all staff and visitors are aware of the precaution

requirements • Isolate patient in a single room with ensuite • If a single room is not available, consider cohorting the infected persons with others who have the same

infection or with those in whom the infection is a low risk. Discuss this option with the Infection Prevention, Control and Staff Health Department or refer to the Infection Control Risk Assessment Flow Chart to guide the cohort decision making process

• Shared equipment must be cleaned between patient uses, using the green Clinell disinfectant wipes • Environmental cleaning and discharge cleaning needs to be performed as per section 10.1.2 of this

manual • Encourage the infected person to comply with cough etiquette and hand hygiene • The patient should be encouraged to remain within their room, however they are allowed to leave if

they would like to (e.g. to attend the main café or to go outside). They must comply with hand hygiene, wear a surgical mask and minimise time spent in shared patient areas (e.g. patient kitchenettes)

• The infectious patient must wear a surgical mask during transfers or when outside of their room/cubicle • Staff must comply with PPE requirements when transferring the patient to another clinical area or for a

procedure (e.g. Medical Imaging). 4.2.3 Airborne Precautions Airborne precautions are used to interrupt the airborne transmission route. Airborne transmission occurs by the dissemination of small expelled aerosols that can remain suspended in the air for long periods of time. Management of Airborne Precautions:

• PPE including a P2/N95 mask must be worn during patient contact • Display airborne precaution signage to ensure all staff and visitors are aware of the precaution

requirements • Patients may require isolation in a negative pressure room – this decision will be made by either the

Respiratory Physician, the Infectious Diseases Physician or the Infection Prevention, Control and Staff Health Department

• If a negative pressure room is either not available or not required, admit the patient to a single room with ensuite. The door of the room must remain closed and strict adherence to airborne precautions needs to occur

• Shared equipment must be cleaned between patient uses, using the green Clinell Green disinfectant wipes

• Environmental cleaning and discharge cleaning needs to be performed as per section 10.1.2 of this manual

• Encourage the infected person to comply with cough etiquette and hand hygiene • The infectious patient should be contained to their room but if it is essential to transfer the patient

between clinical areas, the patient must wear a surgical mask during the transfer.








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4.3 Infection Control Risk Assessment

To assist in preventing the spread of infectious pathogens, a risk assessment should be conducted to ensure that patients are moved to the appropriate bed spaces. There are some diseases and conditions that require physical separation of patients by placing them in a single room, such as Methicillin Resistant Staphylococcus aureus (MRSA), faecal incontinence and/or respiratory conditions. 4.3.1 Procedure

• The Infection Prevention, Control and Staff Health Department must be informed of all patients who are admitted with a suspected or confirmed infectious disease

• Risk identification should be achieved by a structured approach (use the Infection Control Risk Assessment Flow Chart as a guide)

• Analysis of the risk in relation to the cause, consequences and likelihood of occurrence must determine what controls are in place

• Factors to be considered in determining the level of risk and the resulting protective measures required in a work environment must include:

o Routes of transmission (contact, droplet, airborne) o Type of transmission (person to person, contact between contaminated surfaces/person) o Work methods or procedures that may result in exposure o Employee contact with persons who are/may be infectious or materials/equipment that

are/may be contaminated. • Priorities must be set and resources appropriately allocated to reduce/eliminate risks • Communication and consultation to relevant key stakeholders is required during each process to assist

in adherence to the procedures • Refer to the Quick Reference Guide to Transmission Based Precautions for a list of infectious conditions

requiring transmission-based precautions. During business hours please contact the Infection Prevention, Control and Staff Health Department for further assistance.

4.3.2 Determination of Patient Placement Determine patient placement based on the following principles:

• Route(s) of transmission of the known or suspected infectious agent (refer to the Quick Reference Guide to Transmission Based Precautions)

• Availability of single rooms • Cohorting options (decisions to cohort must be discussed with the Infection Prevention, Control and

Staff Health Department or based on the guidelines provided in the Infection Control Risk Assessment Flow Chart)

• Risk factors for adverse outcomes resulting from healthcare-associated infection in other patients in the area including:

- Immunosuppressed patients - Patients with invasive devices (intravascular devices, urinary catheters) - Patients with surgical wounds.

Relevant resources for this section: • Infection Control Risk Assessment Flow Chart • Quick Reference Guide to Transmission Based Precautions















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4.4 Hand Hygiene

Relevant resources for this section: • 5 Moment for Hand Hygiene Poster • ECOLAB Hand Wash Technique Poster • ECOLAB Hand Rub (ABHR) Technique Poster • Hand Hygiene Flyer – A Guide for Patients and Visitors • Hand Hygiene Products Made Simple Poster

Effective hand hygiene is the single most important strategy in preventing healthcare associated infections. Hand hygiene includes one of the following:

• Hand washing with liquid soap and water • Decontamination using alcohol based hand rub.

4.4.1 When to Perform Hand Hygiene The designated 5 moments for hand hygiene must be used by all staff when attending to patient care and can be performed with either soap and water or alcohol based hand rub. The 5 moments for hand hygiene are:

• Moment 1: Before touching a patient • Moment 2: Before a procedure • Moment 3: After a procedure or body fluid exposure risk • Moment 4: After touching a patient • Moment 5: After touching a patient’s surrounding.

All HCWs have a responsibility to remind other healthcare workers of the need for hand hygiene if they observe a member of staff who fails, or is about to fail, to perform hand hygiene. Such reminders must be delivered in a courteous and supportive manner to allow staff to achieve a high standard of patient care. 4.4.2 Promoting Patient, Visitor and Volunteer Hand Hygiene

• HCWs must encourage patients to perform hand hygiene after going to the toilet, using a bedpan or urinal, before eating and after sneezing or coughing into their hands

• Hand hygiene products must be offered to bed ridden patients to promote hand hygiene • HCWs must educate patients on correct hand hygiene technique • Visitors and volunteers must be encouraged to comply with hand hygiene products before entering the

ward and/or patient rooms. 4.4.3 Gloves and Hand Hygiene

• Gloves are not a substitute for hand hygiene • Hand hygiene must still be performed before putting on gloves and after removal of gloves • Gloves must be removed, hand hygiene performed and new gloves applied as per the 5 moments for

hand hygiene. 4.4.4 Hand Hygiene Auditing

• Hand hygiene auditing is conducted three times a year as per the National Hand Hygiene Initiative audit requirements

• The audit measures HCWs compliance with the 5 moments for hand hygiene • The number of observations to be undertaken is determined by the size of the healthcare facility • Hand hygiene audit results must be displayed in a location visible to staff and patients on their

ward/unit.

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4.4.5 Hand Hygiene and Appropriate Attire for Healthcare Workers in the Healthcare Setting HCWs must comply with the ‘bare below the elbow’ principle when providing clinical care. Clothing:

• For hand hygiene to be effective HCWs must not have clothing below the elbow or covering forearms. This is to ensure that good hand and wrist washing can occur without being impeded by clothing

• Clothing worn by all staff must be clean and fit for purpose. Jewellery, ties and lanyards:

• Jewellery must not inhibit compliance with proper hand hygiene • Rings should be limited to one plain flat band • No wrist watches and/or bracelets are to be worn in a clinical area • Avoid wearing ties when carrying out clinical activities • Lanyards must not be used by clinical staff.

Fingernails:

• Fingernails must be kept short, clean and healthy at all times • Nail polish and nail enhancements must not be worn (this includes artificial nails, tips, wraps, acrylics,

shellac and/or gels). Dermal Piercings:

• Dermal piercings below the elbow are not acceptable when working in clinical areas as they inhibit the ability of the clinician to practice proper and effective hand hygiene, may be a source for micro-organisms and increase the risk for the clinician of exposure to infective organisms

• Clinical staff with dermal piercings below the elbow must cover each piercing with an appropriate clean waterproof dressing.

4.4.6 Skin Care Requirements

• Use only hospital supplied hand hygiene products • Ensure hands are wet before application of soap for hand washing • Use warm water for hand washing whenever possible – extremes of temperature can damage skin • Moisturise hands, using the hospital supplied moisturiser, at least four times during the shift to prevent

dryness and skin abrasions • Cover cuts and abrasions with an occlusive waterproof dressing to prevent invasion of micro-organisms

and replace dressings that become dislodged or damaged • For food service staff, cleaning staff and sterilising staff - wear appropriate protective gloves to minimise

risk of damage from extremes of temperature and chemicals • Report and seek prompt medical attention for any skin problems related to the use of hand hygiene

products • Seek professional advice for skin infections and dermatological conditions.

4.4.7 Placement of Hand Hygiene Products

• Placement of products should be easily accessible for staff to be able to perform hand hygiene according to the 5 moments for hand hygiene

• Alcohol based hand rub must be available at the point of care (i.e. within a metre from the treatment chair or patient bed)

• Alcohol based hand rub must be available at the entry to all healthcare facilities and at the entry to the ward and clinical areas

• Procedure trolleys should have alcohol based hand rub attached so that staff can easily perform hand hygiene






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• Hand washing basins should be kept clear of excess items to allow easy access • The staff in charge of the ward should ensure adequate supplies of products are available for use at all

times. Staff must:

• Not remove the alcohol based hand rub brackets from the end of the bed • Not re-use dispensing plunger • Not refill containers of hand hygiene products • Not top up part filled containers • Not use out-of-date products • Not bring any products from home without approval from the Infection Prevention, Control & Staff

Health Department. 4.4.8 Occupational Dermatitis/Skin Breakdown Management

• Staff who experience occupational dermatitis/skin breakdown are required to notify the Infection Prevention, Control and Staff Health Department

• The Infection Prevention, Control and Staff Health Department staff will follow the below flow chart for management:

Flow Chart 1: Hand Hygiene Skin Care Management

Staff member to notify Infection Prevention, Control & Staff

Health Department

0-3 Mild- Advise

- Educate - Offer alternate product for

trial

Review: One month

4-8 Moderate- Refer to GP/Dermatologist - Educate/persist with ABHR

- No soap and water (unless hands are visibly soiled)

- Increase moisturiser use - Staff member to complete a

riskman Review: 2 weeks

9-12 Severe- Refer to GP/Dermatologist

- Follow up as per Dermatologist - Possible reassignment of clinical

duties- Return to clinical areas once

medically cleared- Staff member to complete a

riskman

Initial assessment by Infection Prevention, Control & Staff Health Department Staff:

- Obtain history- Review hand hygiene practices

- Photograph hands






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4.5 Personal Protective Equipment

Relevant resources for this section: • PPE Poster – Sequence for putting on and removing PPE • Contact Precaution Poster • Droplet Precaution Poster • Airborne Precaution Poster

Personal protective equipment (PPE) refers to a variety of barriers, used alone or in combination to protect mucous membranes, airways, skin and clothing from contact with infectious agents. PPE includes aprons, gowns, gloves, surgical masks, protective eyewear and face shields. The selection of PPE is based on the type of patient interaction, known or possible infectious agents, and/or the likely mode(s) of transmission. 4.5.1 Gowns A protective gown should be worn by all healthcare workers when:

• Close contact with the patient, materials or equipment may lead to contamination of skin, uniforms or other clothing with infectious agents

• There is a risk of contact with blood, body substances, and/or secretions (except sweat). Characteristics of Gowns:

Plastic Apron o Impervious/fluid resistant o Disposable and single-use, for one procedure or episode of patient care o Worn when there is a risk that clothing may become exposed to blood or body substances

(usually from the environment) during low-risk procedures and where there is low risk of contamination to the arms.

Full Body Gown o Fluid resistant o Single-use, long sleeved o Worn when there is a risk of contact of the skin with a patient’s broken skin, extensive skin to

skin contact (e.g. lifting a patient with scabies or non-intact skin), or a risk of contact with blood and body substances which are not contained (e.g. vomiting, uncontrolled faecal matter)

o Worn when there is the possibility of extensive splashing of blood and body substances o Worn when there is a risk of exposure to large amounts of body substances (e.g. in some

operative procedures) o Worn when additional precautions (contact, droplet and/or airborne) are required.

Sterile Gown o Pre-packaged o Used for procedures requiring an aseptic or sterile field.

Note: Clinical and/or laboratory coats or jackets worn over personal clothing for comfort and/or purposes of identity are not considered to be PPE and need to be laundered frequently. Wearing of Gowns:

• Gowns should be worn correctly (e.g. covering shoulders, opening at the back and tied at the back) • Gowns and aprons must be changed between patients • Gowns should be put on immediately prior to patient care activity.

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Removal of Gowns: • Gloves need to be removed and hand hygiene performed prior to removing gown • Gowns need to be removed before leaving the patient-care area (e.g. just outside the patient room or in

the anteroom), to prevent possible contamination of the environment outside the patient’s room • To remove gown the outer ‘contaminated’ side of the gown is turned inward, rolled into a bundle and

then discarded into a designated container for waste or linen. 4.5.2 Gloves Gloves can protect both patients and healthcare workers from exposure to infectious agents that may be carried on hands. As part of standard precautions, gloves are used to prevent contamination of healthcare workers’ hands when:

• Anticipating direct contact with blood or body substances, mucous membranes, non-intact skin and other potentially infectious materials

• Handling or touching visibly or potentially contaminated patient-care equipment and environmental surfaces.

As with all PPE, the need for gloves is based on careful assessment of the task to be carried out and the related risk of transmission of microorganisms to the patient and the risk of contamination of clothing and skin by blood and/or body substances. A risk assessment includes consideration of:

• Who is at risk (whether it is the patient or the healthcare worker) • Whether sterile or non-sterile gloves are required, based on contact with susceptible sites or clinical

devices and the aspect of care or treatment to be undertaken • The potential for exposure to blood or body substances • Whether there will be contact with non-intact skin or mucous membranes during general care and

invasive procedures • Whether contaminated instruments will be handled.

Note that:

• Gloves are single-use items • Gloves must be changed between patients and after every episode of individual patient care • Hand hygiene should be performed before putting on gloves and after removal of gloves • When gloves are worn in combination with other PPE, they are put on last. Please refer to the PPE

Poster - Sequence for putting on and removing PPE • Gloves are not required for routine patient care (e.g. taking temperatures, blood pressures or for

subcutaneous, intramuscular or intradermal injections, unless exposure to blood or body fluids is anticipated, or if the patient is in transmission based precautions – see section 4.2 of this manual for more information).

Non-sterile gloves: • Used for potential exposure to blood, body substances, secretions or excretions and contact with non-

intact skin or mucous membranes. Sterile gloves:

• Used for contact with susceptible sites or clinical devices where aseptic conditions must be maintained.








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Reusable utility gloves: • Indicated for non-patient-care activities (sterilising technicians use disposable single use gloves) • Intended for use when a more physically protective glove is required • Clean according to the manufacturer’s instructions and stored dry between uses and replace when they

are showing signs of deterioration. 4.5.3 Face and Eye Protection Face and eye protection, such as goggles and face shields, reduce the risk of exposure to splashes or sprays of blood and bodily substances (secretions and excretions) and is an important part of standard precautions. Goggles:

• Goggles must fit snugly on the face to provide protection from splashes, sprays, and respiratory droplets • Goggles are available that fit over prescription glasses with minimal gaps • Personal eyeglasses and contact lenses are not considered adequate eye protection • Reusable eye protection must be cleaned with detergent solution or impregnated wipes (e.g. green

Clinell wipes) and be completely dry before being stored. Face Shields:

• Single-use or reusable face shields may be used as an alternative to protective eyewear • Face shields extending from chin to crown provide better protection from splashes and sprays than

goggles • Reusable face shields must be cleaned with detergent solution or impregnated wipes (e.g. green Clinell

wipes) and be completely dry before being stored. 4.5.4 Masks Masks are used as part of standard, droplet and airborne precautions to keep splashes, sprays and droplets from reaching the mouth and nose of the person wearing them. There are 2 different types of masks used at CPHB & CBPH – surgical masks and P2/N95 masks. 4.5.4.1 Surgical Masks Surgical masks must be worn:

• For procedures or patient care activities that generate splashes or sprays of large droplets of blood, body substances, secretions and/or excretions

• For procedures requiring a surgical aseptic technique • For routine care of patients on droplet precautions • For routine care of patients in contact precautions where the microorganism is in the sputum of the

patient • By patients in droplet or airborne precautions when they are taken outside their room for transportation

to another clinical areas.

