A nurse is reviewing the results of routine laboratory tests performed as part of a clients annual

There are around 200,000 healthcare-associated infections (HAIs) in Australian acute healthcare facilities each year. This makes HAIs the most common complication affecting patients in hospital. As well as causing unnecessary pain and suffering for patients and their families, these adverse events prolong hospital stays and are costly to the health system.

Understanding the modes of transmission of infectious organisms and knowing how and when to apply the basic principles of infection prevention and control is critical to the success of an infection control program. This responsibility applies to everybody working and visiting a healthcare facility, including administrators, staff, patients and carers.

Successful approaches for preventing and reducing harms arising from HAIs involve applying a risk-management framework to manage 'human' and 'system' factors associated with the transmission of infectious agents. This approach ensures that infectious agents, whether common (for example, gastrointestinal viruses) or evolving (for example, influenza or multi-resistant organisms [MROs]), can be managed effectively.

These guidelines provide recommendations that outline the critical aspects of infection prevention and control. The recommendations were developed using the best available evidence and consensus methods by the Infection Control Steering Committee. They have been prioritised as key areas to prevent and control infection in a healthcare facility. It is recognised that the level of risk may differ according to the different types of facility and therefore some recommendations should be justified by risk assessment. When implementing these recommendations all healthcare facilities need to consider the risk of transmission of infection and implement according to their specific setting and circumstances.

The Process Report is available at Appendix 2 of the guideline.

Clinical Educators Guide for the Prevention and Control of Infection in Healthcare

This Clinical Educators Guide for the prevention and control of infection in healthcare has been developed to provide strategies for clinical educators and supervisors to assist students and graduate healthcare workers integrate a risk management approach into their daily tasks/duties that involve infection prevention and control. The Guide aims to ensure students, and new graduates:

• are aware of the issue of healthcare associated infections in Australia
• understand the chain of infection and the different modes of transmission of infection in healthcare
• have a basic understanding of a risk management approach to infection prevention and control
• are able to identify potential risk for transmission of infection in the delivery of healthcare and decide what measures they should implement.

The Guide should be used in conjunction with the Australian Guidelines for the prevention and control of infection in health care (2010) and its key recommendations, as well as the healthcare facility's infection control orientation program.

Consumer fact sheets to support this guideline

These consumer factsheets have been developed to support the messages on healthcare associated infection contained in the NHMRC Australian Guidelines for the prevention and control of infection in healthcare (2010). The factsheets aim to inform patients, visitors, families and carers about healthcare associated infection, what activities healthcare facilities may have in place to make sure infections are prevented as much as possible, and what they can do to limit the spread of infections.

There are specific factsheets on the Methicillin resistantStaphylococcus aureus, Vancomycin Resistant Enterococci and Clostridium difficile.

Information on infection control issues relating to Creutzfeldt Jacob disease (CJD)

Information on infection control issues relating to Creutzfeldt Jacob disease (CJD) and in particular the reprocessing of reusable medical instruments, is beyond the scope of this guideline. Please refer to the Department of Health website.

Acknowledgements

Infection Control Guidelines Steering Committee

The production of a document such as this requires a considerable effort over a long period. Special thanks and acknowledgment are due to the Infection Control Guidelines Steering Committee members for their generous donation of time, their technical advice and ongoing commitment to the project.

• Dr Ann Koehler (Chair)
• Prof Chris Baggoley
• Clinical Prof Keryn Christiansen
• Dr Liz Coates
• Prof Peter Collignon
• Dr Celia Cooper
• Dr Nick Demediuk
• Ms Sylvia Gandossi
• A/Prof Tom Gottlieb
• Mr Brett Mitchell
• Assoc Prof Peter Morris
• Ms Claire Boardman

NHMRC – ICG Project Team, Canberra

• Tanja Farmer
• Stephanie Goodrick
• Cathy Mitchell
• Kay Currie

Technical writers – Ampersand Health Science Writing

• Elizabeth Hall
• Jenny Ramson

Australian Commission on Safety and Quality in Health Care

• Marilyn Cruickshank
• Sue Greig
• Susanne Panasko

Disclaimer

This document aims to combine a review of the best available evidence with current clinical and expert practice. It is designed to provide information based on the best evidence available at the time of publication to assist in decision-making. The members of the Infection Control Guidelines Steering Committee, the Australian Commission for Safety and Quality in Health Care and the National Health and Medical Research Council give no warranty that the information contained in this document and any online updates available on the NHMRC website is correct or complete.

Infection prevention and control guidelines are necessarily general and are not intended to be a substitute for a healthcare professional's judgment in each case. The members of the Infection Control Guidelines Steering Committee, the Australian Commission for Safety and Quality in Health Care and the National Health and Medical Research Council shall not be liable for any loss whatsoever whether due to negligence or otherwise arising from the use of or reliance on this document.

Summary of recommendations

These guidelines provide recommendations that outline the critical aspects of infection prevention and control. The recommendations were developed using the best available evidence and consensus methods by the Infection Control Steering Committee.[1] They have been prioritised as key areas to prevent and control infection in a healthcare facility. It is recognised that the level of risk may differ according to the different types of facility and therefore some recommendations should be justified by risk assessment. When implementing these recommendations all healthcare facilities need to consider the risk of transmission of infection and implement according to their specific setting and circumstances.

The recommendations should be read in the context of the evidence base. This is discussed in Sections B1, B2 and B3, which also include advice on the practical application of the recommendations. Table 1 lists recommendations and the section of the guidelines in which they are discussed.

Finding information

These recommendations provide the basis for appropriate infection prevention and control practice in the healthcare setting. Practical guidance on their implementation is given in Part B of these guidelines. Table 2 provides a directory for this guidance.

Table 2: Directory of key information in these guidelines

(table or link list??? See page 4 - 5 of PDF)

Introduction

Effective infection prevention and control is central to providing high quality health care for patients and a safe working environment for those that work in healthcare settings.

Healthcare-associated infection is preventable

There are around 200,000 healthcare-associated infections (HAIs) in Australian acute healthcare facilities each year [2]. This makes HAIs the most common complication affecting patients in hospital. As well as causing unnecessary pain and suffering for patients and their families, these adverse events prolong hospital stays and are costly to the health system. The problem does not just affect patients and workers in hospitals—HAIs can occur in any healthcare setting, including office-based practices (for example, general practice clinics, dental clinics) and long-term care facilities (see Glossary). Any person working in or entering a healthcare facility is at risk. However, healthcare- associated infection is a potentially preventable adverse event rather than an unpredictable complication. It is possible to significantly reduce the rate of HAIs through effective infection prevention and control.

Infection prevention and control is everybody's business

Understanding the modes of transmission of infectious organisms and knowing how and when to apply the basic principles of infection prevention and control is critical to the success of an infection control program. This responsibility applies to everybody working and visiting a healthcare facility, including administrators, staff, patients and carers.

Successful approaches for preventing and reducing harms arising from HAIs involve applying a risk-management framework to manage 'human' and 'system' factors associated with the transmission of infectious agents. This approach ensures that infectious agents, whether common (for example, gastrointestinal viruses) or evolving (for example, influenza or multi-resistant organisms [MROs]), can be managed effectively.

Development of the guidelines

As part of the Australian Commission on Safety and Quality in Health Care's (ACSQHC) HAIs priority program, the National Health and Medical Research Council (NHMRC) was asked to develop national guidelines that would provide a coordinated approach to the prevention and management of HAI. The NHMRC appointed an expert group to guide the development process (Steering Committee membership and terms of reference are given in Appendix 1). The guidelines are based on the best available evidence. They build on existing guidelines and reviews, as well as systematic reviews of the evidence.

Aim

By assisting healthcare workers to improve the quality of the care they deliver, these guidelines aim to promote and facilitate the overall goal of infection prevention and control:

The creation of safe healthcare environments through the implementation of practices that minimise the risk of transmission of infectious agents.

Scope

The scope of these guidelines was established, following an initial period of consultation that included forums involving a wide range of stakeholders (see Appendix 2).

The guidelines were developed to establish a nationally accepted approach to infection prevention and control, focusing on core principles and priority areas for action. They provide a basis for healthcare workers and healthcare facilities to develop detailed protocols and processes for infection prevention and control specific to local settings.

This approach is underpinned by a risk-management framework to ensure the basic principles of infection prevention and control can be applied to a wide range of healthcare settings including office-based practice, long-term care facilities, remote area health services, home and community nursing and emergency services.

The evidence base for the guidelines addresses the highest level of risk of infection transmission in the healthcare setting, and has predominantly been drawn from the acute-care setting. However, case studies giving examples of risk assessments have been included to help illustrate how these recommendations can be applied to other settings.

Supporting documents have been developed for healthcare workers, patients and health facility managers to assist with implementation of the guidelines. These materials will be available on the NHMRC website.

The guidelines make reference to but do not include detailed information on:

• infectious diseases
• pandemic planning
• the reprocessing of reusable medical instruments or devices
• occupational health and safety
• hospital hotel services such as food services, laundry services or waste disposal
• engineering/health facility design.

The guidelines do not duplicate information provided in existing Australian Standards but refer to specific standards wherever relevant.

Target audience

The guidelines are for use by all those working in healthcare—this includes healthcare workers, management and support staff.

Evidence base

These guidelines are based on the best available evidence and knowledge of the practicalities of clinical procedures. They draw from other work in this area, including the two previous national infection control guidelines,[3] international infection control guidelines, systematic literature reviews conducted to inform the development of these guidelines, work on HAI prevention from ACSQHC, national discipline-based infection control guidelines, and Australian Standards relevant to infection prevention and control. Australian data are used wherever available.

Limitations of the grading process as it applies to the practice of infection control

The recommendations in these guidelines were formulated by the Infection Control Steering Committee through a process of consensus. Recommendations are given when an action is deemed critical to preventing or managing infection. Recommendations are graded according to the revised NHMRC gradings for assessing evidence, with the addition of good practice points, which outline actions that are essential to infection prevention and control but where evidence grades cannot be applied.

In many areas of infection prevention and control, the evidence may be limited by the inability to conduct certain study designs that are difficult to implement in real practice. This has implications for the level of grading that is assigned to the recommendations, since grading systems will tend to favour study designs that are sometimes not feasible or ethical to conduct in infection control settings, such as randomised controlled trials. For example, it is unethical to compare the incidence of infection related to surgical instruments by allocating one patient group to have sterilised instruments used on them and one patient group to have non-sterile instruments used on them. This may result in a lower grading due to the available evidence but sterilisation of surgical instruments is universally deemed critical to infection control.

Given that there is limited evidence available to support many routine practices intended to reduce infection risk, practice is based on decisions made on scientific principles. Some activities, such as performing hand hygiene between administering care to successive patients, have a credible history to support their routine application in preventing cross-infection. Others, such as some uniform and clothing requirements, have more to do with the ethos of quality care and workplace culture than with a proven reduction of cross-infection.

It is not acceptable to discontinue practices for which there is a solid scientific basis, even if the level of evidence is not high. Rather, routine practices should continue unless there is sufficient evidence to support alternative procedures. Continuing research is needed to keep evaluating practice, to identify evidence gaps and promote research in these areas, and to ensure that poor practices do not continue.

The ICG Steering Committee also assigned additional 'grade' referred to as a good practice point (GPP).

Structure of the guidelines

These guidelines are based around the following core principles:

• an understanding of the modes of transmission of infectious agents and of risk management
• effective work practices that minimise the risk of transmission of infectious agents
• governance structures that support the implementation, monitoring and reporting of infection prevention and control work practices
• compliance with legislation, regulations and standards relevant to infection control.

The parts of the document are based on these core principles and are organised according to the likely readership.

Part A presents background information that should be read by everyone working in health care (for example as orientation or as part of annual review) – this includes important basics of infection prevention and control, such as the main modes of transmission of infectious agents and the application of risk-management principles. This part of the guidelines does not include recommendations.

Part B is specific to the practice of healthcare workers and support staff, and outlines effective work practices that minimise the risk of transmission of infectious agents. Recommendations are given in Sections B1 to B3. Each section includes advice on putting the recommendations into practice, a risk-management case study and resources.

• Section B1 describes standard precautions used at all times to minimise the risk of transmission of infectious agents
• Section B2 outlines transmission-based precautions to guide staff in the presence of suspected or known infectious agents that represent an increased risk of transmission
• Section B3 outlines approaches to the management of multi-resistant organisms (MROs) or outbreak situations
• Section B4 outlines processes for risk identification and the application of standard and transmission-based precautions for certain procedures
• Section B5 includes supplementary information to assist in the application of standard and transmission-based precautions.

Part C describes the responsibilities of management of healthcare facilities, including governance structures that support the implementation, monitoring and reporting of effective work practices.

The chapters outline the main components of a systems approach to facility-wide infection prevention and control, giving guidance on management and staff responsibilities, protection of healthcare workers, requirements for education and training of all staff, considerations for facility design and renovation, and other important activities such as surveillance and antibiotic stewardship.

Legislation, regulations and standards relevant to infection prevention and control are listed at the end of each section before the references.

The appendices provide additional information on the guideline development process.

Key information is highlighted in the guidelines as follows.

Case studies illustrate the application of risk-management principles (Sections B1, B2 and B3) and measures to support good practice (Part C)

Table 6 summarises the key topics discussed in the document.

PART A: BASICS OF INFECTION PREVENTION AND CONTROL

Summary

• Healthcare-associated infections (HAIs) can occur in any healthcare setting. While the specific risks may differ, the basic principles of infection prevention and control apply regardless of the setting.
• In order to prevent HAIs, it is important to understand how infections occur in healthcare settings and then institute ways to prevent them. Risk management is integral to this approach.
• If effectively implemented, the two-tiered approach of standard and transmission-based precautions recommended in these guidelines provides high-level protection to patients, healthcare workers and other people in healthcare settings.
• Infection prevention and control is integral to clinical care and the way in which it is provided. It is not an additional set of practices.
• Involving patients and their carers is essential to successful clinical care. This includes ensuring that patients' rights are respected at all times, that patients and carers are involved in decision-making about care, and that they are sufficiently informed to be able to participate in reducing the risk of transmission of infectious agents.

The information presented in this part is relevant to everybody employed by a healthcare facility, including management, healthcare workers and support service staff.

A1: Infection prevention and control in the healthcare setting

Summary

• Infectious agents (also called pathogens) are biological agents that cause disease or illness to their hosts. Many infectious agents are present in healthcare settings.
• Infection requires three main elements – a source of the infectious agent, a mode of transmission and a susceptible host.
• Patients and healthcare workers are most likely to be sources of infectious agents and are also the most common susceptible hosts. Other people visiting and working in health care may also be at risk of both infection and transmission. In some cases, HAIs are serious or even life threatening.
• In healthcare settings, the main modes for transmission of infectious agents are contact (including bloodborne), droplet and airborne.

A1.1: Risks of contracting a healthcare-associated

Most infectious agents are microorganisms. These exist naturally everywhere in the environment, and not all cause infection (for example, 'good' bacteria present in the body's normal flora). Several classes of microorganism—including bacteria, viruses, fungi, parasites and prions—can be involved in either colonisation or infection, depending on the susceptibility of the host:

• With colonisation, there is a sustained presence of replicating infectious agents on or in the body, without the production of an immune response or disease.
• With infection, invasion of infectious agents into the body results in an immune response, with or without symptomatic disease.

Transmission of infectious agents within a healthcare setting requires the following elements:

• a source or reservoir of infectious agents
• a mode of transmission
• a susceptible host.

Chain of infection

Infectious agents transmitted during health care come primarily from human sources, including patients, healthcare workers and visitors. Source individuals may be actively ill, may have no symptoms but be in the incubation period of a disease, or may be temporary or chronic carriers of an infectious agent with or without symptoms. Other sources of transmission include:

• endogenous flora of patients (for example, bacteria residing in the respiratory or gastrointestinal tract)
• environmental sources such as air, water, medications or medical equipment and devices that have become contaminated.

Infection is the result of a complex interrelationship between a host and an infectious agent and people vary in their response to exposure to an infectious agent:

• some people exposed to infectious agents never develop symptomatic disease while others become severely ill and may die
• some individuals may become temporarily or permanently colonised but remain asymptomatic
• others progress from colonisation to symptomatic disease either soon after exposure, or following a period of asymptomatic colonisation.

Important predictors of an individual's outcome after exposure include his or her:

• immune status at the time of exposure (including whether immune status is compromised by medical treatment such as immunosuppressive agents or irradiation)
• age (for example, neonates and elderly patients are more susceptible)
• health status (for example, when a patient has other underlying disease such as diabetes or is a smoker);
• the virulence of the agent
• other factors that increase the risk of transmission of infection (for example, undergoing surgery, requiring an indwelling device such as a catheter, or remaining in hospital for lengthy periods).

Factors influencing healthcare-associated infection

In healthcare settings, the most common susceptible hosts are patients and healthcare workers.

• Patients may be exposed to infectious agents from themselves (endogenous infection) or from other people, instruments and equipment, or the environment (exogenous infection). The level of risk relates to the healthcare setting (specifically, the presence or absence of infectious agents), the type of healthcare procedures performed and the susceptibility of the patient.
• Healthcare workers may be exposed to infectious agents from infected or colonised patients, instruments and equipment, or the environment. The level of risk relates to the type of clinical contact healthcare workers have with potentially infected or colonised patient groups, instruments or environments, and the health status of the healthcare worker (for example, immunised or immunocompromised).