Wearing a surgical mask: • It must be changed when it becomes soiled or wet • It is a single use item and must not be reapplied after it has been removed • It must not be left dangling around the neck to be reapplied at a later time • The front of the mask must not be touched while wearing it as this area of the mask is contaminated • Hand hygiene must be performed upon touching or discarding a used mask.






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Types of surgical masks: • Level 1 Barrier –

o For general purpose medical procedures, where the wearer is not a risk of blood or body fluid splash, or to protect staff and/or the patient from droplet exposure to microorganisms

• Level 2 Barrier – o For use in emergency departments, dentistry, changing dressings on small wounds or healing

wounds where minimal blood droplet exposure may occur • Level 3 Barrier –

o For all surgical procedures, major trauma first aid or in any area where the healthcare worker is at risk of blood or body fluid splash.

4.5.4.2 P2/N95 Masks P2/N95 masks must be worn:

• For routine care of patients on airborne precautions • When performing high-risk procedures, such as a bronchoscopy, when the patient’s infectious status is

unknown • When performing procedures that involve aerosolisation of particles (e.g. collection of a nasopharyngeal

aspirate). Wearing a P2/N95 masks:

• In order to offer the maximum desired protection it is essential that the wearer is properly fitted and trained in their use

• Healthcare workers must perform fit checks every time they put on a P2/N95 mask to ensure it is properly applied

• Fit checks ensure the mask is sealed over the bridge of the nose and mouth and that there are no gaps between the mask and face

• If a good facial seal cannot be achieved (e.g. the intended wearer has a beard or long moustache) an alternative mask should be used – discuss with the Infection Prevention, Control and Staff Health Department

• Masks must be changed when they become moist • Masks are a single use item and must never be reapplied after they have been removed • Masks must not be left dangling around the neck to be reapplied at a later time • Hand hygiene must be performed upon touching or disposing of masks • Masks must be removed outside the patient-care area and disposed of in an appropriate closed clinical

waste receptacle. Fit checking of a P2/N95 mask: The procedure for fit checking includes (see Figure 1):

• Placement of the respirator on the face • Placement of the headband or ties over the head and at the base of the neck • Compressing the respirator to ensure a seal across the face, cheeks and the bridge of the nose • Checking the positive pressure seal of the respirator by gently exhaling. If air escapes, the respirator

needs to be adjusted • Checking the negative pressure seal of the respirator by gently inhaling. If the respirator is not drawn in

towards the face, or air leaks around the face seal, readjust the respirator and repeat process, or check for defects in the respirator

• The manufacturer’s instructions for fit checking of individual brands and types of P2 respirator should be referred to at all times






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• Healthcare workers who have facial hair (including a 1–2 day beard growth) must be aware that an adequate seal cannot be guaranteed between the P2 respirator and the wearer’s face.

Figure 1:






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4.6 Aseptic Non-Touch Technique

Relevant resources for this section: • ANTT Flyer – A guide for clinical staff • ANTT – Blood Culture Poster • ANTT – Cannulation Poster • ANTT – IV Therapy Poster • ANTT – Urinary Catheter Poster • ANTT – Venepuncture Poster • ANTT – Wound Care Poster

Aseptic Non Touch Technique (ANTT) guidelines help standardise practice, technique and equipment levels. ANTT can be separated into two types:

• Standard ANTT — Clinical procedures managed with Standard ANTT will characteristically be technically simple, short in duration (approximately less than 20 minutes), and involve relatively few and small key sites and key parts. Standard ANTT requires a main general aseptic field and non-sterile gloves.

• Surgical ANTT — Surgical ANTT is demanded when procedures are technically complex, involve

extended periods of time, large open key sites or large or numerous key parts. To counter these risks, a main critical aseptic field and sterile gloves are required and often full barrier precautions. Refer to Table 1 below for a detailed list of standard and surgical ANTT procedures.

Hand hygiene is an essential component of ANTT. In standard ANTT, hand hygiene or a procedural wash should be performed for one (1) minute if using soap and water. For surgical ANTT the ACORN Standards state the first scrub is five (5) minutes and a three (3) minute scrub is required thereafter.

4.6.1 Use of Standard and Surgical ANTT

Prior to aseptic procedures, healthcare workers must ensure that there are no avoidable nearby environmental risk factors, such as bed making, patients using commodes, or ward cleaning.

HCWs must:

• Ensure the patient is aware that ANTT is being used and of the associated implications for the patient • Understand the correct procedure to don and doff PPE – refer to PPE Poster – Sequence for putting on

and removing PPE • Conduct hand hygiene as per the 5 moments for hand hygiene – refer to Hand Hygiene Poster • Clean wounds from clean to dirty.

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To prepare an aseptic field:

• Assess whether a general or a critical aseptic field is required • Gather and prepare equipment immediately prior to procedure • Never prepare an aseptic field on a patient bed or treatment chair. Use the designated stainless steel

trolleys for this purpose. • Clean the trolley with a green Clinell disinfected wipe from top to bottom before and after use.

To maintain an aseptic field:

• Always face the aseptic field • Do not speak, cough, sneeze or laugh over the aseptic field • Minimise air movement around the aseptic area - shut doors and curtains if possible • Never reach across the field, instead;

- Move around the field, while continuing to face the field - Reach around the edges of the aseptic field - If required, cautiously turn the entire aseptic field by touching either the edges of the bottom wrap

or by reaching underneath bottom wrapper. • Keep unsterile objects off the aseptic field • Avoid wetting the wrapping of sterile equipment • Recognise that the area up to 2.5 cm from the edge of an aseptic field is considered unsterile.

To maintain sterile stock as sterile:

• Keep sterile stock dry – avoid external wrap/packaging becoming wet • Do not write on sterile packaging with markers or pens • Open sterile stock immediately prior to performing the procedure • Always check the integrity of the external wrapping for damage • Always check the sterilisation indicator on the external wrapper (if present) before opening • Always check the sterility expiry date (if present) on the external package • Avoid using reprocessed equipment/instruments that are not reprocessed in a laminated/paper self-

sealing pouch.

Sterile stock must not be used when:

• There is no indication on the individual item or its original box that the item has been through a sterilizing process as indicated, by date of sterilization or colour change chemical indicator

• There is any suspicion that the integrity of the packaging has been compromised; i.e. - If the packaging is wet or oily or the packaging has been written on with pen or marker (the

packaging must be dry, not wet or oily), and/or - If the package is open or damaged prior to use, (the packaging must be complete, not open or

damaged). • The item is incorrectly wrapped/packaged • If you suspect or witness an item/package has been dropped on the floor or other dirty surface • The item has exceeded the sterility expiry date (the 'use by' date) indicated on individual item or original

box.






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Table 1: Use of Aseptic Non-Touch Technique for Specific Procedures

4.7 Single Use or Single Patient Use Equipment/Items Any designated single-use equipment or instrument must be discarded into the appropriate waste stream either immediately after use or at the end of the procedure, whichever is more appropriate. Single use items must not be re-used or reprocessed.

• Single use item – The item is to be used once only on an individual patient, during a single procedure, and then discarded at the point of use into an appropriate waste stream. It must not be reprocessed and/or used on the same or another patient. Generally, these items have blue or green handles, and/or have a ‘single use’ impression/symbol marked on the instrument or packaging.

• Single patient use – The item may be used more than once on the patient the item was opened or used

on originally (e.g. disposable tourniquet, disposable oxygen mask/respirator, disposable blood pressure cuff), providing it undergoes cleaning using a green Clinell disinfectant wipe between use. Generally, the packaging of the equipment will indicate the requirement for single patient use.

Single use symbol:

Procedure Standard /Surgical ANTT Rationale/typical procedure

IV therapy Standard aseptic technique Key parts can typically be protected by optimal critical micro fields and non-touch technique. Key sites are small. Procedures are technically simple and <20 mins duration.

Simple wound dressings

Standard aseptic technique Key parts and sites can be protected by optimal critical micro fields and non-touch technique. Procedures are technically simple and <20 mins duration.

Complex or large wound dressings

Surgical aseptic technique The complexity, duration or number of key parts may demand a critical aseptic field.

Urinary catheterisation

Standard/surgical aseptic technique

An experienced healthcare worker can perform catheterisation with the use of a main general aseptic field, micro-aseptic-fields and non-touch technique. However, less experienced healthcare workers may require a critical aseptic field.

Cannulation Standard/ Surgical aseptic technique

Although technically quite simple the close proximity of healthcare workers hands to the puncture site and key parts may demand sterile gloves – dependent upon the healthcare worker’s competency.

PICC/CVC insertion Surgical aseptic technique The size of the CVC or PICC line, invasiveness, numerous key parts and equipment and duration will demand a critical aseptic field and full barrier precautions.

Surgery / Procedures performed in Interventional suites

Surgical aseptic technique Surgical access involves deep or large exposed wounds, numerous key parts and equipment and long procedures. Standard operating room precautions required.






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4.8 Notifiable Diseases

Relevant resources for this section: • Notifiable Diseases Folder available in all Clinical Areas • ACT Public Health (Reporting of Notifiable Conditions) Code of Practice 2017 (No1) • Printable copy of the Notification Form

The Public Health Act 1997 imposes obligations on healthcare professionals to report notifiable conditions to the Chief Health Officer. A full list of notifiable conditions can be found in Appendix 1 of the ACT Public Health (Reporting of Notifiable Conditions) Code of Practice 2017 (No1). The Chief Health Officer has delegated the role of accepting reports of notifiable conditions to Public Health Officers within the Communicable Disease Control section of the Health Protection Services. 4.8.1 Procedure When to notify:

• A diagnosis (strongly suspected or confirmed) of any of the diseases listed in Appendix 1 of the ACT Public Health (Reporting of Notifiable Conditions) Code of Practice 2017 (No1)

• Appendix 1 of the above document lists notifiable diseases and categorises them as Group A or Group B • Group A diseases, upon initial diagnosis (presumptive or confirmed), require immediate notification by

telephone call to the Communicable Disease Control section of the Health Protection Services, plus written notification within 5 days

• Group B diseases only require written notification within 5 days. Who to Notify:

• Notify Communicable Disease Control and Infection Prevention, Control and Staff Health Department • It is the responsibility of the treating team to ensure the condition has been notified • After hours notifications by the treating team or after hours CNC can be made to the on-call Public

Health Officer • Notifications can be made to Communicable Disease Control who will then contact the relevant

jurisdiction’s public health unit. How to Notify:

• Use the Notifiable Diseases notification form located in the Notifiable Diseases Folder in all Clinical Area and also available online here

• For Group A diseases requiring phone notification contact: o Business hours: (02) 6205 2155 o After hours/weekends: (02) 9962 4155.

• For Group A follow up notifications and Group B diseases requiring fax notification: o Fax: (02) 6205 1739.

4.9 Code of Dress or Attire in Restricted/Semi Restricted Procedure Areas All staff working in restricted or semi restricted procedure areas, such as operating rooms, endoscopy, or any area where other invasive operative procedures are performed must wear surgical scrub attire. Surgical scrub attire is worn as part of multiple activities designed to promote and maintain a high level of cleanliness, hygiene and infection control within the restricted or semi restricted area. ‘Street clothes’ are not to be introduced into restricted or semi restricted areas. Scrub attire should not be worn outside of either the

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restricted or semi-restricted area (except in circumstances outlined in 4.9.2 below). Scrub attire must not be worn outside the healthcare facility (i.e. in the carpark, walking between facilities) as outlined in the Australian College of Perioperative Nurses (ACORN) Standards. 4.9.1 Scrub Attire When entering the restricted or semi restricted procedure areas, all persons must wear appropriate scrub attire.

• Remove all outer garments, including t-shirts and spencers that will not be completely covered by the scrub attire. For effective hand hygiene compliance, clinical staff must not have clothing below the elbow.

• Don freshly laundered scrub attire, provided by CPHB and CBPH • Scrub attire is to be changed daily or more frequently when wet or soiled. Clean scrub attire must be

stored in the appropriate storage compartments only and not in staff lockers • Scrub attire must fit securely so inadvertent contamination of the aseptic field does not occur • Clean jackets provided by CPHB and CBPH may be worn fastened. These are to be changed daily, or

more frequently when wet or soiled, and must not impede effective hand hygiene (i.e. sleeves must be pushed above the elbow when performing hand hygiene and providing patient care

• Scrub attire must be laundered by the linen contractor. 4.9.2 Scrub Attire Outside of Restricted or Semi Restricted Area Staff cannot leave the hospital in theatre scrubs. If leaving the restricted or semi restricted area in scrub attire for a short period of time (i.e. ward rounds or visiting another clinical area) it is essential to ensure:

• The scrub suit and shoes are completely clean and free of blood and debris • A clean (unused) white cover gown (supplied by the hospital) is worn over the scrub suit. Cover gowns

must be donned appropriately (e.g. tied at the back) and must be removed upon re-entrance to the restricted or semi restricted area (e.g. not worn into the procedural / operating rooms). If attending a patient with an MRO or an oozing wound then the staff member must change their scrubs before returning to the operating room

• Surgical masks and overshoe covers (if used) must be removed before leaving the restricted or semi restricted area

4.9.3 Headwear

• Head and facial hair coverings are to be made of low lint fabric and designed to minimise the shedding of hair and dandruff

• Head and facial hair including sideburns must be covered when entering the restricted/semi restricted areas. Hair covers must be changed daily or when visibly wet or soiled

• Personally supplied headwear may only be worn under hospital supplied headwear • Bouffant or hood (balaclava) style hair coverings are preferred as skullcaps may fail to contain hair on

side of head and nape of the neck. Facial hair such as a moustache must be covered when wearing a facial mask

• Balaclavas must be worn for joint replacement surgery. 4.9.4 Footwear

• Footwear must be clean and meet Work, Health and Safety Standards (e.g. well-fitting with impervious and non-slip soles, enclosed forefoot and grip at the heel). It is preferred that dedicated footwear for operating rooms is worn

• The routine use of overshoes is not recommended since bacterial numbers are increased on hands when applied or removed and an association has been established between surgical site contamination with






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bacteria of floor origin and the rate of surgical site infection. If overshoes are worn, hand hygiene must be performed after application

• Theatre shoes/boots must be cleaned regularly, and whenever they are contaminated by blood or body fluids

• Overshoes are recommended for visitors to the operating room (OR). Overshoes must be removed and disposed of prior to leaving the restricted/semi restricted area. If visitor’s shoes become soiled whilst in theatres they must be cleaned prior to leaving the operating rooms.

4.9.5 Jewellery

• All jewellery needs to be confined within the scrub attire or removed. • All rings must be removed before scrubbing • Jewellery such as necklaces may be lost during a surgical procedure, so must be contained within scrub

attire. Necklaces must be of a plain design (silver or gold metal chain). Necklaces with multi-part strings of beads, shells, wood, cotton and leather strands or other organic matter must not be worn

• Earrings must be stud or sleeper design only and confined within the scrub attire (e.g. covered by theatre headwear). Stud earrings should be plain without a stone in them as the stone might fall out during a surgical procedure

• Body piercing jewellery must be removed unless confined within the scrub attire.

4.9.6 Fingernails • Good hand and fingernail hygiene is essential in restricted/semi restricted areas • Fingernails must be short and clean • Skin integrity should be intact • Nail polish and nail enhancers must not be worn. Nail enhancers include anything applied to natural

nails such as artificial nails, tips, wraps, acrylics, gels and any additional item applied to the nail surface • Refer to the Hand Hygiene Section (section 4.4) for more detail.

4.9.7 Surgical Masks Surgical masks must be worn for personal protection and Work Health and Safety, as well as for the protection of the patient undergoing surgery. All scrub personnel must wear masks. Filtration levels differ and masks should be selected according to the level of protection necessary:

• A level 3 single use face mask must be worn for all surgical procedures. A level 2 or level 3 single use face mask must be used for endoscopy procedures

• Masks are worn in restricted areas where open sterile supplies and equipment are present or scrubbed personnel are located

• In addition Anaesthetic and Post Anaesthetic Care Unit staff must wear masks during intubation and extubation of the patient

• All staff in the restricted area must wear masks when power tools or irrigation under pressure (pulse lavage) is being used

• The surgeon, instrument nurse and circulating nurse involved in the administration of cytotoxic drugs must wear a particulate respirator N95 mask as outlined in the policy Cytotoxic Medication Administration in the Perioperative Environment

• Masks should be removed by handling ties only and avoiding touching the front of the mask. Mask should be immediately discarded and hand hygiene performed

• Masks must not be saved by hanging around the neck or carried in the pocket as they are a single use item only

• Masks must be removed before leaving the restricted area.

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4.9.8 Protective Eyewear Protective eyewear with side shields are provided by the hospital and must be worn for personal protection and Work Health and Safety reasons:

• All scrub personnel must wear protective eyewear. Protective eyewear includes safety goggles or masks with splash shields. Prescription glasses without side shields are not considered as protective eyewear

• Protective eyewear must be worn by all staff when power tools or irrigation under pressure (pulse lavage) are used

• Anaesthetic staff must wear protective eyewear during intubation, extubation or splash prone procedures

• Laser goggles, which meet Australian Safety Standards and are provided by the hospital, must be worn when the laser is in use.

4.10 Outbreak Management Note: This section is only relevant for Calvary Public Hospital Bruce (CPHB). Calvary Bruce Private Hospital (CBPH) has a separate Outbreak Management Procedure available on Calvary Connect.

Relevant resources for this section: • Outbreak Management Kit (Available in Office 2B 09, Level 2 Sr Mark Maher Building. Contact security

for access to the room). 4.10.1 Preliminary Phase

• Infection Prevention & Control actions: o Confirm the outbreak o Establish an early case definition: this may include clinical symptoms and/or laboratory

confirmation o Notify Health Protection Service/Public Health Unit/Laboratory o Appropriate infection control precautions should be implemented immediately o Set up spread sheet for tracking purposes o Collect further clinical epidemiological and laboratory findings

• If an outbreak is confirmed the Outbreak Management Team (OMT) must be convened. OMT actions: o Establish email contact list o Arrange and ensure availability of adequate staff and equipment resources o Regular-daily (initially) communication: email, face to face meetings with all stakeholders/media

for updates/changes. Responsibility for the response to an outbreak would be managed by an Outbreak Management Team (OMT). Key personnel include:

• CPHB Executive Representative (usually the Exec on call for the week) – Outbreak Coordinator • Infection Prevention, Control and Staff Health Department Manager • Infection Prevention, Control and Staff Health Department staff • Infectious Diseases Consultant • Director of Clinical Services - Medical • Nursing Director – Medical & Surgical Service • Nursing Director – Critical Care, Mental Health & Clinical Support • Patient Flow Unit Manager • Shift/After-hour Coordinator • CNC and ADON for affected area/s






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• Allied Health Manager (Representative for all Allied Health Services incl. Medical Imaging & Pharmacy) • Pastoral Care Manager (Representative for Support Services, incl. volunteers, pastoral care, medical

records, reception, security & facilities management) • Pharmacy Department Manager (if outbreak involve drug prophylaxis or utilisation) • Media/Communications Manager • Supply Manager • Environmental Services Manager (Representative for non-clinical Support Services incl. linen, food,

cleaning and waste services) • Other liaison members would be included depending on the nature and scope of the outbreak

4.10.2 Control Measures Nursing Care: Additional precautions and PPE will depend on case definitions, however most commonly the following will apply -

• Patients must be placed in contact precautions in single rooms with an ensuite • Cohorting of patients may be necessary - this is to be determined by the Infection Prevention, Control

and Staff Health Department • Staff must wear and dispose of PPE appropriately – refer to section 4.5 of this manual • If multiple patients are cohorted in a shared room PPE must be changed between each patient (as is

usual practice) • Face and eye protection should be worn where there is a likelihood of body fluid splashes • Dedicated single patient use equipment should be used, and all shared patient equipment is to be

cleaned immediately after use with green Clinell disinfectant wipes • Notes and charts are not to be taken into the room, and should be routinely cleaned with green Clinell

disinfectant wipes. Hand Hygiene:

• All staff must perform hand hygiene with soap and water or alcohol based hand rub before and after patient contact, as per the 5 moments for hand hygiene – refer to section 4.4 of this manual

• If a healthcare workers hands are visibly soiled, he/she must wash their hands with soap and water instead of using alcohol based hand rub

• Catering and cleaning staff must be instructed on the use of hand washing procedures and hand hygiene.

Cohorting:

• During suspected or confirmed outbreaks patients should be placed in single rooms with ensuites • If it is not possible to allocate a single room to all patients in the outbreak ward, patients may be

cohorted into the following groups – o Symptomatic o Exposed but asymptomatic o Unexposed

• Cohorting of patients during outbreaks must be approved by the Infection Prevention, Control and Staff Health Department prior to bed moves.

Admission and Discharges: • During an outbreak, the outbreak ward or part of it, might be closed for further/new admissions to the

ward/area. The movement/transfer of patients already within the outbreak ward/area will be restricted (e.g. no bed movements or transfer to another ward).






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• Patients from an outbreak ward/area may be discharged home once clinically stable • Patients from an outbreak ward/area should not be discharged to an assisted living or group home

facility until the outbreak has ceased. Special consideration however needs to be given when the assisted living or group home facility is considered the permanent home of the patient.

• Patients from an outbreak ward/area requiring increased medical treatment (e.g. ICU admission) may be transferred to another department after consultation with the Outbreak Coordinator and Infection Prevention, Control & Staff Health Department Manager.

Documentation:

• Infection Prevention, Control and Staff Health Department staff are responsible to list cases, including staff members affected, onto a spreadsheet

• Update list daily with date of onset of symptoms • All notifications, alerts, and correspondence should be minuted.

Staff:

• All staff, including ward based, relief pool and agency staff, are not allowed to be deployed to other areas if they were working in the affected area at the beginning of the outbreak

• All staff must adhere to the 5 moments of hand hygiene • Staff affected by the outbreak must remain off work until free of symptoms for 48 hours or as

determined by the outbreak team • A designated ward support officer should be allocated to the affected area • Non-essential staff, students and volunteers should be excluded from working in areas experiencing

outbreaks Visitors:

• Visitors should be restricted to immediate family only, children should be discouraged from visiting until the outbreak has ceased

• Visitors are required to wear the same PPE as staff and must comply with hand hygiene directives Environmental Services:

• Dedicated cleaning staff must be allocated for the period of the outbreak • Floors, lockers, bedside tables, toilets, hand washing basins, taps, showers, surface areas in clean and

dirty utility rooms require daily cleaning with bleach based disinfectant (mixed as per manufacturers recommendations)

• Soiled linen should be placed in a linen skip at the bedside • All waste should be placed in clinical waste bins inside patient’s room • Once the outbreak is deemed over a terminal clean of the affected area is to be completed, including

changing curtains and cleaning commodes • Reusable window curtains must be removed and cleaned via the contracted linen provider • If carpets are present they must be steam cleaned.

4.10.3 Evaluation

• The Outbreak Coordinator will determine when the outbreak is over • At the conclusion of the outbreak a final report needs to be prepared. This report must be tabled at the

following Hospital Associated Infection Committee Meeting • The report must include results of outbreak investigation, control interventions, problems and

shortcomings.






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4.10.4 Outcome Measures • A debrief session with all staff involved should occur post outbreak • Recommendations should be made to all relevant stakeholders to reduce the chance of recurrence.

4.11 Infection Control and Nebuliser Use Nebuliser therapy is an aerosol-generating procedure and is associated with an increased risk for infection transmission. As a result of this they should be minimised where possible, and metered dose inhalers (MDI) with spacer should be considered as an alternative. Nebulisers remain necessary for a limited number of indications (e.g. upper airway obstruction and severe bronchospasm in the absence of pneumonia). If the use of a nebuliser is deemed essential, only those healthcare workers needed to perform the procedure should be present, so as to reduce unnecessary exposure. Staff should wear masks and googles to prevent contact with infectious material during procedures. Prior to the procedure, a risk assessment needs to be conducted in order to determine the level of infection control precautions required to prevent the risk of aerosol generation for infectious respiratory conditions – refer to Table 2 below. Contact the Infection Prevention, Control and Staff Health Department (during business hours) or the afterhours nursing coordinator if assistance or advice is required. Table 2 - Nebuliser Risk Assessment Flow Chart

Specialist MO/VMO confirm necessity for nebuliser therapy and confirm that the use of MDI (with spacer) is not an option for treatment.

Nebulisation therapy is prescribed to:

• Administer medications • Assist in the removal of accumulated bronchial secretions • Liquefy bronchial secretions • Relieve bronchospasm & dyspnoea.

Low risk history: - Patient does not meet any of

the high risk criteria listed under high risk history.

High risk history: - Respiratory symptoms associated with at least

one of the following : o Fever o History of fever o Runny nose o Sore throat

And one of the below: - History of recent overseas travel - History of recent contact with another person

who became unwell with a respiratory condition - Viral respiratory infection is suspected or

confirmed - Signs & symptoms suggestive of pulmonary TB*






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No requirement to isolate the patient. Ensure:

- 1m distance between beds - Curtain drawn between beds

during nebulising procedure

Nebulisation therapy must be attended to in a single room with the door closed. Place an Airborne Precaution Poster on the door/entrance to the room. Before attending to the procedure don the appropriate PPE. This includes a high filtration mask (N95).

Document in the medical records the risk assessment conducted and level of Infection Control

Precautions applied during the nebuliser procedure *The Infection Prevention, Control and Staff Health Department must be contacted to conduct a TB risk assessment and determine the need for a negative pressure room. Each single patient use nebuliser set should be used for a maximum of one week before being routinely discarded. The set should be labelled (on the tubing rather than pot) and any changes of set documented in the nursing notes. 4.12 Reporting and Investigating Infection Control Breaches Infection control breaches include:

• Use of a reusable item during a clinical procedure which has not been reprocessed by following the standard AS/NZS 4187:2014

• Re-use of a single use item • Contact with blood or body fluids where there is a risk of transmission of a blood-borne virus • Any non-compliance with infection control policies and/or procedures.

4.12.1 Procedure Reporting

• All incidents where a potential or actual infection control breach has occurred must be reported as soon as practicable to the relevant Department Manager for further action

• The person reporting the incident must complete a Riskman Report • If the incident relates to an instrument then that instrument must be isolated and made available to the

person or team investigating the incident.

Investigation • The Infection Prevention, Control and Staff Health Department, in conjunction with relevant clinicians,

will initiate a risk assessment of the incident and decide if further investigations are required • If the investigating team believes that the incident has had, or will have, serious consequences to the

patient or to the organisation, a report will be provided to the General Manager and the Director of Clinical Governance, Patient Safety and Quality

• The decision to report an infection control breach to the ACT Health Directorate, the patient and the hospital’s insurers will be made by the General Manager.






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5. Managing Patients with Infections or Colonisations of Pathogens 5.1 Multi-Resistant Organism (MRO) Screening and Clearance

Relevant resources for this section: • MRO Screening and Clearance Guide • CBPH MRO Screening Form (only for use in the Private Hospital) • MRSA Flyer – Information for patients • VRE Flyer – Information for patients • MRO Flyer – Information for patients

At CPHB and CBPH, targeted screening is undertaken to identify patients colonised or infected with multi-resistant organisms (MROs). Targeted groups include those transferred from other hospitals or residential care facilities, previous known MRO positive patients, all patients admitted to the Intensive Care Unit and patients that have been admitted in overseas hospitals within the last 12 months. 5.1.1 MRO Screening See the MRO Screening and Clearance Guide for screening requirements.

• If screening returns a positive sample, transmission-based precautions should be applied. See the Quick Reference Guide to Transmission Based Precautions poster for guidance

• It is the responsibility of the treating medical officer to advise the patient of the MRO isolation requirements

• In CPHB, screening can be requested on an ACT Pathology request form. When requesting screening it is important to accurately record on the pathology request form the MRO being screened for, the site of specimen collection and a clinical history of previous MRO isolation and recent antibiotics treatment

• In CBPH (Private Hospital), screening can be requested using the CBPH MRO Screening Form. Please note:

• Screening requirements for carbapenemase-producing Enterobacteriaceae (CPE) is slightly different to other MROs. Please refer to Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE): A guide for acute care health facilities for further information

• Management of CPE contacts: o A CPE contact is a person who has shared a room, bathroom or toilet facilities with a confirmed

CPE positive patient for more than 24 hours o All CPE contacts should be identified and screened once a week until discharged (please refer to

Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE): A guide for acute care health facilities for further information)

o All CPE contacts should be isolated and/or cohorted, and contact precautions should be initiated.

5.1.2 MRO Clearance

• See the MRO Screening and Clearance Guide for clearance requirements • There are specific requirements that need to be met before an individual can be declared ‘clear’ of an

MRO

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• As such it is essential for the Infection Prevention, Control and Staff Health Department to be directly involved with this process to ensure the clearance criteria have been met.

Please note: • Clearance requirements for carbapenemase-producing Enterobacteriaceae (CPE) is slightly different to

other MROs. Please refer to Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE): A guide for acute care health facilities for further information.

5.1.3 Healthcare Facility Transfer Screening

• It is the responsibility of the receiving facility to screen patients on admission from another healthcare facility

• Patients cannot be refused admission to acute care, nursing homes or long term care facility on the basis of their MRO status

• If a patient is known to have an MRO this must be clearly documented and conveyed to the staff of the receiving healthcare facility.

5.2 Management of Patients with an MRO in the Acute Care Setting

Relevant resources for this section: • Quick Reference Guide to Transmission Based Precautions • Contact Precaution Poster • PPE Poster – Sequence for putting on and removing PPE • MRSA Flyer – Information for patients • VRE Flyer – Information for patients • MRO Flyer – Information for patients

5.2.1 Procedure

• To limit or prevent the transmission of MROs in the acute care setting, patients with a known or suspected MRO are to be nursed using contact precautions - refer to section 4.2.1 of this manual and the Contact Precaution Poster.

5.2.2 Core Strategies Patient Accommodation:

• Single room with ensuite • Place Contact Precaution signage at the room door • Cohorting may be undertaken following consultation with Infection Prevention, Control and Staff Health

Department staff. The Infection Control Risk Assessment Flow Chart can be used to guide options to cohort patients

• The patient should be encouraged to remain within their room, however they allowed to leave if they would like to (i.e. to attend the main café or to go outside). They must comply with hand hygiene and minimise time spent in shared patient areas (e.g patient kitchenettes)

• The patient does not need to wear PPE if they leave their room (unless a mask is required), however staff must comply with PPE requirements when transferring the patient to another clinical area or for a procedure (i.e. medical imaging)

• Patients and their visitors should be encouraged to perform hand hygiene.