In healthcare settings, the main modes of transmission of infectious agents are contact (including bloodborne), droplet and airborne. The modes of transmission vary by type of organism. In some cases the same organism may be transmitted by more than one route (for example, norovirus, influenza and respiratory syncytial virus [RSV] can be transmitted by contact and droplet routes).

A1.1.1 Routes of transmission

Contract transmission

Contact is the most common mode of transmission, and usually involves transmission by touch or via contact with blood or body substances. Contact may be direct or indirect.

• Direct transmission occurs when infectious agents are transferred from one person to another – for example, a patient's blood entering a healthcare worker's body through an unprotected cut in the skin.
• Indirect transmission involves the transfer of an infectious agent through a contaminated intermediate object or person—for example, a healthcare worker's hands transmitting infectious agents after touching an infected body site on one patient and not performing hand hygiene before touching another patient, or a healthcare worker coming into contact with fomites (for example, bedding) or faeces and then with a patient.

Examples of infectious agents transmitted by contact include multi-resistant organisms (MROs), Clostridium difficile, norovirus and highly contagious skin infections/infestations (for example, impetigo, scabies).

Droplet transmission

Droplet transmission can occur when an infected person coughs, sneezes or talks, and during certain procedures. Droplets are infectious particles larger than 5 microns in size.[6] Respiratory droplets transmit infection when they travel directly from the respiratory tract of the infected person to susceptible mucosal surfaces (nasal, conjunctivae or oral) of another person, generally over short distances. Droplet distribution is limited by the force of expulsion and gravity and is usually at least 1 metre. However, droplets can also be transmitted indirectly to mucosal surfaces (for example, via hands).

Examples of infectious agents that are transmitted via droplets include influenza virus and meningococcus.

Airborne transmission

Airborne dissemination may occur via particles containing infectious agents that remain infective over time and distance. Small-particle aerosols are created during breathing, talking, coughing or sneezing and secondarily by evaporation of larger droplets in conditions of low humidity. Certain procedures, particularly those that induce coughing, can promote airborne transmission. These include diagnostic sputum induction, bronchoscopy, airway suctioning, endotracheal intubation, positive pressure ventilation via face mask and high-frequency oscillatory ventilation. Aerosols containing infectious agents can be dispersed over long distances by air currents (for example, ventilation or air conditioning systems) and inhaled by susceptible individuals who have not had any contact with the infectious person. These small particles can transmit infection into small airways of the respiratory tract.

Examples of infectious agents that are transmitted via the airborne route include measles (rubeola) virus, chickenpox (varicella) virus and M. tuberculosis.

Other modes of transmission

Transmission of infection can also occur via common sources such as contaminated food, water, medications, devices or equipment.

A1.2 Standard and transmission-based precautions

Successful infection prevention and control involves implementing work practices that prevent the transmission of infectious agents through a two-tiered approach including:

• routinely applying basic infection prevention and control strategies to minimise risk to both patients and healthcare workers, such as hand hygiene, personal protective equipment, cleaning and appropriate handling and disposal of sharps (standard precautions)
• effectively managing infectious agents where standard precautions may not be sufficient on their own—these specific interventions control infection by interrupting the mode of transmission (transmission-based precautions; formerly referred to as additional precautions).

If successfully implemented, standard and transmission-based precautions prevent any type of infectious agent from being transmitted.

A1.2.1 Standard precautions

All people potentially harbour infectious agents. Standard precautions refer to those work practices that are applied to everyone, regardless of their perceived or confirmed infectious status and ensure a basic level of infection prevention and control. Implementing standard precautions as a first-line approach to infection prevention and control in the healthcare environment minimises the risk of transmission of infectious agents from person to person, even in high-risk situations.

Standard precautions are used by healthcare workers to prevent or reduce the likelihood of transmission of infectious agents from one person or place to another, and to render and maintain objects and areas as free as possible from infectious agents. Guidance on implementing standard precautions is given in Sections B1 and B5.

A1.2.2 Transmission-based precautions

Any infection prevention and control strategy should be based on the use of standard precautions as a minimum level of control. Transmission-based precautions are recommended as extra work practices in situations where standard precautions alone may be insufficient to prevent transmission. Transmission-based precautions are also used in the event of an outbreak (for example, gastroenteritis), to assist in containing the outbreak and preventing further infection.

Transmission-based precautions should be tailored to the particular infectious agent involved and its mode of transmission. This may involve a combination of practices.

Guidance on when and how to implement transmission-based precautions is given in Sections B2, B3 and B5.

A2 Overview of risk management in infection prevention and control

Summary

• Identifying and analysing risks associated with health care is an integral part of successful infection prevention and control.
• Adopting a risk-management approach at all levels of the facility is necessary. This task requires the full support of the facility's management as well as cooperation between management, healthcare workers and support staff.
• Differing types and levels of risk exist in different healthcare settings. In developing local policies and procedures, each healthcare facility should conduct its own risk assessment (that is, how to avoid, identify, analyse, evaluate and treat risks in that setting), and also refer to discipline-specific guidance where relevant.

A2.1 Risk management basics

In the context of these guidelines, 'risk' is defined as the possibility of acquisition or infection of patients or healthcare workers arising from activities within a healthcare facility. Risk management is the basis for preventing and reducing harms arising from healthcare-associated infection. A successful approach to risk management occurs on many levels within a healthcare facility:

• facility wide—for example, providing support for effective risk management through an organisational risk-management policy, staff training, follow-up of outcomes and monitoring and reporting
• ward or department based—for example, embedding risk management into all policies so that risks are considered in every situation
• individual—for example, considering the risks involved in carrying out a specific procedure and questioning the necessity of the procedure as part of clinical decision-making, attending education sessions (for example, hand hygiene or respirator fit testing).

As healthcare settings differ greatly in their day-to-day function, it is not possible to provide a one size fits all approach to risk management. Even within a single setting (for example, primary care), increasingly complex care is delivered by a range of health professionals with diverse qualifications and training. All healthcare facilities need to be able to determine the risks in their own context and select the appropriate course of action. Therefore it is necessary for facilities to regularly conduct infection prevention risk assessments within their facility and ensure that all staff understand their responsibility in managing these risks.

The Australian/New Zealand Standard on Risk Management AS/NZS ISO 31000:2009 outlines a stepwise approach to risk management that allows continuous quality improvement and involves:

• establishing context—identifying the basic parameters in which risk must be managed (for example, the type of health facility, the extent of and support for the facility's infection prevention and control program)
• avoiding risk —establishing whether there is a risk and whether potential risk can be averted (for example, by questioning whether a procedure is necessary)
• identifying risks—a systematic and comprehensive process that ensures that no potential risk is excluded from further analysis and treatment (for example, using root cause analysis)
• analysing risks—considering the sources of risk, their consequences, the likelihood that those consequences may occur, and factors that affect consequences and likelihood (for example, existing controls) (see risk analysis matrix below)
• evaluating risks—comparing the level of risk found during the analysis process with previously established risk criteria and assessing available options for ease of implementation and impact, resulting in a prioritised list of risks for further action
• treating risks—implementing appropriate management options for dealing with identified risk (for example, modifying procedures, protocols or work practices; providing education; and monitoring compliance with infection prevention and control procedures).

Monitoring and review is an essential component of the risk-management process. This ensures that:

• new risks are identified
• analysis of risk is verified against real data, if possible
• risk treatment is implemented effectively.

Communication and consultation are also key elements of clinical risk management. An interactive exchange of information between management, healthcare workers, patients and other stakeholders provides the basis for increased awareness of the importance of infection prevention and control, identification of risks before they arise and prompt management of risks as they occur.

A2.2 Risk management process

The following flowchart outlines key considerations during the process of risk management in the context of infection prevention and control in the healthcare setting.

Risk-management flowchart

The following case study gives an example of applying the risk-management process in a primary care setting. Case studies giving examples of how to use this process in primary, acute and longterm care settings, including relevant considerations in specific situations, are included in Part B. While the basic process of risk management applies regardless of setting, all healthcare facilities should develop risk-management policies and procedures that are appropriate to the setting.

Case study: measles (rubeola) virus outbreak

State health authorities notify a general practice of an outbreak of measles, and will assist the practice with advice about management of potential exposures.

Communicate and consult

• Information about the outbreak is communicated to clinicians and practice staff.
• Collaboratively, protocols and procedures are formulated to implement at the practice if there is a presentation of measles (see below).
• Communication occurs between clinicians, managers and reception staff to ensure that all understand why protocols and procedures are in place and that there is a clear understanding of how to apply them.

Establish context

In developing protocols and procedures, consideration is given to the following questions:

• Are there members of the practice community likely not to be immunised against measles or at risk (for example, young children, recent migrants)?
• Is this an area where uptake of immunisation low due to issues of access or acceptance?
• What aspects of the practice offer the opportunity for the transmission of measles infection?

Identify risks

Consideration is given to how measles might be transmitted within the practice:

• What can happen? This includes the range of activities undertaken at the facility and that are associated with the airborne transmission of measles.
• Where and when? The primary risk is exposure of non-immune patients to infectious patients in the waiting room or contact with non-immune staff.
• How and why? The infection can be transmitted to any susceptible person breathing the same air as an infectious patient for up to 2 hours after the patient has left the area.
• Failure to ensure that all staff members are vaccinated/ immune, and inadequate use of PPE by non-immune staff.

Analyse risks

• Facility staff members consider and discuss the consequences and likelihood of transmission of infection in their particular setting.
• Using the risk analysis matrix above, the risks associated with the measles outbreak are assessed as high, requiring immediate action.

Note that in other settings, outcomes of the analysis may reveal a lower level of risk (for example, if there is sufficient herd immunity in the community to not pose a risk) or a higher level of risk (for example, if there are insufficient resources to manage airborne precautions and triage of patients).

Evaluate risks

• Consideration given to which risks can be managed and which cannot be tolerated using an ease of impact analysis—this involves examining the measures that can be implemented and the ease of implementing and impact of each measure (see examples below).
• Priority is given to the activities that are the simplest to do and have the greatest impact but does not exclude activities that are hard to do if their impact is high.

Note that priority must be given to activities that address risks that are high and which have a potentially catastrophic outcome.

Treat risks

• A sign is placed on the door advising patients who suspect they may have measles to phone before entering the practice, so that the doctor can see them in their home, or they can be put into a separate waiting area where they will not mix with other patients.
• Patient information is displayed at reception warning about suspected measles cases.
• Respiratory etiquette is encouraged and alcohol-based hand rub dispenser placed in waiting and consultation rooms (this is good practice but will not reduce transmission of measles).
• Additional education is provided for staff on measles identification and management.
• At-risk staff identified, vaccinated, and requested to wear a P2 respirator for which they have been fit-tested (see B2.4.3).
• Uptake of patient and staff immunisation against measles is encouraged; staff vaccination policy established.

Monitor and review

Mechanisms are implemented to ensure early awareness of notifications from public health authorities to assist in the early implementation of additional infection control measures.

Source: Adapted from RACGP (2006) Infection Control Standards for Office-Based Practices (4th edition).

A3. A patient-centred approach

Summary

• A patient-centred health system is known to be associated with safer and higher quality care.
• A two-way approach that encourages patient participation is essential to successful infection prevention and control.

A3.1 Patient-centred health care

People receiving healthcare increasingly expect to be given information about their condition and treatment options and this extends to their rights and responsibilities as users of healthcare services. Although patient satisfaction with health services in Australia is generally high, patients' experiences are not always valued and their expectations are not always met. While this does not necessarily lead to poor outcomes for the individuals concerned, the best possible outcomes are more likely where patient-centred health care is a priority of the healthcare facility and a strong and consistent effort is made to respect patients' rights and expectations.

The ACSQHC has developed an Australian Charter of Healthcare Rights,[8] which recognises that people receiving care and people providing care all have important parts to play in achieving healthcare rights. The Charter allows patients, families, carers and services providing health care to share an understanding of the rights of people receiving health care. The Charter stipulates that all Australians have the right to:

• access services that address their healthcare needs
• receive safe and high quality health services, provided with professional care, skill and competence
• receive care that shows respect to them and their culture, beliefs, values and personal characteristics
• receive open, timely and appropriate communication about their health care in a way they can understand
• join in making decisions and choices about their care and about health service planning
• have their personal privacy and personal health and other information properly handled
• comment on or complain about their care and have their concerns dealt with properly and promptly.

Patient-centred care cannot just be 'added on' to usual care. The rights, experiences and views of patients should be at the centre of the care process and drive the way in which care is delivered. In most healthcare facilities, a significant culture change is necessary to embed patient-centred care principles into the philosophy and practices of the organisation. Healthcare workers and organisations need to acknowledge and understand the Charter of Healthcare Rights and work to ensure that patients' rights are integral to the care process.

A3.2 How does patient-centred care relate to infection prevention and control?

Infection prevention and control is ultimately about people. Effective infection prevention and control is central to providing high quality, patient-centred health care.

Putting patients at the centre of infection prevention and control and enabling them to participate in the care process is not just about explaining the risks of treatments, but involves considering patients' needs at every level. This ranges from designing the facility to maximise patient comfort and safety to having a range of processes to engage patients in their care and listen and act on their feedback as well as providing the patient with education and support so that they can be involved in looking after themselves.

To support a two-way approach to infection prevention and control and encourage the patient participation required to minimise cross-infection or transmission, it is important to:

• take patients' perspectives into account when developing policies and programs
• familiarise patients with the infection prevention and control strategies that are employed in healthcare facilities to protect them, the people caring for them and the healthcare environment
• discuss with patients the specific risks associated with their medical and/or surgical treatment
• encourage patients to disclose their health or risk status if there is a potential risk or source of infection to healthcare workers or others within the healthcare facility
• provide opportunities for patients to identify and communicate risks and encourage them to use feedback procedures for any concerns that they have about infection prevention and control procedures
• provide educational materials about infection prevention and control using a variety of media (for example, posters in waiting rooms, printed material and educational videos)
• inform patients about the protocols for protecting their privacy and confidentiality.

Specific guidance on providing patient-centred care is highlighted throughout the guidelines, in text boxes, in the 'Putting it into practice' section at the end of each chapter in Part B, and in each chapter of Part C.

PART B: STANDARD AND TRANSMISSION-BASED PRECAUTIONS

Summary

• The use of standard precautions is the primary strategy for minimising the transmission of healthcare-associated infections.
• Transmission-based precautions are used in addition to standard precautions, where the suspected or confirmed presence of infectious agents represents an increased risk of transmission.
• The application of transmission-based precautions is particularly important in containing multi-resistant organisms (MROs) and in outbreak management.
• Medical and dental procedures increase the risk of transmission of infectious agents. Effective work practices to minimise risk of transmission of infection related to procedures require consideration of the specific situation, as well as appropriate use of standard and transmission-based precautions.

The information presented in this part is particularly relevant to healthcare workers and support staff. It outlines effective work practices that minimise the risk of transmission of infectious agents.

Patient-care tip

In applying standard and transmission-based infection prevention and control strategies as part of day-to-day practice, healthcare workers should ensure that their patients understand why certain practices are being undertaken, and that these practices are in place to protect everyone from infection. Patients and visitors should also be aware of their role in minimising risks by following basic hand hygiene and respiratory hygiene and cough etiquette and informing staff about aspects of their care or services if necessary.

B1 Standard precautions

Summary

It is essential that standard precautions are applied at all times. This is because:

• people may be placed at risk of infection from others who carry infectious agents
• people may be infectious before signs or symptoms of disease are recognised or detected, or before laboratory tests are confirmed in time to contribute to care;
• people may be at risk from infectious agents present in the surrounding environment including environmental surfaces or from equipment
• there may be an increased risk of transmission associated with specific procedures and practices.

Standard precautions consist of:

• hand hygiene, before and after every episode of patient contact
• the use of personal protective equipment
• the safe use and disposal of sharps;
• routine environmental cleaning;
• reprocessing of reusable medical equipment and instruments
• respiratory hygiene and cough etiquette
• aseptic non-touch technique;
• waste management;
• appropriate handling of linen.

Standard precautions should be used in the handling of: blood (including dried blood); all other body substances, secretions and excretions (excluding sweat), regardless of whether they contain visible blood; non-intact skin; and mucous membranes.

Evidence supporting practice [9]

• World Health Organization (2009) Guidelines on Hand Hygiene in Health Care
• Boyce JM & Pittet D, Healthcare Infection Control Practices Advisory C, Force HSAIHHT (2002) Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 51: 1–45
• Grayson L, Russo P, Ryan K et al (2009) Hand Hygiene Australia Manual. Australian Commission for Safety and Quality in Healthcare and World Health Organization
• Pratt RJ, Pellowea CM, Wilson JA et al (2007) epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. J Hosp Infect 65S, S1–S64
• Siegel JD, Rhinehart E, Jackson M et al (Healthcare Infection Control Practices Advisory Committee), (2007) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. United States Centers for Disease Control and Prevention
• Sehulster LM & Chinn RYW (2003) Guidelines for Environmental Infection Control in Health-care Facilities. Recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Chicago IL: American Society for Healthcare Engineering/ American Hospital Association.

Importance of hand hygiene

These images illustrate the critical importance of hand hygiene in caring for patients, including those not known to carry antibiotic-resistant organisms. An imprint of a healthcare worker's ungloved hand was obtained after routine abdominal examination of a patient with no history of MRSA infection but found on routine surveillance to have MRSA colonisation. The resultant culture shows MRSA colonies (image on left). Another hand imprint obtained after the worker's hand had been cleaned with alcohol-based hand rub was negative for MRSA (image on right).