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Patient Equipment: • Single patient use items/equipment must be used • If single patient use items are unavailable, shared equipment must be cleaned with a green Clinell

disinfectant wipe in-between patient use • Patient notes and charts are not to be taken into the room.

Inter Hospital Transfer:

• Ensure the receiving department and transport staff are aware of patients MRO status • If the MRO is in the sputum and the patient is coughing, the patient should wear a surgical mask during

transport • Limit the amount of time that the MRO patient is waiting pre and post procedure.

Environmental Cleaning:

• Daily environmental cleaning of the patient environment should be attended to as per section per 10.1.2.1 of this manual

• Following patient discharge, the patient room and bathroom must be terminally cleaned as per section 10.1.2.2 of this manual.

Waste Disposal:

• All waste to be placed in a clinical waste bin inside, or directly outside, the patient’s room. 5.3 Management of Patients with an MRO in the Subacute Unit (Mental Health Units) 5.3.1 Procedure

• Transmission based precautions are not required for patients in subacute settings • All subacute patients must be cared for using standard precautions – refer to section 4.1 of this manual.

5.3.2 Personal Protective Equipment (PPE)

• Appropriate PPE must be used for procedures where it is anticipated that there will be contact with body fluid – refer to section 4.5 of this manual.

5.3.3 Room Placement

• A single room with an ensuite is preferred for an MRO colonised or infected patient with diarrhoea or faecal and/or urinary incontinence.

5.3.4 Movement of Patients within the Unit

• Patients infected or colonised with MROs admitted to subacute units should not be restricted from participation in social or therapeutic group activities

• If any of these patients have conditions such as diarrhoea, infective respiratory symptoms or discharging wounds, they cannot participate in group activities, including shared meals

• Prior to leaving their room the patient must wash their hands with soap and water or apply alcohol based hand rub, have wounds covered and contain diarrhoea with incontinence aids as required

• The importance of hand hygiene, especially after using the toilet, should be explained and, if necessary, be supervised.






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5.3.5 Visitors • Visitors are not required to wear gowns or gloves but should be instructed to perform hand hygiene by

using alcohol based hand rub or wash their hands with soap and water when leaving the patient’s room. 5.3.6 Transfer of Patients from Sub-Acute to an Acute Care Ward

• If transfer to an acute care ward is required the patient must be admitted to a single room in contact precautions. Refer to section 4.2.1 of this manual and the Contact Precaution Poster.

5.3.7 Patients going for ECT • Patients receiving Electroconvulsive Therapy (ECT) must be screened for MRSA and VRE prior to

receiving this therapy • Knowing the patients infectious status will facilitate the management and cleaning of the environment

after the therapy, but will not impact on the management of the patient within the unit.

5.4 Management of Patients with an MRO in Operating Theatres Where possible, patients with MROs will be placed last on the list, to reduce the need for interruption to the scheduled list for terminal cleaning of the operating theatre following surgery on a patient with an MRO. 5.4.1 Preparation of Operating Theatre and Surrounding Area

• All staff working in the operating theatre and surrounding areas to comply with the 5 moments for hand hygiene

• Limit equipment in the operating theatre and anaesthetic bay to the minimum required to safely perform the procedure. Remove the non-essential equipment and place in the centacore

• Equipment too difficult to move outside the theatre should be pushed to the perimeter of the room and covered by clean sheets or not touched by staff until after the patient has left the room and the room has been terminally cleaned

• Any items taken into the operating theatre during the operation will be considered contaminated. All equipment used in the operating theatre must be terminally cleaned following use and instruments will need to be reprocessed (even if not opened)

• Essential items such as gloves, gowns and alcohol based hand rub remain available for staff use during the surgical procedure.

• Infection Control Precaution signage is placed on each door leading into the operating room. A small trolley should be set up in the centacore for the outside scout with yellow gowns, a range of non-sterile gloves (boxes), shoe covers, alcohol based hand rub and detergent wipes

• The Outside Scout should locate themselves in the centacore during the case to: o Ensure staff are wearing correct attire for contact precautions o Remind staff of the need to clean equipment with green Clinell disinfectant wipes if it is removed

during the procedure (e.g. x-ray equipment) o Ensure compliance with hand hygiene

• Clinical waste bins are to be available to dispose of all PPE exiting the operating theatre • Anaesthetic Nurse to confer with Anaesthetist and select sufficient stock for immediate use and place

Schedule 4 & 8 Drug Registers in the anaesthetic bay • Leave the anaesthetic drug trolley in the anaesthetic bay for the procedure.







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5.4.2 Transport of the Patient within Perioperative Unit • The patient will arrive in unit and be taken directly into the operating theatre without accessing the

holding bay or anaesthetic bay • Ensure all staff are aware of the patient’s MRO status • Personnel caring for the patient are required to wear PPE for transmission based precautions – refer to

section 4.5 of this manual • Do not place clinical notes or equipment on the patient’s bed • After the patient has been transferred to the operating table the ward bed is pushed into the

anaesthetic bay and cleaned using a green Clinell disinfectant wipe. When dry, the bed is made up with clean linen.

5.4.3 Management During and on Completion of Surgical Procedure

• If staff need to leave the room during a procedure, remove PPE and perform hand hygiene. Don new PPE on return to the operating theatre

• Minimise all movement from operating room to centacore. If items in the centacore or anaesthetic bay need to be accessed, remove gloves only, clean hands with alcohol based hand rub and touch only the items required. Reapply gloves and re-enter the room

• Personnel attempting to enter operating theatre via the anaesthetic bay should be requested to enter via the centacore where gowns and gloves are available

• Patient should be recovered in theatre if possible, depending on unit requirements. Notify Post Anaesthetic Care Unit (PACU) prior to patient transfer. See section 5.4.5 below for requirements

• Discard all disposable equipment present in the operating theatre into the contaminated waste including unused rolls of tape. Some consideration may be given to variations from this procedure if large financial loss is to be avoided, e.g. an implantable item taken into the operating theatre and not opened, may be considered for decontamination:

o If the outer wrapper over the non-sterile cardboard box is waterproof and intact, a decision could be made to disinfect the outer wrapper and retain the implant

o Advice should be sought from the Infection Prevention, Control and Staff Health Department • Contain all used equipment within the drapes on the instrument trolley as per routine practice. If not

sufficiently contained, use a plastic drape to achieve complete coverage • Send all re-usable stock on the scrub trolley to pre-rinse for reprocessing, even if not opened • Suck any remaining fluids into the sucker, seal and discard in contaminated waste and double bag • After the surgical procedure is completed all rubbish is disposed of in contaminated rubbish, including

any disposable items that have not been used • Remove sterile gown and gloves, clean hands with alcohol based hand rub and don yellow gown and

non-sterile gloves. Write up paperwork, all paperwork and X-Rays should be carried when transferring patient and not placed on the patient bed, to avoid risk of contamination of the notes

• Ensure the Schedule 4 & 8 Drug Register is signed by the Anaesthetist only after they perform hand hygiene

• A terminal clean of the operating theatre is required at the end of the case. All equipment used in the operating theatre must be terminally cleaned and instruments will need to be reprocessed (even if not opened)

• Staff leaving the operating theatre should remove PPE and perform hand hygiene.






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5.4.5 Caring for Patients in Post Anaesthetic Care Unit that Require Infection Control Precautions • It is preferable to recover the patient in the operating room and then transfer them directly back to their

room on the ward. The MRO patient should be nursed by one dedicated recovery room nurse wearing appropriate PPE

• If the patient needs to recover in the Post Anaesthetic Care Unit (PACU), it is important that PACU staff are made aware of the MRO status of the patient prior to transfer, by the transferring team

• A bay away from the main recovery area with a dedicated recovery nurse is allocated, with a temporary PPE station located outside this area. A terminal clean of the bay is performed after patient discharge.

5.5 Isolation Rooms Patients with known or suspected infectious conditions should be cared for in an isolation room if available. 5.5.1 Types of Isolation Rooms There are four types or classes of isolation rooms:

• Class S - Standard Pressure • Class P - Positive Pressure (not present in CPHB or CBPH) • Class N - Negative Pressure (not present in CBPH) • Class Q - Quarantine Isolation (not present in CPHB or CBPH).

5.5.2 Class S – Standard Pressure Isolation Room

• A class S isolation room is a single room with an ensuite • It is used for patients who require contact or droplet isolation • A hand basin is required within the room • A hand washing/PPE bay may be provided outside the door and may be shared with an adjoining room.

5.5.3 Class N – Negative Pressure Isolation Room

• CBPH (Private Hospital) does not have a Class N Negative Pressure Isolation Room • CPHB have four Class N Negative Pressure Isolation Room located in ICU/CCU • A class N isolation room is a single room with an ensuite • It is used for patients who require airborne isolation (e.g. Varicella, Measles, Pulmonary tuberculosis,

etc.) to reduce transmission of disease via the airborne route • An enclosed anteroom is recommended, however if not available a hand wash and PPE bay will be

required outside the room with space to store gowns, gloves and masks etc • Anterooms allow staff and visitors to change into, and dispose of, personal protective apparel used on

entering and leaving rooms when caring for infectious patients.






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5.5.4 The Functional Classification of Isolation Rooms

Class S Class N

Key ventilation criteria

No air pressure difference between room and the adjacent corridor

Lower air pressure in the room than in the adjacent corridor or anteroom

Transmission based rationale

To prevent contact or droplet transmission

To prevent airborne transmission

Examples for use

VRE / MRSA; Other multi-resistant infections, C difficile, gastroenteritis, Influenza, Pertussis etc.

Measles & Varicella (suspected or proven), Pulmonary tuberculosis, etc.

6. Animals, Toys, Plants and Electronics in the Healthcare Setting 6.1 Animals/Pets in the Healthcare Setting Note: This section does not apply to licenced/registered service or guide dogs.

Relevant resources for this section: • Animal/Pet visitation agreement form

Animal/pet visitation can occur inside or external (on the grounds) of CPHB or CBPH. The preferred site for interaction between patients and visiting animals is in an external garden or courtyard, as weather and space permits. In all Situations: 1. Animal/pet visitation is restricted to:

• Complex continuing care or rehabilitation patients who have a prolonged hospital stay • Patients requesting a visit for compassionate reasons such as palliative care • One animal/pet per visit allowed.

2. Animals excluded from visits include: • Animals over 65 kilograms • Animals younger than 12 months • Non-human primates (monkeys, chimpanzees etc.) • Native animals of any description • Poisonous animal(s) • Rodents (e.g. rats, guinea pigs, ferrets or mice) • Poultry

3. The visits must be pre-arranged with the nurse unit manager or team leader in charge who will seek approval from the treating clinicians and the Infection Prevention, Control and Staff Health Department before the visit is allowed to occur

4. The duration of the visit must be planned to avoid treatment or meal times

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5. Visits should be kept short and visits are only allowed to a patient when: • Medical, allied health and/or nursing care will not be compromised • The patient’s health and recovery will not be compromised.

Note: Please contact the Infection Prevention, Control and Staff Health Department in the case of a request from a palliative patient and/or their family/carers for a visit from a pet listed as excluded. The Infection Prevention, Control and Staff Health Department can work with the Nurse Unit Manager and the patient to facilitate if possible special arrangements for the visit to occur in a safe manner.

6.1.1 Patients and/or their Family/Carers

• Patients who are in any of the following categories should be excluded from animal therapy or pet visitation:

o Exhibiting agitation and aggression o Have wounds that are open to air (e.g. without dressings), unless able to be covered for the

period of the visit o Patients who have undergone a splenectomy or who are myelosuppressed.

• The patient and/or their family/carers must sign the Animal/Pet visitation agreement form • The patient and/or their family/carers must facilitate and oversee/supervise the visit. The handler and

patient must ensure that the pet will not dislodge or damage patient devices • A towel or other protective layer may be placed between the animal and the patients clothing if the

animal is to be held on the lap • Animals should not be in the vicinity of a patient during treatment (this procedure excludes guide dogs,

hearing dogs or assistance /companion animals that must be kept quiet during the treatment and an appropriate distant from the point of procedure)

• At the end of the visit, all patients and/or their family/carers that came into contact with the visiting animals must perform hand hygiene after handling the animal, its excreta or its saliva. The animal handler who brings in the pet/animal is also required to perform hand hygiene before entry to the facility/patient area.

6.1.2 Nurse Unit Manager or Nursing Team Leader in Charge Nurse unit manager or the team leader in charge should:

• Ensure the patient and/or their family/carers sign the Animal/Pet visitation agreement form • Inform the patient about the care needed in respect to patient treatment devices (e.g. IV lines,

dressings, catheters) • As far as practicable cover/protect patient treatment devices with plastic bags, sheets, etc. • If the visit is going to occur inside the facility notify and check pet allergy status of staff and other

patients who might become exposed to the animal/pet during the visit. Consideration must be given to staff and other people, in the vicinity of the visit, who may have:

o Phobias and/or previous traumatic experience o Allergies to pet hair or chemicals used in animal care, and/or o Religious or cultural differences related to particular animals that may be considered unclean or

offensive. • If the visit occurred inside the facility arrange with the contracted cleaning provider a thorough clean of

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6.1.3 Staff Working Inside the Health Care Facility • All staff that came into contact with the visiting animals must perform hand hygiene immediately after

handling the animal, its excreta or its saliva • Staff members who perform invasive and/or aseptic procedures or work in food preparation areas must

avoid all contact with the visiting animal.

6.1.4 Mandatory Requirements for Visiting Animals • All visiting pets and assistance or therapy animals must be:

o At least one (1) year old o Leashed, or in cage/box, throughout visit, with handler in close proximity o Toilet trained o Happy and placid in nature, and friendly towards strangers. If an animal becomes disruptive they

must be removed from the area o Obedient, attentive and responsive o Dry, clean, well-groomed with short nails, and well socialised o Used to being indoors, quiet and not boisterous (not applicable for a visit that is planned to take

place outside of the hospital) o Able to manage around wheel chairs, frames, and other equipment and furniture o Under the care and supervision of a qualified veterinary surgeon o Regularly and currently treated for infestations of heart and intestinal worms/parasites and fleas

in accordance with product manufacturer's instructions o Healthy and fully vaccinated o Free from obvious infection (e.g. open wound, ulcer, weeping eyes, sores on lips, ears etc.) o Excluded if they show any sign of being unwell – not eating as usual, changed bowel motions,

dull and listless, change in disposition, or have open wound – until cleared by veterinarian • All faecal deposits are to be collected immediately by the animal handler using gloved hand, or inverted

plastic bag, and disposed of into land fill via standard waste management disposal processes (normal rubbish bins)

• Animals should have been toileted before entering the premises • Food is not to be served to the patient during the animal’s visit • Food is not to be given to the animal during the visit. Water can be provided but the owner or their

family/carers are to provide the water bowl • For inside visits one pet per visit per patient. For outside visits no restriction is required.

6.1.5 Environmental Considerations The following environmental issues need consideration:

• The preferred site for interaction between patient and visiting animals is in an external garden or courtyard, as weather and space permits

• Animals should not be in the vicinity during food preparation or consumption • Drugs and dangerous objects should be removed from the area where animals will be spending time.

6.1.6 Reporting Incidents and Recording Patient Feedback

• All adverse events/incidents including injury or infection experienced by staff, patients, family, carers, visitors, handlers or the visiting animal during the visit or as a result of the visit must be reported through Riskman

• Patient feedback of satisfaction and/or complaints should be encouraged • Staff should record verbal feedback from patients and/or families.






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6.2 Toys in the Hospital It is necessary to ensure that toys provided in the workplace are:

• Of a construction that minimises the risk of harm and able to be effectively cleaned to minimise the development and transmission of infection.