Source: Donskey CJ & Eckstein BC (2009).

Improved hand hygiene practices have been associated with:

• sustained decreases in the incidence of infections caused by MRSA and VRE (Webster et al 1994; Zafar et al 1995; Malik et al 1999; Larson et al 2000a; Pittet et al 2000; Pittet & Boyce 2001)
• reductions in healthcare-associated infections of up to 45% in a range of healthcare settings (Fendler et al 2002; Pittet et al 2000; Ryan et al 2001)
• greater than 50% reduction in the rates of nosocomial disease associated with MRSA and other multi-resistant organisms, after 1–2 years (Grayson et al 2009; Johnson et al 2005).

Hand hygiene practices alone are not sufficient to prevent and control infection and need to be used as part of a multifactorial approach to infection control.

This section discusses routine hand hygiene. Surgical hand preparation is discussed in Section B4.3.2.

B1.1.2 When should hand hygiene be performed?

Hands can become contaminated with infectious agents through contact with a patient, patient surroundings, the environment, or other healthcare workers. Cross-contamination can occur from one site to another in the same patient, between healthcare worker and patient, between patient or healthcare worker and the environment, or between healthcare workers. Practicing hand
hygiene before every episode of patient contact (including between caring for different patients and between different care activities for the same patient) and after any activity or contact that potentially results in hands becoming contaminated (such as removal of gloves) reduces the risk of cross-contamination.

The 5 moments for hand hygiene

The '5 moments for hand hygiene' developed by the World Health Organization (WHO 2009) and adopted by Hand Hygiene Australia (Grayson et al 2009):

• protect patients against acquiring infectious agents from the hands of the healthcare worker
• help to protect patients from infectious agents (including their own) entering their bodies during procedures
• protect healthcare workers and the healthcare surroundings from acquiring patients' infectious agents.

The 5 moments for hand hygiene

Source: Grayson et al (2009).

While Figure B1.2 illustrates application of the 5 moments in an acute-care setting, the 5 moments are still generally applicable to other healthcare settings including primary care. The key emphasis in any setting is to perform hand hygiene before and after any procedure, and after each consultation with a patient.

Recommendation

1 Routine hand hygiene - Grade B

Hand hygiene must be performed before and after every episode of patient contact. This includes:

• before touching a patient
• before a procedure
• after a procedure or body substance exposure risk
• after touching a patient;
• after touching a patient's surroundings.

Hand hygiene must also be performed after the removal of gloves.

In addition to the 5 moments, hand hygiene should be performed in a range of non-clinical situations (see Table B1.1).

Table B1.1: Non-clinical situations when hand hygiene should be performed

B1.1.3 What product should be used?

Existing guidelines (WHO 2009; Boyce & Pittet 2002; Pratt et al 2007; Canada Standards and Guideline Core Committee 2008; PIDAC 2008) and literature reviews (Pittet & Boyce 2001; Picheansathian 2004; Rotter 2004; Nicolay 2006; Larmer et al 2008; Grayson et al 2009) agree that hand hygiene using alcohol-based hand rubs is more effective against the majority of common infectious agents on hands than hand hygiene with plain or antiseptic soap and water.

One advantage of alcohol-based hand rubs is that they are easily accessible at point of care. They have (Grayson et al 2009):

• excellent antimicrobial activity against Gram-positive and Gram-negative vegetative bacteria, Mycobacterium tuberculosis and a wide range of fungi
• generally good antimicrobial activity against enveloped viruses
• lesser and/or variable antimicrobial activity against non-enveloped viruses (such as norovirus)
• no activity against protozoan oocysts and bacterial spores (such as C. difficile) (see Section B2.2).

The range of antimicrobial activity in alcohol-based hand rubs varies with the alcohol compound (ethanol, isopropanol or n‑propanol) used. Different alcohol species have different levels of activity (60% v/v n-propanol is approximately equivalent to 70% v/v isopropanol and to 80% v/v ethanol) and many commercial formulations consist of blends of different alcohol species. Most published clinical studies that have demonstrated reductions in HAIs with the use of alcohol-based hand rubs have been associated with products that contain at least 70% alcohol (isopropanol), 0.5% chlorhexidine and a skin emollient (Grayson et al 2009). However the efficacy of alcohol-based hand hygiene products is affected by a number of factors including the type of alcohol used, concentration of alcohol, contact time, volume of product used, and whether the hands are wet when the product is applied. These factors are generally assessed through testing standards for skin disinfectants, for which TGA is the regulatory body responsible for approving products for use in Australia.

Plain soaps act by mechanical removal of microorganisms and have no antimicrobial activity. They are sufficient for general social contact and for cleansing of visibly soiled hands. They are also used for mechanical removal of certain organisms such as C. difficile and norovirus.

When C. difficile and non-enveloped viruses are suspected or known to be present, use of alcohol-based hand rubs alone may not be sufficient to reduce transmission of these organisms. Alcohol-based hand rubs are effective at removing vegetative forms of C. difficile, but not effective at removing spores (Maiwald 2009). If gloves are worn during the care of patients in settings where C. difficile or non-enveloped viruses are suspected or known to be present, spore contamination of the hands will be minimal and alcohol-based hand rub remains the agent of choice for hand hygiene ( Johnson et al 1990; Jabbar et al 2010). [41, 42] However, if gloves have not been worn or
the hands are visibly soiled, they must be meticulously washed with soap and water and patted dry, to facilitate the mechanical removal of spores.

There is a tendency for antimicrobial soaps to be more effective than plain soaps, although the evidence around this is inconsistent. Antimicrobial soap is associated with skin care issues and it is not necessary for use in everyday clinical practice (Pratt et al 2001; Boyce & Pittet 2002; Pratt et al 2007.)

Neutral hand-wipe products may be considered in instances where hygienic access to soap and water is not readily available, such as in community care settings. Alcohol-based hand rubs are also suitable for use in resource-limited or remote areas with lack of accessibility to sinks or other facilities for hand hygiene (including clean water, towels etc.).

Choosing an alcohol-based handrub

It is necessary to choose products:

• that have excellent antimicrobial efficacy combined with good user acceptability and skin tolerability (dermal tolerance, fragrance, colour, texture and ease of use)
• that are TGA approved for skin antisepsis
• meet the requirements of EN1500 testing standard for bactericidal effect (which are currently referred to by TGA).

Healthcare worker acceptance of alcohol-based hand rub is a crucial factor in the success of any program to improve hand hygiene practice. Several studies showed that user acceptability and skin tolerability tend to be determined by the overall hand rub composition (for example, consistency as gel or rub, texture, fragrance) and by emollient additives, but both are largely independent of a formulation's antimicrobial activity (Rotter et al 1991; Kramer et al 2002a; Girard et al 2006; WHO 2009). Even where emollient agents are present in the product, ready access to a moisturising skin-care product is essential (see Section B1.1.5). The selected alcohol-based hand rubs, soaps and moisturising lotions should be chemically compatible, to minimise skin reactions and ensure that the decontaminating properties of the hand hygiene product are not deactivated. It is advisable to purchase hand hygiene and hand-care products from a range made by a single manufacturer, as this ensures compatibility between the products.

Different healthcare workers and healthcare settings have different preferences, and the choice between a gel or liquid needs to be evaluated on an individual basis (Maiwald & Widmer 2007; Pittet 2007). In some healthcare facilities, it may be useful to offer both liquid and gel alongside each other, in order to provide a choice that suits a wide range of healthcare workers (Pittet 2007; Traore et al 2007, Girard R et al 2006). Some studies have noted that gel formulations have generally significantly less antimicrobial activity than liquid alcohol-based hand rub formulations, even if the total alcohol content is similar (Pietsch 2001; Kramer et al 2002b; Picheansathian 2004).

The Hand Hygiene Australia Manual (Grayson et al 2009) outlines the following alcohol-based hand rub features as important in influencing acceptability, as well as ready accessibility at each bedside and in all patient-care areas:

• fragrance and colour—these may increase the initial appeal but may cause allergenic reactions, and are therefore discouraged
• emollient agent(s) in the alcohol-based hand rub—these should prevent skin drying and irritant skin reactions, but not leave a sticky residue on hands
• drying characteristics—in general, solutions have lower viscosity than gels and therefore tend to dry more quickly
• risk of skin irritation and dryness—proactive and sympathetic management of this problem is vital.

There is some evidence to suggest that gels are preferred to solutions (WHO 2009), however it is important for staff to evaluate products themselves before implementation where possible. Even where emollient agents are present in the product, ready access to a moisturising skin-care product is essential. All hand hygiene products should be chemically compatible. It is advisable that hand hygiene and hand-care products are from a range made by a single manufacturer, as this ensures compatibility between the products.

Other issues associated with alcohol-based hand rubs

Other factors that should be considered when choosing products include cost issues, availability, convenience and functioning of dispenser, and ability to prevent contamination. Consideration should also be given to occupational health and safety issues associated with alcohol-based hand rubs. Alcohols are flammable, and healthcare workers handling alcohol-based preparations should respect safety standards. Accidental and intentional ingestion and dermal absorption of alcohol-based
products used for hand hygiene have also been reported (Roberts et al 2005; Brown et al 2007). The risk of these issues can be mitigated by appropriate placement of dispensers within the facility (see Section C; in addition, the Hand Hygiene Australia risk assessment form outlines the safety issues in more detail).

Recommendation

2 For all routine hand hygiene practices in healthcare settings, use alcohol-based hand rubs that:

• contain between 60% and 80% v/v ethanol or equivalent (Grade B); and
• meet the requirements of EN1500 (GPP).

3 Choice of hand hygiene product when hands are visibly soiled

If hands are visibly soiled, hand hygiene should be performed using soap and water (Grade B).

4 Hand hygiene for Clostridium difficile and non-enveloped viruses

Hand hygiene should be performed using soap and water when Clostridium difficile or non-enveloped viruses such as norovirus are known or suspected to be present and gloves have not been worn. After washing, hands should be dried thoroughly with single-use towels (GPP).

Technique

Effective hand hygiene relies on appropriate technique as much as on selection of the correct product. Inappropriate technique can lead to failure of hand hygiene measures to appropriately remove or kill microorganisms on hands, despite the superficial appearance of having complied with hand hygiene requirements.

Key factors in effective hand hygiene and maintaining skin integrity include (Boyce & Pittet 2002):

• the duration of hand hygiene measures
• the exposure of all surfaces of hands and wrists to the preparation used (Widmer & Dangel 2004)
• the use of rubbing to create friction
• ensuring that hands are completely dry.

Table B1.2: Use of alcohol-based hand rub

Table B.1.3: Using soap (including antimicrobial soap) and water

B1.1.4 Other aspects of hand hygiene

As intact skin is a natural defence against infection, cuts and abrasions reduce the effectiveness of hand hygiene practices. Breaks or lesions of the skin are possible sources of entry for infectious agents (Larson 1996) and may also be a source of them. Similarly, the presence of fingernail disease may reduce the efficacy of hand hygiene and result in the transmission of pathogens (WHO 2009). To reduce the risk of cross-transmission of infectious agents, cuts and abrasions should be covered
with waterproof dressings.

The type and length of fingernails can have an impact on the effectiveness of hand hygiene (Boyce & Pittet 2002; Lin et al 2003). Artificial or false nails have been associated with higher levels of infectious agents, especially Gram-negative bacilli and yeasts, than natural nails (Pottinger et al 1989; Passaro et al 1997; Foca et al 2000; Hedderwick et al 2000; Moolenaar et al 2000; Parry et al 2001; Boyce & Pittet 2002; Gupta et al 2004; Boszczowski et al 2005). Fingernails should therefore be kept short (for example, the length of the finger pad) and clean, and artificial fingernails should not be worn. Studies have also demonstrated that chipped nail polish may support the growth of organisms on the fingernails (Grayson et al 2009). It is good practice to not wear nail polish, but if it must be used it should not be chipped and should be removed every 4 days (AORN 2007).

Although there is less evidence concerning the impact of jewellery on the effectiveness of hand hygiene, rings can interfere with the technique used to perform hand hygiene resulting in higher total bacterial counts (Boyce & Pittet 2002). Hand contamination with infectious agents is increased with ring wearing (Boyce & Pittet 2002; Trick et al 2003), although no studies have related this practice to healthcare worker-to-patient transmission. The consensus recommendation is to strongly discourage the wearing of watches, rings or other jewellery during health care; however if jewellery must be worn in clinical areas it should be limited to a plain band (for example, wedding ring) and this should be moved about on the finger during hand hygiene practices. In high-risk settings such as operating suites/rooms, any jewellery, even a plain band, should not be worn.

Each healthcare facility should develop policies on the wearing of jewellery, artificial fingernails or nail polish by healthcare workers.

B1.1.5 Hand care

The main type of skin irritation associated with hand hygiene, irritant contact dermatitis, includes symptoms such as dryness, irritation, itching and sometimes cracking and bleeding. Allergic contact dermatitis is rare and represents an allergy, which may be to some ingredient in a hand hygiene product.

Generally, alcohol-based hand rubs cause significantly less skin reaction or irritation than hand hygiene with plain or antiseptic soaps (Pittet & Boyce 2001).

Expert opinion concludes that (Pratt et al 2001; Boyce & Pittet 2002; Grayson et al 2009):

• skin damage is generally associated with the detergent base of the preparation, poor hand hygiene technique and/or frequent use of alcohol-based hand rub immediately before or after performing hand hygiene with soap
• frequent use of hand hygiene agents may cause damage to the skin and alter normal hand flora
• excoriated hands are associated with increased colonisation by potentially infectious agents
• the irritant and drying effects of hand preparations are one reason why healthcare workers fail to adhere to hand hygiene guidelines
• appropriate use of hand lotion or moisturisers added to hand hygiene preparations is an important factor in maintaining skin integrity, encouraging adherence to hand hygiene practices and assuring the health and safety of healthcare workers.

Use of hand cream

An emollient hand cream should be applied regularly, such as after performing hand hygiene before a break or going off duty, and when off duty. Hand hygiene technique should be reviewed if skin irritation occurs. If the irritation persists or if it caused by a particular soap, antiseptic agent or alcohol-based product, the person with designated responsibility for infection control or occupational health should be consulted.

B1.1.6 Putting it into practice

Individual actions for reducing the risk

• Follow the 5 moments for hand hygiene, even when it seems that there is not enough time
• Become familiar with your facility policy on hand hygiene and follow it
• Use the appropriate product for the situation and use it as directed
• Follow facility policy on cuts and abrasions, fingernails, nail polish and jewellery
• Use hand-care products provided by your organisation; your own products may not be compatible with the hand hygiene products provided
• Minimise physical contact with patient surroundings
• Lead by example and champion hand hygiene in your setting
• Attend hand hygiene education sessions regularly to refresh your knowledge and skills
• Contact the person with designated responsibility for occupational health or infection prevention and control if you have a reaction to hand hygiene and hand-care products used in your setting
• If alcohol-based hand rub is not readily accessible at key points of care in a patient-care area, consider approaching management

Involving patients in hand hygiene

The following information may be provided to patients to assist them in becoming involved in identifying and reducing risks related to poor hand hygiene.

• Hand hygiene is the most important aspect of reducing the risk of infection—this applies to everyone including healthcare workers, patients and visitors
• The '5 moments for hand hygiene' tell healthcare workers, patients and visitors when hand hygiene should be performed to reduce the risk of infection
• Healthcare workers generally use alcohol-based hand rub as it is effective and easy to use but, if their hands are visibly dirty, they need to use soap and water first
• Performing hand hygiene regularly reduces the risk of infection to you and others. If in hospital, remind your visitors to use alcohol-based hand rub when they come into the ward and before they leave
• No matter what product you use to clean your hands, the solution should come into contact with all surfaces
• After hand hygiene, the hands should be dry. If alcohol-based hand rub is used, the solution will dry on the hands. After hand hygiene with soap and water, hands should be patted dry
• Healthcare workers should have short, clean fingernails and not wear artificial fingernails or jewellery
• It's okay to question healthcare workers about their hand hygiene practices

Risk management case study: Hand hygiene in a neonatal intensive care unit

The neonatal intensive care unit in a large regional hospital identifies colonisation or infection with Pseudomonas aeruginosa in a number of infants. Surveillance cultures from other infants in the unit, from the hands of staff on the unit and from possible environmental reservoirs are assessed. The cultures show that an additional three infants are colonised. Cultures of environmental specimens are negative but cultures of three of twenty-four healthcare workers are positive. Of these, two have recently joined the unit and received no education on hand hygiene in orientation and the third has artificial fingernails.

B1.1.7 Resources

Standards

AORN (2007) Standards, Recommended Practices and Guidelines

Legislation

• National Occupational Health and Safety Commission. National Code of Practice for the Control of Work-related Exposure to Hepatitis and HIV (blood-borne) Viruses [NOHSC 2010 (2003) 2nd ed.] Canberra: Australian Government National Occupational Health and Safety Commission. 2003.
• Australian Infection Control Association. Standard 13 Hand Hygiene. Brisbane: AICA. 2006

Guidelines

Tools and web-based resources

Hand Hygiene Australia's website contains numerous educational resources, tools, and information on implementing hand hygiene programs

B1.1.8 References

AORN (2007) Standards, Recommended Practices & Guidelines. Association of periOperative Nurses.