6.2.1 Purchasing / Obtaining Toys

• The toy selection will be kept to a minimum, and suited to the children who attend the specific area either as patient or relatives of patients

• Toys must be durable, washable, and of a design that encourages children to develop their social, emotional, cognitive and physical skills

• Toys used by patients in a clinical setting, waiting room or clinic area must be: o Lead free and of good quality construction and design o Made of durable hard plastic o Free from holes that may allow fluid inside the toy o Free from sharp or pointed edges o Big enough to discourage being put in the mouth, and o Free from small pieces that may be dislodged and swallowed, or pose a choking hazard.

Note: Avoid plush/soft toys/mobiles and those with cracks and crevices as they provide ideal sites for dirt collection and potential infectious agents. 6.2.2 Cleaning of Toys

• Toys used for assessment or during examination must be washed with hot soapy water or wiped over with a Clinell green wipes and dried by clinical staff after each use

• Toys in playrooms and waiting areas must be washed daily with hot soapy water or wiped over with a green Clinell disinfectant wipe

• Toys observed to be contaminated with nasal discharge, saliva (or other body substances), or dirt or soil from the floor, must be immediately removed from circulation and cleaned as soon as possible

• Toys may be washed separately in a dishwasher/ utensil washer. Note: During a period of high incidence of infection (e.g. outbreak of an infectious disease) all toys must be removed from the waiting area. Advise the parents/carers of the reasons for this action. 6.2.3 Storage of Toys

• Toys must be stored, in plastic baskets or plastic storage boxes/units, on shelves or in cupboards: o Storage boxes/units with a lid must not have a locking device that will allow a child to become

trapped inside, and must contain ventilation holes for fresh air flow, and o Containers and storage areas must be cleaned weekly with hot soapy water or wiped over with a

Clinell green wipes by clinical or administrative staff, as per local area cleaning schedule. • Magazines for use by waiting adults must also be kept away from the area where small children play.

6.3 Flowers and Pot Plants Flowers and pot plants are prohibited in the rooms of immuno-compromised patients. Clinical Staff should not, where possible, care for the flowers or pot plants of patients. This should be the responsibility of support staff, volunteers and family.






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When handling flowers or pot plants the following must be considered: • Flowers must be handled by support staff and volunteers who have no patient contact or, when this is

not feasible, those handling flowers must wear gloves • Pot plants must only be in those areas where invasive procedures are not being performed • Hands must be washed after any contact with plant material even when wearing gloves • Vase water must be changed at least every two days • Vase water must be disposed of in pan room sinks only, and not into hand washing sinks or

kitchen/pantry sinks • Vases must be washed in detergent and hot water after use or can be washed in the utility dishwashers

located in the pan rooms • Cleaned and dried vases must be stored in the dedicated vase cupboard in the patient kitchen area

located on every ward.

6.4 Mobile Phones and Electronic Devices If mobile phones and/or electronic devices are being used in the clinical areas, the devices must be regularly cleaned, in particular:

• If the electronic devices are being shared between patients or patient bed spaces, the devices must be cleaned and disinfected in between every use. This process must adhere to the device manufacturer’s instructions

• The personal mobile phones of staff must be cleaned daily and if used in a clinical area, the device should be cleaned after every use.

7. Antimicrobial Stewardship 7.1 Antimicrobial Stewardship (AMS)

Relevant resources for this section: • Receiving Antibiotics in Hospital – Information for Patients and Carers • Antimicrobial Stewardship Clinical Care Standard • Antimicrobial Stewardship: Clinician Fact Sheet

For Calvary Public Hospital Bruce (CPHB): Please refer to the CPHB Antimicrobial Stewardship Policy and Antimicrobial Prescribing Procedure. For Calvary Bruce Private Hospital (CBPH): Please refer to Antimicrobial Stewardship Policy and Procedure.

http://connect.calvarycare.org.au/Services/PublicHospitals/Bruce/Departments/_layouts/15/WopiFrame.aspx?sourcedoc=/Services/PublicHospitals/Bruce/Departments/Infection%20Control%20and%20Staff%20Health/Calvary%20-%20Antibiotics%20In%20Hospital%20Patient%20flyer.pdf&action=default

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http://connect.calvarycare.org.au/teams/InfectionControlCollaborative/_layouts/15/WopiFrame.aspx?sourcedoc=/teams/InfectionControlCollaborative/Documents/AMS/Antimicrobial%20Stewardship%20Policy.docx&action=default&DefaultItemOpen=1

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8. Staff Health 8.1 Vaccination and Screening Refer to the relevant resources listed for this section.

Relevant resources for this section: • Occupational Assessment, Screening and Vaccination Policy • Occupational Assessment, Screening and Vaccination for Category A Staff Procedure • Occupational Assessment, Screening and Vaccination for Category B Staff Procedure • Management of Healthcare Workers with Blood Borne Viruses Policy

8.2 Occupational Exposure Incident Management Refer to the relevant resources listed for this section.

Relevant resources for this section: • Management of Occupational Exposures to Blood and Body Fluid Procedure • Occupational Exposure Pack • Management of Exposures to Blood or Body Fluid Incident Flowchart

8.3 Exclusion Periods for Healthcare Workers Exposed to or diagnosed with an Infectious Condition 8.3.1 Procedure To protect against infectious conditions all category A staff must meet the requirements of the Occupational Assessment, Screening and Vaccination Policy (refer to section 8.1 for additional information). This involves providing evidence of protection against Hepatitis B, Measles, Mumps, Rubella, Varicella, Diphtheria, Tetanus and Pertussis. Following diagnosis of a transmissible infectious disease staff will be required to remain off work for a period of time. Refer to Table 3 for information on specific illnesses and their exclusions periods. Table 3 – Exclusion periods following infection or exposure to communicable diseases

Organism

Infected Healthcare Worker

Exposed Healthcare Worker (if applicable)

Viral Respiratory Tract Infections (e.g. common cold)

• Depends on specific organism and severity. The healthcare worker must be excluded from contact with susceptible persons until they are no longer symptomatic

• The healthcare worker with viral respiratory tract infections must stay at home until they feel well.

N/A

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Organism



Gastroenteritis: • Unknown Viral • Rotavirus virus • Norovirus • Campylobacter • Salmonella • Cryptosporidiosis • Giardiasis • Undiagnosed

diarrhoea

• To remain off duty for 48 hours after last symptom has resolved

• Healthcare workers diagnosed with Salmonella must seek advice from the Infection Prevention, Control and Staff Health Department as to when they can return to work

• Food handlers must seek medical advice and obtain a clearance certificate prior to returning to work, in any scenario.

• Contact the Infection Prevention, Control and Staff Health Department for advice

• The Infection Prevention, Control and Staff Health Department will implement contract tracing if required, in line with Public Health and HICMR guidelines.

Cytomegalovirus (CMV) • No restrictions Pregnant healthcare workers - should avoid direct prolonged contact with patients known to have CMV infection

Conjunctivitis (acute infectious)

• Remain off work for 48 hours after eye drops have commenced and discharge has ceased.

N/A

Hand, foot and mouth disease

• Remain off work until all blisters have dried.

N/A

Hepatitis A • Remain off work for at least seven days after the onset of jaundice.

N/A

Herpes Simplex (Cold Sores)

• Healthcare workers must cover lesion whenever possible

• When lesions uncovered exclude healthcare worker from caring for neonates, immunocompromised patients (severely neutropenic patients), operating rooms and delivery suite until 48 hours after anti-viral medication has commenced or until lesion is dry

• Healthcare workers can be deployed to a non-clinical area.

N/A

Herpes Zoster (Shingles)

• Must not provide ANY direct patient care if lesions cannot be covered (e.g. ophthalmic zoster)

• If active lesions can be covered, can provide care to all patients except for pregnant women, neonates, severely immunocompromised patients, burns patients and patients with extensive eczema.

• Healthcare workers who are exposed and not immune to Chickenpox should contact the Infection Prevention, Control and Staff Health Department or their medical practitioner for advice and to confirm immunity status.

Influenza • Healthcare workers infected with influenza must remain away from work: − until 72 hours after anti-viral

treatment has commenced or − seven (7) days if untreated and

• Healthcare workers must be fever free for at least 24 hours before returning to work.

N/A






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Organism



Measles

• Measles infected healthcare worker must remain off work until four (4) days after the onset of the rash

• If infection is suspected, the healthcare worker must remain off work until appropriate test results are known

• Healthcare workers who are exposed and not immune (or unsure about their immunity status) should contact the Infection Prevention, Control and Staff Health Department or their medical practitioner for advice and to confirm immunity status.

• Healthcare workers who are non-immune must not care for patients with suspected or confirmed measles.


Mumps • Healthcare workers infected with Mumps must be excluded for 9 days after the onset of parotid gland swelling


• Healthcare workers who are non-immune must not care for patients with Mumps


Pediculosis (Head Lice)

• Exclude from patient contact or clinical work until 24 hours after the first treatment has been commenced and healthcare worker is free of lice.

N/A

Pertussis (Whooping Cough)

• Healthcare workers infected with pertussis must be excluded from work for at least 5 days after commencing effective antibiotic therapy, or for 21 days after the onset of symptoms if not receiving antibiotic treatment.


• Healthcare workers who are non-immune must not care for patients with Pertussis.

• The Infection Prevention, Control and Staff Health Department will implement contract tracing if






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Organism



required, in line with Public Health and HICMR guidelines.

Rubella (German Measles)

• Healthcare workers infected with Rubella must be excluded from work for at least 4 days after the onset of the rash.

• All healthcare workers, especially female healthcare workers of child bearing age, should ensure their immune status against rubella is adequate


• Healthcare workers who are non-immune must not care for patients with Rubella

• The Infection Prevention, Control and Staff Health Department will implement contract tracing if required in line with Public Health and HICMR guidelines.

Scabies • Remain off work for at least 24 hours after commencement of effective treatment.

N/A

Streptococcal Infection (e.g. impetigo, streptococcal tonsillitis)

• Cover lesions (if applicable) with an occlusive dressing whilst at work

• If lesions cannot be covered, the healthcare worker must not provide direct patient care or prepare hospital food until 24hrs after commencement of appropriate antibiotic therapy

• Healthcare workers with pharyngitis/tonsillitis must avoid patient contact for at least 24hrs after starting appropriate antibiotic therapy.

N/A

Staphylococcal Infection (MSSA & MRSA)

• Any staphylococcal lesions (e.g. boils, wound infections) must be covered with an occlusive dressing while at work. If lesions cannot be covered, the healthcare worker must not perform patient care or prepare hospital food until they have received appropriate antibiotic therapy and the infection has resolved.

N/A

Varicella (Chicken pox) • Healthcare workers infected with Chicken Pox must avoid contact with patients until all lesions are dry and no new lesions have developed for 48 hours

• Healthcare workers who are exposed and not immune (or unsure about their immunity status) should contact the Infection Prevention,






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Organism



Control and Staff Health Department or their medical practitioner for advice and to confirm immunity status.

• Healthcare workers who are non-immune should not care for patients with Chickenpox or Herpes Zoster (Shingles).


Tuberculosis (TB) • If TB disease is suspected or is present, notify the Infection Prevention, Control & Staff Health Department for advise

• Any personnel with pulmonary TB must be excluded from the workplace until cleared by the Dept. of Respiratory Medicine at The Canberra Hospital.

• Contact the Infection Prevention, Control and Staff Health Department or your medical practitioner for advice.

• The Infection Prevention, Control and Staff Health Department will implement contract tracing if required in line with Public Health and HICMR guidelines.

9. Reprocessing of Reusable Medical Devices

Relevant resources for this section How to access these resources • AS/NZS4187:2014

Access Australian and selected International Standards via SAI Global accessible through Calvary Connect.

• HICMR Infection Prevention and Control Manuals - Endo/Probes

• HICMR Infection Prevention and Control Manuals - Sterilising Services

Access the HICMR Infection Prevention and Control Manuals through the HICMR Client Portal. Username: calacticm Password: calact1759

• Reprocessing of reusable medical devices (RMDs) used in the Operating Room: Cleaning, packaging, sterilization and storage

Calvary Public Hospital Bruce: Available here Calvary Bruce Private Hospital: Available here

• Reprocessing of reusable medical devices (RMDs) used in the Medical Imaging

Calvary Public Hospital Bruce: In development. Link to follow.

• Reprocessing of reusable medical devices (RMDs) used in the Endoscopy Department

Calvary Public Hospital Bruce: In development. Link to follow. Calvary Bruce Private Hospital: In development. Link to follow.

http://connect.calvarycare.org.au/Tools/Pages/sai-global.aspx

https://harp.hicmr.com.au/

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9.1 Reprocessing of Reusable Medical Devices Any infectious agents introduced into the body can establish infection. As such, all Reusable Medical Devices (RMDs) should be handled in a manner that will prevent patient, healthcare worker and environmental contact with potentially infectious material. 9.1.1 Principles of reprocessing reusable medical devices

• Only RMDs included in the Australian Register of Therapeutic Goods (ARTG) by the Therapeutic Goods Administration (TGA) should be used. Before purchase, healthcare facilities should ensure that manufacturer’s reprocessing instructions are provided and are able to be followed by the healthcare facility

• All RMDs and patient-care equipment used in the clinical environment must be reprocessed according to their intended use and manufacturer’s advice

• Single-use medical devices must not be reprocessed.

9.1.2 Procedure • All RMDs must be cleaned, packaged, sterilised and stored in a manner that ensures they can be safely

reused without risk of infection transmission • All personnel involved in the reprocessing and use of RMDs must have undertaken relevant education

and training and shall comply with AS/NSZ 4187: 2014. This training shall ensure an understanding and knowledge of:

a. Sterilisation principles and practices b. Current relevant standards and guidelines.

• A person involved in the reprocessing of RMDs who has not completed relevant education and/or does not understand sterilising principles, practices, standards and guidelines must be supervised by a person who has completed relevant education and training

• All items that have been unwrapped are subject to the full cleaning processes, including trays/items that have not been used

• No RMDs will be processed without Therapeutic Goods Association (TGA) approval documentation, and cleaning and reprocessing instructions provided to the sterilising department from medical device companies

• All personnel involved in reprocessing reusable items must apply standard precautions – see section 4.1 of this manual for more information.






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9.1.3 Categories of RMDs

For additional information and area specific guidelines/procedures, refer to the resources listed for this section of the manual.

10. Cleaning 10.1 Cleaning Procedures to Prevent the Spread of Hospital Acquired Infections 10.1.1 Routine Cleaning (i.e. in the absence of a suspected or known infectious patient) A. Cleaners:

• General surfaces can be divided into two groups - those with minimal hand contact (e.g. floors and ceilings) and those with frequent hand/skin contact (‘frequently touched’ or ‘high risk’ surfaces)

• Surfaces that are in close proximity to the patient and frequently touched surfaces in the patient care areas should be cleaned more frequently than minimal touch surfaces. Examples of frequently touched surfaces include doorknobs, bedrails, over-bed tables, patient entertainment system, light switches, patient call bells, tabletops and wall areas around the toilet and in the patient’s room

• Clean frequently touched surfaces with detergent solution once a day, when visibly soiled and after every known contamination. Allowing the cleaned surface to dry is an important part of the cleaning process.

• Once a week (preferably Friday’s) clean and disinfect frequently touched surfaces with a combination/ one step cleaner and disinfectant product (e.g. Actichlor Plus). Allowing the disinfected surface to dry (approximately 10 minutes) is an important part of the disinfection process.

B. Clinical Staff:

• Responsible for cleaning of all shared clinical equipment and patient notes/folders • Green Clinell disinfectant wipes may be used to clean single pieces of equipment and small surface

areas • Clean touched surfaces of shared clinical equipment and patient notes/folders between patient contact

with green Clinell disinfectant wipes • Use surface barriers (e.g. sheet) to protect clinical surfaces (including equipment) that are:

o Touched frequently with gloved hands during the delivery of patient care o Likely to become contaminated with blood or body substances o Difficult to clean.

Category Description Critical These items confer a high risk for infection if they are contaminated with any microorganism

and must be sterile at the time of use. This includes any objects that enter sterile tissue or the vascular system, because any microbial contamination could transmit disease.

Semi-critical These items come into contact with mucous membranes or non-intact skin, and should be single use or sterilised after each use. If this is not possible, high-level disinfection is the minimum level of reprocessing that is acceptable.

Non-critical These items come into contact with intact skin but not mucous membranes. Thorough cleaning is sufficient for most non-critical items after each individual use, although either intermediate or low-level disinfection may be appropriate in specific circumstances.






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10.1.2 Additional Levels of Cleaning when Transmission-Based Precautions are in Place (i.e. known or suspected infectious patient in room) 10.1.2.1 Daily Cleaning of the Patient Surrounding while in Hospital: A. Cleaners:

• The cleaning staff are responsible for the daily cleaning/disinfecting of frequently touched surfaces with a suitable combination/one step cleaner and disinfectant product (e.g. Actichlor Plus). Time must be allowed for the surface to dry (approximately 10 minutes).

• Disinfectant must be diluted according to manufacturer’s recommendations. B. Clinical Staff:

• Clinical staff to clean touched surfaces of shared clinical equipment and patient notes/folders between patient contact with a Clinell green disinfectant wipe and allow for the surface to dry

• Clinical staff to use surface barriers (e.g. sheet) to protect clinical surfaces (including equipment) that are:

o Touched frequently with gloved hands during the delivery of patient care o Likely to become contaminated with blood or body substances o Difficult to clean.

10.1.2.2 Terminal Cleaning of Room on Discharge or Transfer of Patient: A. Cleaners:

• The cleaning staff are responsible for the cleaning/disinfection of ALL horizontal and vertical surfaces and equipment within the room with a suitable combination/one step cleaner and disinfectant product (e.g. Actichlor Plus). Time must be allowed for the surface to dry (approximately 10 minutes).

• Disinfectant must be diluted according to manufacturer’s recommendations. B. Clinical Staff:

• Clinical staff clean all equipment to be reused with a green Clinell disinfectant wipe. • Clinical staff to dispose of all items in the room that cannot be cleaned, disinfected or sterilised (this

includes used boxes of tissue paper and left over consumables such as wound dressings) into a general waste bin

• If reusable fabric curtains are used, the Ward Support Officers must remove all bed curtains and replace them with fresh curtains. The replacement of curtains are not necessary when disposable curtains are used (due to the biocidal coating of the disposable curtains).

10.1.3 Additional Levels of Cleaning in SSU, ED and Medical Imaging Additional levels of cleaning are required in the Short Stay Unit (SSU), Emergency Department (ED) and Medical Imaging Department. A. Cleaners:

• The contracted cleaning staff are responsible for the daily cleaning of all frequently touched surfaces with a suitable combination/one step cleaner and disinfectant product (e.g. Actichlor Plus). Time must be allowed for the surface to dry (approximately 10 minutes).

B. Clinical Staff:

• Clinical staff to clean shared clinical equipment (e.g. beds, chairs, tables) and patient notes/folders between use with green Clinell disinfectant wipes.






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10.1.4 Cleaning of Carpet in Healthcare Facilities The following is required for all areas with carpet/carpet tiles:

• Weekly full surface vacuuming • Spot vacuuming in-between weekly vacuums if required • Immediate replacement of all damaged, stained, worn or loose areas/tiles • Quarterly steam clean.

Note: Vacuum cleaners must be industrial type with HEPA filters. Steam cleaners must be industrial type. Patient rooms with carpet: In addition to the above cleaning requirements patient rooms require the following -

• Daily vacuuming • If the patient is in transmission based precautions – daily vacuuming and a steam clean upon discharge.

10.1.5 Colour Coding of Cleaning Equipment

• The identification of cleaning equipment utilised in the different areas of a health facility is considered essential to prevent the spread of infectious organisms within the healthcare facility

• Clear identification, by colour coding, of the various items of cleaning equipment is considered the most effective method of restricting equipment to individual areas of health facilities:

o Infectious/Isolation Areas - YELLOW o Toilets/Bathrooms/Dirty Utility Rooms - RED o Food Service/Preparation Areas - GREEN o General Cleaning - BLUE o Operating Theatres - WHITE

• Equipment includes – microfiber mop heads, buckets and cloths • All wards/clinical areas to have their own set of cleaning equipment. All equipment must be clearly

marked indicating the ward/clinical area where it should be used. No sharing of equipment should be allowed.

10.1.6 Cleaning Products • Department Managers to ensure the availability of the cleaning products and the appropriate storage of

these products.

Product Purpose Directions Who will use this product Precautions

Clinell Green Universal Wipes

Surface & equipment Disinfectant

Wipe surfaces requiring disinfecting Time must be allowed for the surface to dry

Clinical staff See ChemAlert database (on Intranet) or Safety Data Sheet Folder

LIV-Wipes (Isopropyl alcohol 70%)

Surface & equipment Disinfectant (only indicated for items sensitive to bleach cleaning)

Wipe surfaces requiring disinfecting Time must be allowed for the surface to dry

Clinical staff Mainly in use in the Imaging Department and ICU & CCU on bleach sensitive equipment

See ChemAlert database (on Intranet) or Safety Data Sheet Folder






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• Cleaning Contractor/Housekeeper to ensure the availability of the cleaning products and the appropriate storage of these products.

10.1.7 Evaluation Regular audits of ward rooms are to be performed to ensure that the standard of hygiene is being met and that infection prevention and control measures are being adhered to. These audits will be carried out by the cleaning contractor in conjunction with the Infection Prevention, Control and Staff Health Department and the Domestic Services Manager in CPHB, and by the Housekeeper in conjunction with the Infection Prevention, Control and Staff Health Department in CBPH. 10.2 Environmental Services Refer to the relevant resources listed for this section.

Relevant resources for this section: How to access these resources • HICMR Infection Prevention and Control

Manuals – Environmental Services


11. Waste, Sharps and Spills Management 11.1 Waste Management Refer to the relevant resources listed for this section.


Manuals – Clinical an Related Waste, and Linen


CPHB only: Please refer to the CPHB Environmental Sustainability Strategy 2015-2025 located on the Calvary Intranet.

Product Purpose Directions Who will use this product Precautions

Citra-Mist Detergent

Detergent solution to clean surfaces and equipment

Spray onto surface. Spread and wipe off with a clean damp cloth Time must be allowed for the surface to dry

Contracted or In-House cleaning staff


Actichlor Plus Combination/one step surface and equipment disinfectant and cleaner

- Diluted as per manufacturer instructions - Must be mixed daily and discarded at end of the day Time must be allowed for the surface to dry

Contracted or In-House cleaning staff (for infectious discharge cleaning and infectious occupied room cleaning)




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11.2 Sharps Management and Disposal

Relevant resources for this section: • Sharps Management & Disposal – General Areas Poster 1 • Sharps Management & Disposal – General Areas Poster 2 • Sharps Management & Disposal – Peri-operative Area Poster • Management of Exposure to Blood or Body Fluid Incidents Flowchart

Department managers are responsible for providing the appropriate sharp transfer equipment. All healthcare workers are responsible when handling and disposing of sharps to conduct appropriate planning for its safe disposal. Sharp containers must be available in all clinical areas to allow for the safe disposal of the sharp at the point of use.

11.2.1 Procedure

• Before handling and disposing of sharps, the healthcare worker must plan how to safely conduct the procedure, transport and dispose of the sharps

• Staff must familiarise themselves with the safety mechanisms of the sharps product to ensure safe handling post procedure

• Used needles must not be re-sheathed, bent, broken or in any way manipulated by hand prior to disposal • Used needles and syringes are disposed of as one unit (e.g. do not remove the used needle from the

syringe by hand). If it is necessary in the operating room to remove the needle or scalpel blade, then a needle holder or safety engineered blade remover may be used

• Sharps must not be passed by hand to any other person. In the operating room a neutral zone should be created for the safe passing of sharps, for example a kidney dish or bladesafe device (see the Sharps Management & Disposal – Peri-operative Area Poster)

• All used sharps must be placed in the sharps disposal bin immediately after use and where possible, at the point of use. Avoid crossing your hands to dispose of sharps

• If immediate disposal is not possible a puncture resistant tray must be used to transfer sharps via a clear pathway (e.g. kidney dish)

• Only one sharp at a time must be in the tray. In the operating room a designated magnetic needle board or puncture resistant container should be used

• Do not dispose of any sharps into linen, general waste or contaminated waste bags/bins • It is imperative that sharp containers be used only for the disposal of sharps, as any other item (such as

kidney dishes, unbroken vials, packaging) can cause blockage of the unit thereby preventing the sharp being safely captured

• Unbroken medication vials can be placed into the yellow contaminated waste bins as they are not considered a sharp

• All sharps containers must be securely locked when three quarters full. Disposable bins must be properly closed and secured before disposal by the waste contractors. Place the secured sharps bin into the clinical waste room for collection

• All non-reusable containers for the collection of sharp medical items used in healthcare areas must meet Australian Standard AS4031

• Reusable sharps must be placed in an appropriately labelled puncture resistant container located in the dirty utility room after use and before transport to Pre-rinse for reprocessing

• Gloves should be worn when handling sharps where there is a risk of an occupational exposure to a blood borne virus. Scrubbed surgical personnel should wear double gloves.

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11.3 Management of Blood and Body Fluid Spills Note: This procedure does not include spills of hazardous waste. Please refer to the Hazardous Drugs Spill Management procedure for information regarding management of hazardous spills. 11.3.1 Management of Blood or Body Substance Spills

• In patient-care areas, healthcare workers can manage small spills by cleaning with detergent solution • For spills containing large amounts of blood or other body substances, healthcare workers should

contain and confine the spill prior to the contracted cleaners cleaning the area with a detergent solution • Appropriate PPE should be worn at all times (refer to section 4.5 of this manual) • If spillage has occurred on soft furnishings, healthcare workers should contain and confine the spill and

then contact the cleaners immediately to minimise the chance of the spill causing a permanent stain. • Alcohol solutions should not be used to clean spillages due to the risk of additional hazards (e.g.

flammability).

Small spills (up to 10cm diameter)

Health Care Worker: • Select appropriate PPE – see section 4.5 of this manual • Wipe up spill immediately with absorbent material

(e.g. paper hand towels) • Place contaminated absorbent material into

impervious container or plastic bag for disposal in clinical waste bin

• Clean the area with a green Clinell disinfectant wipe • Allow time to dry • Remove PPE • Perform hand hygiene.

Large spills (greater than 10cm diameter)

Health Care Worker: • Select appropriate PPE – see section 4.5 of this manual • Cover area of the spill with an absorbent clumping

agent found in the blood and body fluid spill kit • Allow time to absorb • Use disposable scraper and pan (found in the blood

and body fluid spill kit) to scoop up absorbent material and any unabsorbed blood or body substances

• Place all contaminated items into plastic bag (found in the blood and body fluid spill kit) for disposal

• Discard contaminated materials into the clinical waste bin

• Remove PPE • Perform hand hygiene • Contact the contracted cleaning provided to clean

area. Contracted cleaners:

• Mop the area with detergent solution (as provided by contractor cleaning group)

• Allow time to dry.

• In non-clinical areas where a spill has occurred (such as the main foyer or cafeteria) the spill is to be immediately confined and contained to prevent any slip injuries

• If necessary, a chair should be placed over the spill to avoid injury from someone stepping into the spill • The cleaning contractors should be notified immediately.

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12. Food Safety – Food Brought into the Hospital for Patient Consumption 12.1 Food Safety – Management of Food for Patient Consumption

Relevant resources for this section: • Patient Food Fridge Signage – Information for Patients and Carers • Patient Food Fridge - Temperature Signoff Sheet • Reading Patient Food Fridge Monitors Poster • Patient Food Fridge – Managing temperature above 5°C Flowchart

Nursing staff should advise patients and visitors that if food is brought in from outside the hospital it must be:

• Wrapped and labelled with the patients’ name and date received • Exclusively for that patient and NOT to be shared with other patients • Cooked foods should be cooled before transporting to the hospital • Perishable food items brought into the hospital must be:

o Eaten straight away or immediately stored in the refrigerator o Consumed or discarded within 24 hours of receipt.

• Nursing staff are to be notified when the food item is brought into the hospital to check for compliance for the above

• If food is not labelled as above, nursing staff will label the food item with patients’ name, date and time • Hospital staff should communicate to the patient and visitors:

o CPHB and CBPH cannot accept responsibility for food that is prepared outside the hospital and is brought in by relatives and visitors

o The contracted kitchen staff who refill and monitor the fridges on the wards, will on a daily basis dispose of all unlabelled food products stored in the fridge.

• The ward kitchen/kitchenette is NOT to be used for food preparation. It can only be used for sealed precooked food.

Patients should be informed of the above by signage affixed to the front of patient food refrigerators. (Refer to: Patient Food Fridge Signage – Information for Patients and Carers. 12.2 Monitoring Patient Food Refrigerators During morning rounds the contracted Food Services Staff will perform daily temperature monitoring of designated patient food fridges. 12.2.1 Daily Monitoring Process View thermometer attached to fridge and note ‘current’ temperature. If current temperature reads less than 5°C:

1. Reset thermometer (Refer to: Reading Patient Food Fridge Monitors Poster) 2. Document on the Patient Food Fridge Temperature Signoff Sheet the following:

• Date • Time monitoring performed • Current fridge temperature in °C • Tick Reset performed column • Name, position & signature of person performing monitoring.

3. Restock / place new food in fridge.

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If current temperature reads higher than 5°C: 1. Immediately notify Food Services or Hospitality Manager 2. Food Services/Hospitality Manager must follow the instructions provided on the Patient Food Fridge –

Managing temperature above 5°C Flowchart 3. Do not restock/place new food in fridge until fridge has been deemed ‘safe’ and cleared for use by the

Food Services/Hospitality Manager.

12.3 Contracted Patient Food Services

Refer to the relevant resources listed for this section. Relevant resources for this section: How to access these resources

• HICMR Infection Prevention and Control Manuals – Food Services


13. Linen & Privacy Curtains 13.1 Laundering Practices The washing machines and dryers located in the clinical areas are only to be used to wash hospital equipment (e.g. slings of lifters). If patient clothing requires washing (e.g. the patient has no family to take the clothing home for a wash), contact the Social Work Department for assistance. In exceptional cases it might be necessary to launder patient clothing onsite and in these cases refer to section 13.1.5. Standard precautions are applied to all laundering practices. Laundering of equipment shall abide by the equipment manufacturer’s instructions regarding water, detergent and drying temperatures. 13.1.1 Machines and Dryers

• All washing machines and dryers must meet the minimum safety standards as applicable under legislative requirement as stated in AS/NZS 4146. The Hospital Asset or Supply Manager must ensure compliance before purchasing washing machines and/or dryers

• Infection Prevention, Control and Staff Health Department must be involved in the selection of all washing machines and dryers for clinical laundering purposes

• When equipment is laundered in the clinical setting, the washing machines and dryers must have the capacity and technology to adequately clean and dry at the correct temperatures and settings as stated by the equipment manufacturer

• All washing machines and dryers shall be regularly cleaned including filters. The clinical area Manager must delegate this responsibility

• The Engineering Department must ensure that all washing machines and dryers are listed on the preventative maintenance schedule and have their regular electrical testing and tagging.