Boszczowski I, Nicoletti C, Puccini DM et al (2005) Outbreak of extended spectrum beta-lactamaseproducing Klebsiella pneumoniae infection in a neonatal intensive care unit related to onychomycosis in a health care worker. Pediatr Infect Dis J 24(7): 648–50.

Brown TL, Gamon S, Tester P et al (2007) Can alcohol-based hand-rub solutions cause you to lose your driver's licence? Comparative cutaneous absorption of various alcohols. Antimicrobial Agents Chemotherapy 51: 1107–08.

Canada Standards and Guideline Core Committee (CHICA) (2008) Hand hygiene. Can J Infect Control 23(114): 116–17.

Donskey CJ & Eckstein BC (2009) Images in clinical medicine. The hands give it away. N Engl J Med 360(3): e3.

Fendler EJ, Ali Y, Hammond BS et al (2002) The impact of alcohol hand sanitizer use on infection rates in an extended care facility. Am J Infect Control 30(4): 226–33.

Foca M, Jakob K, Whittier S et al (2000) Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. N Engl J Med 343(10): 695–700.

Girard R, Bousquet E, Carre E et al (2006) Tolerance and acceptability of 14 surgical and hygienic alcohol-based hand rubs. J Hosp Infect 63: 281–88.

Grayson L, Russo P, Ryan K et al (2009) Hand Hygiene Australia Manual. Australian Commission for Safety and Quality in Healthcare and World Health Organization.

Gupta A, Della-Latta P, Todd B et al (2004) Outbreak of extended-spectrum beta-lactamaseproducing Klebsiella pneumoniae in a neonatal intensive care unit linked to artificial nails. Infect Control Hosp Epidemiol 25(3): 210–15.

Hedderwick SA, McNeil SA, Lyons MJ et al (2000) Pathogenic organisms associated with artificial fingernails worn by healthcare workers. Infect Control Hosp Epidemiol 21(8): 505–09. Johnson PD, Martin R, Burrell LJ et al (2005) Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Med J Aust 183(10): 509–14.

Kramer A, Bernig T, Kampf G (2002a) Clinical double-blind trial on the dermal tolerance and user acceptability of six alcohol-based hand disinfectants for hygienic hand disinfection. J Hosp Infect 51: 114–20.

Kramer A, Rudolph P, Kampf G et al (2002b) Limited efficacy of alcohol-based hand gels. Lancet 359: 1489–90.

Larmer PJ, Tillson TM, Scown FM et al (2008) Evidence-based recommendations for hand hygiene for health care workers in New Zealand. N Z Med J 121(1272): 69–81.

Larson EL (1996) APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 23(4): 251–69.

Larson EL, Early E, Cloonan P et al (2000) An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med 26(1): 14–22.

Lin CM, Wu FM, Kim HK et al (2003) A comparison of hand washing techniques to remove Escherichia coli and caliciviruses under natural or artificial fingernails. J Food Prot 66(12): 2296–301.

Maiwald M & Widmer AF (2007) Are alcohol gels better than liquid hand rubs? Crit Care 11: 418.

Malik RK, Montecalvo MA, Reale MR et al (1999) Epidemiology and control of vancomycin-resistant enterococci in a regional neonatal intensive care unit. Pediatr Infect Dis J 18(4): 352–56.

Moolenaar RL, Crutcher JM, San Joaquin VH et al (2000) A prolonged outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit: did staff fingernails play a role in disease transmission? Infect Control Hosp Epidemiol 21(2): 80–85.

Nicolay CR (2006) Hand hygiene: an evidence-based review for surgeons. Int J Surg 4: 53–65

Parry MF, Grant B, Yukna M et al (2001) Candida osteomyelitis and diskitis after spinal surgery: an outbreak that implicates artificial nail use. Clin Infect Dis 32(3): 352–57.

Passaro DJ, Waring L, Armstrong R et al (1997) Postoperative Serratia marcescens wound infections traced to an out-of- hospital source. J Infect Dis 175(4): 992–95.

Picheansathian W (2004) A systematic review on the effectiveness of alcohol-based solutions for hand hygiene. Int J Nurs Pract 10: 3–9.

PIDAC (2008) Best Practices for Hand Hygiene in all Health Care Settings. Provincial Infectious Diseases Advisory Committee, Ontario Ministry of Health and Long-Term Care, Toronto.

Pietsch H (2001) Hand antiseptics: rubs versus scrubs, alcoholic solutions versus alcoholic gels. J Hosp Infect 48 Suppl A: S33–36.

Pittet D, Hugonnet S, Harbarth S et al (2000) Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 356(9238): 1307–12.

Pittet D & Boyce JM (2001) Hand hygiene and patient care: pursuing the Semmelweis legacy. Lancet Infect Dis 1: 9–20.

Pittet D (2007) Liquid or gel: hand rubbing at the point of care remains the most critical element of hand hygiene promotion. Crit Care 11: 418–19.

Pottinger J, Burns S, Manske C (1989) Bacterial carriage by artificial versus natural nails. Am J Infect Control 17(6): 340–44.

Pratt RJ, Pellowe C, Loveday HP et al (2001) The epic Project: developing national evidence-based guidelines for preventing healthcare associated infections. phase 1: guidelines for preventing hospital-acquired infections. J Hospital Infection 47 (Supplement): S3–82.

Pratt RJ, Pellowea CM, Wilson JA et al (2007) epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. J Hosp Infect 65S, S1–S64.

Roberts HS, Self RJ, Coxon M (2005) An unusual complication of hand hygiene. Anaesthesia 60(1): 100–01.

Rotter ML (2004) Hand washing and hand disinfection. In: Mayhall CG (ed). Hospital Epidemiology and Infection Control. Lippincott Williams and Wilkins, Philadelphia. pp. 1727–46.

Rotter ML, Koller W, Neumann R (1991) The influence of cosmetic additives on the acceptability of alcohol-based hand disinfectants. J Hosp Infect 18 Suppl B: 57–63.

Ryan MAK, Christian RS, Wohlrabe J (2001) Handwashing and respiratory illness among young adults in military training. Am J Preventative Med 21: 79–83.

Traore O, Hugonnet S, Lubbe J et al (2007) Liquid versus gel handrub formulation: a prospective intervention study. Crit Care 11: R52

Trick WE, Vernon MO, Hayes RA et al (2003) Impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital. Clin Infect Dis 36(11): 1383–90.

Webster J, Faoagali JL, Cartwright D (1994) Elimination of methicillin-resistant Staphylococcus aureus from a neonatal intensive care unit after hand washing with triclosan. J Paediatr Child Health 30(1): 59–64.

WHO (2009) Guidelines on Hand Hygiene in Healthcare.

Widmer AE & Dangel M (2004) Alcohol-based handrub: evaluation of technique and microbiological efficacy with international infection control professionals. Infect Control Hosp Epidemiol 25: 207–9

Zafar AB, Butler RC, Reese DJ et al (1995) Use of 0.3% triclosan (Bacti-Stat) to eradicate an outbreak of methicillin-resistant Staphylococcus aureus in a neonatal nursery.
Am J Infect Control 23(3): 200–08.

B1.2 Personal protective equipment

B1.2.1 What are the risks?

Any infectious agent transmitted by the contact or droplet route can potentially be transmitted by contamination of healthcare workers' hands, skin or clothing. Cross-contamination can then occur between the healthcare worker and other patients or healthcare workers, or between the healthcare worker and the environment. Infectious agents transmitted through droplets can also come into contact with the mucous membranes of the healthcare worker.

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 used as part of standard precautions includes aprons, gowns, gloves, surgical masks, protective eyewear and face shields. Selection of PPE is based on the type of patient interaction, known or possible infectious agents, and/or the likely mode(s) of transmission.

There have been few controlled clinical studies evaluating the relationship between the use of PPE and risk of HAIs. However, the use of barriers reduces opportunities for transmission of infectious agents (Pratt et al 2001; Clark et al 2002). PPE also protects patients from exposure to infectious agents in the surrounding environment carried by healthcare workers.

This section discusses the routine use of PPE as part of standard precautions. Specific PPE used when transmission-based precautions are applied is discussed in Section B2. The use of PPE during specific procedures is discussed in Section B4.

B1.2.2 Decision-making about personal protective equipment

Selection of protective equipment must be based on assessment of the risk of transmission of infectious agents to the patient or carer, and the risk of contamination of the clothing or skin of healthcare workers or other staff by patients' blood, body substances, secretions or excretions. Local policies and current health and safety legislation should also be taken into account (Clark et al 2002).

Factors to be considered are:

• probability of exposure to blood and body substances
• type of body substance involved
• probable type and probable route of transmission of infectious agents.

Appropriate sequences and procedures for putting on and removing PPE[10] are shown in Section B1.2.7. Relevant Australian Standards are listed in B1.2.9.