13.1.2 Laundry Powder

• Laundry powder must fully meet the performance criterion set out in AS/NZ Standard 4146:2000, section 3.5.3 for microbiological efficacy of chemical disinfection of laundry products under the wash cycle conditions









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• Staff need to order a commercial grade laundry detergent through the supply department in order to meet the requirements of the AS/NZ Standard 4146:2000.

13.1.3 Laundry Areas

• The laundry area must be kept clear of clutter and must be cleaned regularly. The clinical area Manager must delegate this responsibility

• Dirty linen must not be stored in the laundry area. 13.1.4 Staff

• All staff must comply with hand hygiene practices before and after handling items and equipment that are to be laundered

• PPE should be worn by staff in the appropriate manner when laundering – particularly when in contact with soiled linen

• PPE must be discarded after use before returning to clinical duties. 13.1.5 Washing Patient Clothing

• Patient clothing should not be washed using the washing machines and dryers located in the clinical areas

• In exceptional circumstances (e.g. patient does not have any family to take his/her clothing home for a wash and social work cannot arrange support), patient clothing can be washed on the ward. The following restrictions must be met: o An appropriate detergent and hot water should be used. Refer to section 13.1.2 of this manual for

more information o Individual patient loads should be washed (i.e. not mixed with hospital equipment or other patient

clothing) o The washing machine should be wiped with a green Clinell disinfectant wipe between each load o Clothes dryers should be used to dry personal items as this process significantly reduces the

bacterial load. 13.2 Schedule for the Cleaning of Reusable Curtains and the Replacement of Disposable Curtains The Infection Prevention, Control and Staff Health Department recommends all clinical areas that require bedside curtains, move towards using disposable curtains which are impregnated with antibacterial and anti-mildew chemicals. The Clinical Manager/CNC of each clinical area that uses bedside curtains is responsible to establish a schedule for laundering of reusable curtains and/or the replacement of disposable curtains. The Clinical Manager/CNC is responsible for keeping records when changes of curtains have been undertaken. 13.2.1 Instructions for the Laundering of Reusable Curtains

• In ward areas, the reusable curtains must be changed quarterly or after a terminal clean of a patient’s room

• Reusable curtains must be in good condition (e.g. no visible tears or damage). Curtains must be changed immediately when soiled or torn.






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13.2.2 Instructions for the use of Disposable Curtains Note: These instructions only apply to the Haines brand of Disposable Recyclable Curtains. If any other brand is used, please contact the Infection Prevention, Control and Staff Health Department for guidelines.

• When using disposable curtains, staff must write the date on the curtains at time of hanging. This can be written on the identification label on the curtain

• Disposable curtains must be routinely changed every 12 months • It is not necessary to replace the curtains routinely following a terminal clean • If an outbreak were to occur then disposable curtains would be changed when the outbreak is deemed

to be over (unless visibly soiled or damaged prior to this) • The manufacturer’s instructions should be followed when fitting and during changeover of disposable

curtains • Disposable curtains must be in good condition (e.g. no visible tears or damage). Curtains will be changed

immediately when soiled or torn.

13.3 Contracted Linen Services Refer to the relevant resources listed for this section.


Manuals – Clinical and Related Waste, and Linen


14. Facilities Management 14.1 Maintenance and Engineering Services Refer to the relevant resources listed for this section.


Manuals – Maintenance Services


14.2 Infection Control during Construction, Renovation and Maintenance

Relevant resources for this section: • Infection Prevention & Control Construction Approval Checklist • Infection Prevention & Control – Construction Compliance Audit Tool

• Construction, renovation and maintenance projects can generate large amounts of dust and debris. This

dust and debris may carry tiny micro-organisms, including fungal spores such as Aspergillus, which can cause infection in patients with poorly functioning immune systems

• These organisms can resist drying and can remain suspended in the air for long periods, travelling far from their source



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• Environmental disturbances which occur during construction projects pose both airborne and waterborne risks to patients with poorly functioning immune systems

• Increasing levels of dust and fungal spores in the air have been associated with outbreaks in hospital settings

• Other sources known to cause transmission of fungi within hospital settings have included: improperly functioning or poorly maintained air handling systems, false ceilings, open door construction sites, open windows, hospital vacuum cleaners and air filters.

14.2.1 Preliminary Considerations Before beginning construction or renovation projects, some key issues need to be addressed. Major Projects and Engineering staff, in conjunction with the Infection Prevention, Control and Staff Health Department must consider the following:

a) Design and function of the new structure/area b) Assessment of the infection risk of airborne disease and opportunities for prevention c) Measures to contain dust d) Monitoring requirements of the site during the project.

14.2.2 Construction and Renovation Risk Assessment A risk assessment following the steps detailed below will be undertaken by the Engineering Staff in consultation with the Infection Prevention, Control and Staff Health Department before construction, renovation or maintenance activities commence. Step 1: Construction Activity Type Construction activity type is defined by the amount of dust that is generated, the duration of the activity and any impact on the Heating/Ventilation/Air Conditioning (HVAC) systems. Using the following table, identify the type of Construction Project Type (A-D):

Type A Inspection and Non-invasive Activities Includes but not limited to: • Activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection. Must be able to be completed in single shift.

Type B Small scale short duration activities which create minimal dust Includes but not limited to: • Cutting of walls or ceilings where dust migration can be controlled. Must be able to be completed in single shift.

Type C Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies Includes but not limited to: • Sanding of walls for painting or wall covering • Removal of floor coverings, ceiling tiles and case work • New wall construction • Minor duct work or electrical work above ceilings • Major cabling activity • Any activity that cannot be completed within a single work shift

Type D Major demolition and construction projects Includes but not limited to: • Activities that require consecutive work shifts • Requires heavy demolition or removal of a complete cabling system • New construction






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Where Hospital Engineering Staff are unsure how to determine the type of Construction Project, contact the Infection Prevention, Control and Staff Health Department for assistance. Step 2: Determine Risk Category for the Area or Adjacent Areas to the Renovation and Construction Site The risk category is defined by the project location. Using the following table, identify the risk category. If more than one area will be affected, select the higher risk category.

Low Risk Medium Risk High Risk Highest Risk - Office areas - Non clinical areas (No patients being cared for in these areas)

- Endoscopy (CPHB) - Medical Imaging - MRI - General Outpatient areas - Psychiatric Services - Physiotherapy - Rehabilitation wards - Private Consulting suites

- Emergency Dept - Laboratories - Pharmacy - Medical/ Surgical Wards - Delivery Suite

- Area/Ward/Unit caring for immunocompromised patients - ICU area/s - Special Care Nursery - CSSD - Operating Suite Services - Endoscopy (CBPH)

Where Hospital Engineering Staff are unsure how to determine the risk category for an area or categorise a specific activity, contact the Infection Prevention, Control and Staff Health Department for assistance. Step 3: Match the Risk Category (low, medium, high, highest) with the planned Construction Project Type (A, B, C, D) to determine the Class of Barrier Precautions required (I, II, III, IV).

Patient Risk Category

Construction Project Type

Type A Type B Type C Type D LOW I II II III/IV

MEDIUM I II III IV HIGH I II III/IV IV HIGHEST II III/IV III/IV IV

Where Hospital Engineering Staff are unsure how to determine the risk category for an area or categorise a specific activity, contact Infection Prevention, Control and Staff Health Department for assistance. Step 4: Determine the Class of Barrier Precautions

CLASS During Construction Project Upon Completion of Project I 1. Work in a manner to minimise raising dust from

construction operations. 2. Immediately replace a ceiling tile displaced for visual inspection.






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CLASS During Construction Project Upon Completion of Project II 1. Provide active means to prevent dust in the air

from dispersing into the atmosphere. 2. Complete all construction barriers before construction work begins. 3. Water mist work surfaces to control dust while cutting. 4. Seal unused doors with masking tape. 5. Block off and seal air vents. 6. Place dust mats at entrance to work area and replace or clean regularly.

1. Contain construction waste before being transported in covered containers. 2. Wet mop and/or vacuum before leaving work area. 3. Wipe horizontal surfaces 4. Remove alterations to the air handling system in the area where the work is being performed.

III 1. Provide active means to prevent dust in the air from dispersing into the atmosphere. Area should be regularly vacuumed (with HEPA) throughout project. 2. Alter/isolate the air handling system in the area where the work is being performed to prevent contamination of the duct system. Engineering staff will be responsible for blocking off supply ducts and covering return air ducts to prevent contamination with dust. 3. Complete all construction barriers before construction work begins. Where containment is possible: utilise building walls and doors (all doors except construction access doors), close and seal with duct tape to prevent dust and debris from escaping. Construction, demolition, or reconstruction not capable of containment by utilising existing building walls and doors: use one of the following methods of isolation: • Airtight plastic barriers extending from floor to

ceiling decking, or ceiling tiles if not removed. • Plastic barrier seams to be sealed with duct tape

to prevent dust and debris from escaping. • Drywall barriers. Seams or joints will be covered

or sealed to prevent dust and debris from escaping.

4. Maintain negative pressure within work site if necessary. 5. Direct pedestrian traffic from construction areas away from patient-care areas to limit opening and closing of doors (or other barriers) that may cause dust dispersion, entry of contaminated air, or tracking of dust to patient areas. 6. Contain construction waste before being transported in covered containers. 7. Place dust mats at entrance to work area and replace or clean regularly. 8. Water mist work surfaces to control dust while cutting.

1. Do not remove barriers from the work area until completed project is thoroughly cleaned and air sampling results are available. 2. Vacuum area including barriers using HEPA filter vacuum. 3. Wet mop area and wipe down horizontal surfaces. 4. Remove barrier materials carefully to minimise spreading of dirt and debris associated with construction. 5. Barrier material should be wet wiped before removal. 6. Remove alterations to the air handling system in the area where the work is being performed. 7. Contain construction waste before being transported in covered containers.






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CLASS During Construction Project Upon Completion of Project IV 1. As in iii and

2. Place isolation barriers at penetration of ceiling envelopes, chases and ceiling spaces to stop movement of air and debris. 3. When openings are made into existing ceilings in clinical/ laboratory areas, where possible, the decontamination unit should be used which will seal off openings and fit tightly from ceiling to floor. 4. Construct anteroom to maintain airflow from clean area through anteroom and into work area. Require all personnel to pass through this room. Create overlapping flap (minimum of 2 feet wide) at plastic enclosures for personnel access. 5. Maintain negative pressure within the work site.

As in iii

Hospital Engineering Staff in liaison with the Infection Prevention, Control and Staff Health Department will determine whether construction, renovation or maintenance activity poses sufficient increased risk to require/recommend that patients be moved to an area of the hospital where construction activities are not occurring. 14.2.3 Infection Prevention, Control and Staff Health Department Role Determine Environmental Cultures/Environmental Air Sampling Requirements:

• The Infection Prevention, Control and Staff Health Department will determine requirements for performing environmental cultures/environmental air sampling during construction, renovation and maintenance activities

• The recommissioning process of Operating Rooms and Sterilising Services following construction activities always requires environmental cultures/environmental air sampling to be conducted.

Conduct Random Site Inspections: • The Infection Prevention, Control and Staff Health Department will conduct random inspections

where construction, renovation or maintenance is occurring to ensure the barriers are intact and dust and debris is being contained

• Complete the Infection Prevention and Control Construction Compliance Audit Tool with each inspection.

Conduct Inspection on Completion of Project: • The Infection Prevention, Control and Staff Health Department will conduct an inspection on

completion of the project when final construction cleaning and hospital cleaning has been completed and approve opening or re-opening of the area, if this cleaning is deemed adequate.

Identify Breaches: • The Infection Prevention, Control and Staff Health Department will determine any breach in

construction barriers. If necessary the site will be shut down until barriers are complete and the area has been thoroughly cleaned

• Where breaches result in contamination of the patient environment, Infection Prevention, Control and Staff Health Department will notify Heads of Units of the potential increased risk of fungal infections in patients who were in the area at the time.

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14.2.4 Engineering Staff Role Risk Assessment Documentation:

• Engineering or contract staff will conduct the risk assessment and comply with the barrier precautions stipulated as required for the specific construction activity.

• Complete the Infection Prevention and Control Construction Approval Checklist prior to the start of any construction/renovation activities. Forward this form to the Infection Prevention, Control and Staff Health Department for verification and signoff prior to the start of the planned construction/renovation activity.

Conduct Random Site Inspections: • Engineering or contract staff will conduct random inspections where construction, renovation or

maintenance is occurring to ensure the barriers are intact and dust and debris is being contained. Conduct Inspection on Completion of Project:

• Engineering or contract staff will conduct an inspection on completion of the project when final construction cleaning and hospital cleaning has been completed and approve opening or re-opening of the area, if this cleaning is deemed adequate.

Identify Breaches: • Engineering or contract staff will notify the Infection Prevention, Control and Staff Health

Department immediately of any breach in construction barriers. If necessary the site will be shut down until barriers are complete and the area has been thoroughly cleaned.

15. Communication with Patients and Carers 15.1 Patient Information Pamphlets Refer to the relevant resources listed for this section.

Relevant resources for this section: • Methicillin Resistant Staphylococcus aureus (MRSA) – A Guide for Patients • Vancomycin Resistant Enterococcus (VRE) – A Guide for Patients • Multi-Resistant Organism (MRO) – A Guide for Patients • Clostridium difficile Associated Diarrhoea (CDAD) – A Guide for Patients • Hand Hygiene – A Guide for Patients and Visitors • Viral Respiratory Illness – A Guide for Patients • Receiving Antibiotics in Hospital – Information for Patients and Carers

16. Caring for the Deceased and Infection, Prevention and Control 16.1 Management of Deceased Person with a Confirmed or Suspected Infectious Disease

Relevant resources for this section: • Management of Deceased Person Procedure • BioSeal System 5 Containment System (Available in Office 2B 09, Level 2 Sr. Mark Maher Building.

Contact security for access to the room).

• If transmission based precautions were required before death, the same precautions should be continued after death, and communicated to all persons caring for the deceased. Refer to Table 4 for the different infectious diseases and the care requirements of for each group after death.

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• Where the deceased had active chickenpox or active shingles only staff with VZV immunity should manage the deceased person

• Notify the ward support officer of the transmission-based precautions required prior to transport of the deceased to Mortuary

• If the deceased is known or suspected to be infected with an infectious disease, the body bag must be clearly and indelibly marked with the words “INFECTIOUS DISEASE-HANDLE WITH CARE”. Ensure the opening end of the body bag is positioned at the head of the deceased

• In Hospital, viewing/touching/handling of the deceased by relatives is permitted unless special conditions apply e.g. Viral Haemorrhagic Fever, Creutzfeldt Jakob Disease (CJD)

• The ACT Chief Health Officer must be notified of the death of persons with certain notifiable diseases. Refer to section 4.8 or ACT Public Health (Reporting of Notifiable Conditions) Code of Practice 2017 (No1) for additional information.