All PPE must meet relevant Therapeutic Goods Administration (TGA) criteria for listing on the Australian Register of Therapeutic Goods (ARTG) or equivalent and should be used in accordance with manufacturer's recommendations.

Where to wear PPE

PPE is designed and issued for a particular purpose in a protected environment and should not be worn outside that area. Protective clothing provided for staff in areas where there is high risk of contamination (for example, operating suite/room) must be removed before leaving the area. Even where there is a lower risk of contamination, clothing that has been in contact with patients should not be worn outside the patient-care area. Inappropriate wearing of PPE (for example, wearing operating suite/room attire in the public areas of a hospital or wearing such attire outside the facility) may also lead to a public perception of poor practice within the facility.

B1.2.3 Aprons and gowns

International guidelines recommend that protective clothing (apron or gown) be worn by all healthcare workers when (Garner 1996; Pratt et al 2001; Clark et al 2002; Pratt et al 2007):

• 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 contamination with blood, body substances, secretions or excretions (except sweat).

The type of apron or gown required depends on the degree of risk, including the anticipated degree of contact with infectious material and the potential for blood and body substances to penetrate through to clothes or skin:

• a clean non-sterile apron or gown is generally adequate to protect skin and prevent soiling of clothing during procedures and/or patient-care activities that are likely to generate splashing or sprays of blood or body substances
• a fluid-resistant apron or gown should be worn when there is a risk that clothing may become contaminated with blood, body substances, secretions or excretions (except sweat).

Gowns and aprons must be changed between patients.

Clinical and laboratory coats or jackets worn over personal clothing for comfort and/or purposes of identity are not considered to be PPE. These items of clothing need to be changed dependant on activity and the extent of exposure to potential pathogens.

Aprons/gowns are routinely used upon entering the room of a patient requiring contact precautions. This is discussed in Section B2.2.3.

Plastic aprons

Single-use plastic aprons are recommended for general use when there is the possibility of sprays or spills, to protect clothes that cannot be taken off (Garner 1996; Pratt et al 2001; Clark et al 2002; Pratt et al 2007). Unused aprons should be stored in an appropriate area away from potential contamination (Callaghan 1998).

Gowns

Gowns are used to protect the healthcare worker's exposed body areas and prevent contamination of clothing with blood, body substances, and other potentially infectious material (Boyce et al 1994; Boyce et al 1995; Hall 2000; Kohn et al 2004).

Considerations in choosing a a type of gown (for example, long or short-sleeved) that is appropriate for the activity are:

• the volume of body substances likely to be encountered
• the extent and type of exposure to blood and body substances
• the probable type and route of transmission of infectious agents.

If a fluid-resistant full body gown is required, it is always worn in combination with gloves, and with other PPE when indicated. Full coverage of the arms and body front, from neck to the mid-thigh or below, ensures that clothing and exposed upper body areas are protected.

Table B1.4 Characteristics of aprons/gowns

* Some gown types can be re-used. Reusable gowns need to be laundered or reprocessed according to AS/NZS4146—2000 Laundry Practice

Removing aprons and gowns

Removal of aprons and gowns before leaving the patient-care area (for example, in the room or anteroom) prevents possible contamination of the environment outside the patient's room. Aprons and gowns should be removed in a manner that prevents contamination of clothing or skin. The outer, 'contaminated', side of the gown is turned inward and rolled into a bundle, and then discarded into a designated container for waste or linen to contain contamination (see Section B1.2.7).

Recommendation

5 Wearing of aprons/gowns - Grade C

Aprons or gowns should be appropriate to the task being undertaken. They should be worn for a single procedure or episode of patient care and removed in the area where the episode of care takes place.

B1.2.4 Face and eye protection

The mucous membranes of the mouth, nose and eyes are portals of entry for infectious agents, as are other skin surfaces if skin integrity is compromised (for example, by acne, dermatitis) (Sartori et al 1993; Rosen 1997; Keijman et al 2001; Hosoglu et al 2003).

Face and eye protection reduces the risk of exposure of healthcare workers to splashes or sprays of blood and body substances (Dancer 1999; Pratt et al 2001; Clark et al 2002) and is an important part of standard precautions. Procedures that generate splashes or sprays of blood, body substances, secretions or excretions require either a face shield or a mask worn with protective eyewear (CDC 1978; Davidson et al 1995; Gehanno et al 1999; Scales et al 2003; Seto et al 2003; Fowler et al 2004; Loeb et al 2004; ADA 2008).

Face and eye protection is worn as part of transmission-based precautions as discussed in Sections B2.2.3, B2.3.3 and B2.4.3.

Table B1.5: Use of face and eye protection as part of standard precautions

Surgical masks

Surgical masks are loose fitting, single-use items that cover the nose and mouth. They are used as part of standard precautions to keep splashes or sprays from reaching the mouth and nose of the person wearing them. They also provide some protection from respiratory secretions and are worn when caring for patients on droplet precautions. Surgical masks differ from P2 respirators, as outlined in Table B1.6.

Table B1.6: Properties of different types of mask

Surgical masks can be placed on coughing patients to limit potential dissemination of infectious respiratory secretions from the patient to others (see Section B2.3.3).

Considerations when using a surgical mask include:

• masks should be changed when they become soiled or wet
• masks should never be reapplied after they have been removed
• masks should not be left dangling around the neck
• touching the front of the mask while wearing it should be avoided
• hand hygiene should be performed upon touching or discarding a used mask.

Children should wear a specifically designed child mask and their oxygen saturation should be monitored.

Eye protection

Goggles with a manufacturer's anti-fog coating provide reliable, practical eye protection from splashes, sprays, and respiratory droplets from multiple angles. Newer styles of goggles fit adequately over prescription glasses with minimal gaps (to be efficacious, goggles must fit snugly, particularly from the corners of the eye across the brow).

Other types of protective eyewear include safety glasses with side-shield protection, which are widely used in dentistry and other specialties that use operating microscopes (ADA 2008).

While effective as eye protection, goggles and safety glasses do not provide splash or spray protection to other parts of the face.

Personal eyeglasses and contact lenses are not considered adequate eye protection.

Face shields

Single-use or reusable face shields may be used in addition to surgical masks, as an alternative to protective eyewear. Compared with other forms of protective eyewear, a face shield can provide protection to other parts of the face as well as the eyes. Face shields extending from chin to crown provide better face and eye protection from splashes and sprays; face shields that wrap around the sides may reduce splashes around the edge of the shield.

Removing face and eye protection

Removal of a face shield, protective eyewear and surgical mask can be performed safely after gloves have been removed and hand hygiene performed. The ties, earpieces and/or headband used to secure the equipment to the head are considered 'clean' and therefore safe to touch with bare hands. The front of a mask, protective eyewear or face shield is considered contaminated.

Cleaning reusable face and eye protection

Reusable face shields and protective eyewear should be cleaned according to the manufacturer's instructions, generally with detergent solution, and be completely dry before being stored. If they are to be disinfected, they should be disinfected using either a TGA-registered instrument grade disinfectant - low level, or by heat as per AS/NZS 4187:2003.

Recommendation

6 Use of face and protective eyewear for procedures - Grade C

A surgical mask and protective eyewear must be worn during procedures that generate splashes or sprays of blood, body substances, secretions or excretions into the face and eyes.

B1.2.5 Gloves

Gloves can protect both patients and healthcare workers from exposure to infectious agents that may be carried on hands (Duckro et al 2005). As part of standard precautions, they are used to prevent contamination of healthcare workers' hands when (Siegel et al 2007):

• anticipating direct contact with blood or body substances, mucous membranes, non-intact skin and other potentially infectious material
• handling or touching visibly or potentially contaminated patient-care equipment and environmental surfaces (Boyce & Pittet 2002; Bhalla et al 2004; Duckro et al 2005).

The capacity of gloves to protect healthcare workers from transmission of bloodborne infectious agents following a needlestick or other puncture that penetrates the glove barrier has not been determined (Siegel et al 2007).

Gloves are an essential component of contact precautions (in particular for patients with MROs) (see Sections B2.2.3 and B3.1.2) and may also be used as part of droplet precautions (see Section B2.3.3).

How and when should gloves be worn?

As with all PPE, the need for gloves is based on careful assessment of the task to be carried out, the related risk of transmission of microorganisms to the patient; and the risk of contamination of the healthcare worker's clothing and skin by the patient's blood and body substances (Pratt et al 2001; Clark et al 2002). 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.

When gloves are worn in combination with other PPE, they are put on last (see Section B1.2.7).

When should gloves be changed?

International guidance suggests that changing of gloves is necessary: between episodes of care for different patients, to prevent transmission of infectious material (Pratt et al 2001; Siegel et al 2007) during the care of a single patient, to prevent cross-contamination of body sites (CDC 1995; Boyce & Pittet 2002)

if the patient interaction involves touching portable computer keyboards or other mobile equipment that is transported from room to room (Siegel et al 2007).