Table 4 – Infectious diseases and care requirements of the deceased

Group A Group B Group C Group D Infectious Disease - Infectious disease not

listed under Group B, C or D (these include multi-resistant organisms)

- Acquired Immunodeficiency Syndrome (AIDS) - Human Immunodeficiency Virus (HIV) - Acute viral Hepatitis (unspecified) - Hepatitis B - Hepatitis C - Hepatitis D

- Creutzfeldt Jakob Disease (CJD)

- Plague - Smallpox - Yellow Fever - Anthrax - Rabies - SARS - Avian Influenza - Cholera Any vial haemorrhagic fever (VHF) incl. Lassa, Marburg, Ebola and Congo-Crimean Fevers

Precautions Required

- Standard Precautions and - transmission-based precautions (same as before death)

- Standard Precautions - Standard Precautions

- Standard Precautions and - transmission-based precautions (same as before death) - High Security Isolation for FHV’s

Notification requirements

- Notify ACT Public Health as per ACT Public Health (Reporting of Notifiable Conditions) Code of Practice 2017 (No1)



Containment - Usual body/mortuary bag

- Usual body/mortuary bag

- Leak proof pouch (BioSeal System 5 containment bag) lined with absorbent material (refer to section 16.1.1 for instructions on how to use and locate the BioSeal System). and - Second body bag (outer bag – usual body/mortuary bag)

- Contact ACT Public Health for instructions on the management of the deceased



















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Other requirements

The body/mortuary bag must be clearly labelled: “Infectious Disease - Handle with care”

The body/mortuary bag must be clearly labelled: “Infectious Disease - Handle with care”

Deceased must be dressed in funeral attire prior to placement in the body bag. Arrange in advance for family to have funeral attire ready The outer body/mortuary bag must be clearly labelled: “Infectious Disease - Handle with care” The family might request an autopsy. Refer to section 16.1.2 for information how to facilitate this request

16.1.1 Instructions for use of the BioSeal System 5 Containment System (See training video: http://www.bioseal.com/CN/system5) Step 1: Collect Bioseal Kit from Office 2B 09, Sr Mark Maher Building Lv2. Security can provide access to this room outside normal business hours. The Kit contains:

- Absorbent liner - BioSeal plastic pouch - BioSeal heat sealer - Normal body/mortuary bag.

Step 2: Line the BioSeal plastic pouch with the absorbent liner Step 3: Transfer the patient onto the BioSeal pouch and cover Step 4: Heat seal the edges of the pouch on all opened sides Step 5: Transfer the sealed pouch into a normal body/mortuary bag Step 6: Clearly label the body/mortuary bag with: “Infectious Disease - Handle with care”. 16.1.2 Autopsy Request for Deceased with Suspected CJD It is the responsibility of the treating physician to facilitate this request and to complete the necessary documentation. • Autopsy request forms and delivery instructions (scroll down to the bottom of the page for the appropriate

links): http://www.slhd.nsw.gov.au/RPA/Neuropathology/testservices.html • Contact the Glebe Department of Forensic Medicine: (02) 8584 7820.

17. Implementation This manual will be implemented and communicated to all CPBH & CBPH staff using the following:

• Be incorporated into existing training programs including but not limited to orientation, staff forums, in-services and face to face education and e-learning

• Be available in electronic format via the Intranet on the Document Centre • Be available in electronic format via the Intranet on the Infection Prevention, Control and Staff Health

Department Webpage • Be available in hardcopy format on all clinical areas (included in the Infection Prevention, Control and

Staff Health Resource Folder). • Via the Infection Prevention, Control and Staff Health bimonthly newsletter.

http://www.bioseal.com/CN/system5

http://www.slhd.nsw.gov.au/RPA/Neuropathology/testservices.html






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18. Related Guidelines and Legislation 18.1 National Guidelines

• Australian College of Operating Room Nurses Ltd. - Standards for Perioperative Nursing in Australia • Australian Commission on Safety and Quality in Healthcare - National Safety and Quality Health Service

Standard 3: Preventing and Controlling Healthcare-Associated Infections • Gastroenterological Nurses College of Australia - Infection Control in Endoscopy Guidelines • National Health and Medical Research Council - Australian Guidelines for the Prevention and Control of

Infection in Healthcare • Standards Australia AS/NZS 4187:2014 - Reprocessing of Reusable Medical Devices in Health Service

Organisations. 18.2 Legislation

• Health Practitioners Regulation National Law (ACT) Act 2010 • Medicines, Poisons and Therapeutic Goods Regulation 2008 (ACT) • Public Health Act 1997 (ACT) • Public Sector Management Act 1994 (ACT) • Waste Management and Resource Recovery Act 2016 (ACT) • Work Health and Safety Act 2011 (ACT).

19. References ACT Government. (2019). Disease surveillance. Retrieved from https://www.health.act.gov.au/about-our-health-

system/population-health/disease-surveillance ACT Government. (2018). Public health act 1997. Retrieved from https://www.legislation.act.gov.au/a/1997-69 ACT Government. (2011). Work health and safety act. Retrieved from

https://www.legislation.act.gov.au/View/a/2011-35/current/PDF/2011-35.PDF ACT Government. (2011). Work health and safety regulation. Retrieved from

https://www.legislation.act.gov.au/View/sl/2011-36/current/PDF/2011-36.PDF Allan, J., Cunniffe, J.G., Edwards, C., Lretzer, D., Ledgerton, A., Mackintosh, C., & Murray, A.E. (2005). Nebulizer

decontamination. Journal of Hospital Infection, 59(1), 72-74. Australian College of Operating Room Nurses Ltd. (2018). Standards for perioperative nursing in Australia 15th

Ed. Adelaide, SA: ACORN. Australian Commission on Safety and Quality in Health Care. (2017). Recommendations for the control of

carbapenemase-producing Enterobacteriaceae (CPE): A guide for acute care health facilities. Sydney, NSW: ACSQHC.

Australian Commission on Safety and Quality in Health Care. (2017). National safety and quality health service standard three: Preventing and controlling healthcare-associated infection. Sydney, Australia: ACSQHC.

Australasian Health Infrastructure Alliance. (2016). Australasian health facility guidelines: Part D – Infection prevention and control. North Sydney, NSW: AHIA.

Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine. (2012). Emergency service providers and blood-borne viruses. Darlinghurst, NSW: ASHM.

Department of Health. (2019). Series of national guidelines (SoNGs). Retrieved from https://www.health.gov.au/internet/main/publishing.nsf/Content/cdnasongs.htm.

Department of Health and Ageing. (2011). Therapeutic goods administration: Australian regulatory guidelines for medical devices. Retrieved from https://www.tga.gov.au/sites/default/files/devices-argmd-01.pdf






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Food Standards Australia and New Zealand (FSANZ). (2019). Foods standard code. Retrieved from http://www.foodstandards.gov.au/code/Pages/default.aspx

Government of Western Australia. (2016). Bringing food from home: Patient information. Retrieved from https://rph.health.wa.gov.au/~/media/Files/Hospitals/RPH/For%20patients%20and%20visitors/Your%20hospital%20stay/bringing-food-from-home-brochure.pdf

Gastroenterological Nurses College of Australia. (2010). Infection control in endoscopy. Mulgrave, VIC: GENCA. Hamlin, L., Davies, M., Richardson-Tench, M., & Sutherland-Fraser, S. (2016). Perioperative nursing: An

introduction. Chatswood, NSW: Elsevier. Healthcare Infection Control Management Resources. (2012). Infection prevention and control manual.

Hawthorn East, VIC: HICMR. Khoo, S.M., Tan, L.K., Said, N., & Lim, T.K. (2009). Metered-dose inhaler with spacer instead of nebulizer during

the outbreak of severe acute respiratory syndrome in Singapore. Respiratory Care, 54(7), 855-860. MacCannell, T., Umscheid, C.A., Agarwal, R.K., Lee, I., Kuntz, G., Stevenson, K.B. & the Healthcare Infection

Control Practices Advisory Committee. (2011). Guideline for the prevention and control of norovirus gastroenteritis outbreaks in healthcare settings. Retrieved from https://www.cdc.gov/infectioncontrol/pdf/guidelines/norovirus-guidelines.pdf

Murthy, R., Bearman, G., Brown, S., Bryant, K., Chinn, R., Hewlett, A., George, B.G.,…Weber, D.J. (2015). Animals in healthcare facilities: Recommendations to minimize potential risks. Infection Control and Hospital Epidemiology, 36(5), 495-516.

National Health and Medical Research Council. (2019). Australian guidelines for the prevention and control of infection in healthcare. Retrieved from https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019#block-views-block-file-attachments-content-block-1

National Health and Medical Research Council. (2013). Staying healthy: Preventing infectious diseases in early childhood education and care services – Recommended minimum exclusion periods. Retrieved from https://www.nhmrc.gov.au/about-us/publications/staying-healthy-preventing-infectious-diseases-early-childhood-education-and-care-services#block-views-block-file-attachments-content-block-1

NSW Government. (2019). Creutzfeldt-Jakob disease (CJD) control guidelines. Retrieved from https://www.health.nsw.gov.au/Infectious/controlguideline/Pages/cjd.aspx

NSW Government. (2013). Guidelines for bringing occasional food for patients. Retrieved from https://www.cclhd.health.nsw.gov.au/wpcontent/uploads/Guidelines_for_Bringing_Occasional_Food_to_Patients.pdf

NSW Government. (2017). Infection prevention and control policy. Retrieved from https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2017_013.pdf

NSW Government. (2018). Legionella control in cooling water systems: NSW health guidelines. Retrieved from https://www.health.nsw.gov.au/environment/legionellacontrol/Publications/guidelines-legionella-control.pdf

NSW Government. (2015). Water – Requirements for the provision of cold and heated water. Retrieved from https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2015_008.pdf

Queensland Health. (2019). Guidelines for infection control in health care facilities. Retrieved from https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/diseases-infection/infection-prevention/management-plans-guidance/guidelines

Ryan, K., Havers, S., Olsen, K., & Grayson, M.L. (2018). 5 Moments for hand hygiene. Retrieved from https://www.hha.org.au/component/jdownloads/send/5-implementation/191-hha-manual

Simonds, A.K., Hanak, A., Chatwin, M., Morrell, M., Hall, A., Parker, K.H., Siggers, J.H., & Dickinson, R.J. (2010). Evaluation of droplet dispersion during non-invasive ventilation, oxygen therapy, nebuliser treatment and chest physiotherapy in clinical practice: Implications for management of pandemic influenza and other airborne infections. Health Technology Access, 14(46), 131-172.

Standards Australia. (2015). AS 4381:2015: Single-use face masks for use in health care. Sydney, NSW: SAI Global.






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Standards Australia. (2015). AS/NZS 3500.4:2015: Plumbing and drainage – Heated water systems. Sydney, NSW: SAI Global.

Standards Australia. (2014). AS/NZS 4187:2014: Reprocessing of reusable medical devices in health service organizations. Sydney, NSW: SAI Global.

Standards Australia. (2012). AS/NZS 1716:2012: Respiratory protective devices. Sydney, NSW: SAI Global. Standards Australia. (2011). AS/NZS 3666:2011: Air-handling and water systems of buildings. Sydney, NSW: SAI

Global. Standards Australia. (2009). AS/NZS 1715:2009: Selection, use and maintenance of respiratory protective

equipment. Sydney, NSW: SAI Global. Standards Australia. (2004). AS/NZS 4032.3:2014: Water supply – Valves for the control of heated water supply

temperatures. Sydney, NSW: SAI Global. Standards Australia. (2004). HB 263:2004: Heated water systems. Sydney, NSW: SAI Global. Standards Australia. (2002). AS/NZS 3666.1:2002: Air-handling and water systems of buildings – Microbial

control. Sydney, NSW: SAI Global. Standards Australia. (2000). AS/NZS 4146:2000: Laundry practice. Sydney, NSW: SAI Global. The Association for Safe Aseptic Practice (ASAP). (2018). Aseptic non touch technique. Retrieved from

http://www.antt.org/ANTT_Site/about.html The Society for Healthcare Epidemiology of America. (2015). Infection control experts outline guidance for

animal visitations in hospitals. Retrieved from https://www.shea-online.org/index.php/journal-news/press-room/press-release-archives/235-infection-control-experts-outline-guidance-for-animal-visitations-in-hospitals

Victorian Department of Health. (2011). Cleaning standards for Victorian health facilities. Melbourne, VIC: Department of Health.

Victorian Department of Health. (2014). Infection control principles for the management of construction renovation repairs and maintenance within health care facilities. Retrieved from https://www2.health.vic.gov.au/about/publications/policiesandguidelines/Infection-Control-Principles-for-the-Management-of-Construction-Renovation-Repairs-and-Maintenance-within-Health-Care-Facilities

World Health Organization. (2009). Infection prevention and control during health care for confirmed, probable, or suspected cases of pandemic (H1N1) 2009 virus infection and influenza-like illnesses. Retrieved from https://www.who.int/csr/resources/publications/cp150_2009_1612_ipc_interim_guidance_h1n1.pdf

World Health Organization. (2012). Prevention of hospital-acquired infections: A practical guide (2nd edn). Retrieved from http://apps.who.int/medicinedocs/documents/s16355e/s16355e.pdf

World Health Organization. (2009). WHO guidelines on hand hygiene in health care. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf;jsessionid=F7A1FEB026BFD583104DAF3ECA687746?sequence=1

20. Search Terms Alcohol Based Hand Rub: Alcohol containing preparation designed for application to the hands in order to

reduce the number of viable micro-organisms with maximum efficacy and speed. Burkholderia cepacia: A bacterium that is often found in the sputum of people with Cystic fibrosis or chronic

lung conditions. Clean: Instruments and equipment are clean to the naked eye (macroscopic) and free from visible soil, protein

residue and other stains Cleaning: The removal of all foreign material from objects, such as soil/organic material, and the reduction in

the number of microorganisms from a surface. Cleaning is normally done with water, mechanical action and detergent.






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Cohorting: Placing patients together in the same room who are infected or colonised with the same pathogen and are suitable roommates.

Colonisation: The presence, growth and multiplication of micro-organisms without observable clinical signs or symptoms of infection.

Contact Precautions: A set of practices used to prevent transmission of infectious agents that are spread by direct or indirect contact with the patient or the patient’s environment.

Carbapenem Resistant Enterobacteraciae (CRE): Bacteria in the Enterobacteraciae family (e.g. E.coli, that are resistant to Carbapenem antibiotics)

Critical Item: Instruments should be sterile at the time of use, at entry into sterile tissue, cavity or blood stream.

Disinfection: The inactivation of non-sporing microorganisms using either thermal (heat alone, or heat and water) or chemical means

Food Handler: Anyone who works in a food business or a service preparing food for others and who either handles food or surfaces that are likely to be in contact with food such as cutlery and crockery.

Hand Hygiene: A process that reduces the number of micro-organisms on hands. Hand hygiene is a general term applying to the use of soap solution (non-anti-microbial or anti-microbial) and water or water-less antimicrobial agent to the surface of the hands (e.g. alcohol based hand rub).

Healthcare Associated Infection: Infections that originate from, or are related to, a healthcare setting or the delivery of healthcare.

Health Care Worker: Persons who work in healthcare settings (including students, trainees and voluntary workers) whose activities normally involve patient/client care and/or contact with blood or body fluids.

Infection: The invasion of the body by pathogenic microorganisms that reproduce and multiply causing disease. Multi-Resistant Organisms (MRO): Bacteria resistant to one or more classes of antimicrobial agents and usually

resistant to all but one or two commercially available antimicrobial agents. Methicillin Resistant Staphylococcus aureus (MRSA): A type of Staphylococcus aureus bacteria that are resistant

to all beta lactam antibiotics (e.g. Penicillin) and often other classes of antibiotics. Noncritical Items: An instrument or equipment that is in contact with intact skin. Cleaning alone is generally

sufficient for all non-critical items after every individual use, although either intermediate or low level disinfection may be appropriate in specific circumstances.

Perianal: Pertaining to the area around the anus. Semi-Critical Item: Instruments or equipment are in contact with intact non-sterile mucosa or non-intact skin.

These instruments should be single use or sterilised after each use. If this is not possible, high level disinfection is the minimum level of reprocessing that is acceptable

Sterilisation: Complete destruction of all microorganisms including spores by means of heat, gas, steam and / or irradiation

Surveillance: Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making.

Vancomycin Resistant Enterococci (VRE): Species of Enterococci bacteria that are resistant to the antibiotic Vancomycin.