In-Service Training Program. Managing Drug-Resistant Organisms in Long-Term Care

Transcription

1 In-Service Training Program Managing Drug-Resistant Organisms in Long-Term Care

2 OBJECTIVES 1. Define the term antibiotic resistance. 2. Explain the difference between colonization and infection. 3. Identify ways in which MRSA / VISA / VRSA and VRE are transmitted. 4. List factors that may increase the risk of antibiotic resistant infections. 5. Name four types of Personal Protective Equipment (PPE). 2

3 INTRODUCTION Antibiotics, also known as antimicrobial drugs, are drugs that fight infections caused by bacteria. After their discovery in the 1940s, antibiotics transformed medical care and dramatically reduced illness and death from infectious diseases. However, over time, bacteria have developed resistance to these drugs. 3

4 INTRODUCTION Antimicrobial resistance increases the death rates from certain infections. According to CDC statistics: Nearly two million patients in the United States acquire an infection in the hospital each year. Of those patients, about 90,000 die as a result of their infection. 4

5 INTRODUCTION More than 70 percent of the bacteria that cause hospital-acquired infections are resistant to at least one of the drugs most commonly used to treat them. Persons infected with drug-resistant organisms are more likely to have longer hospital stays and require treatment with second- or third-choice drugs that may be less effective, more toxic, and more expensive. 5

6 ANTIBIOTIC (DRUG) RESISTANCE Antibiotic use promotes development of antibiotic-resistant bacteria. Antibiotic resistance occurs when bacteria change in some way that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections. A key factor in the development of antibiotic resistance is the ability of infectious organisms to adapt quickly to new environmental conditions. 6

7 ANTIBIOTIC (DRUG) RESISTANCE Bacteria are single-celled with a small numbers of genes. Therefore, even a single gene mutation can greatly affect their ability to cause disease. Further, because most bacteria reproduce by dividing every few hours, they can evolve rapidly. Microbes often acquire genes, including those that code for resistance, from each other. 7

8 ANTIBIOTIC (DRUG) RESISTANCE Antibiotics should be used to treat bacterial infections; however, they are not effective against viral infections like the common cold, most sore throats and the flu. 8

9 ANTIBIOTIC (DRUG) RESISTANCE The widespread and sometimes inappropriate use of antibiotics helps promote bacterial adaptation. For example: A physician prescribes antibiotics for a patient ill with a cold or other viral condition. 9

10 ANTIBIOTIC (DRUG) RESISTANCE A physician prescribes antibiotics for a patient with asymptomatic bacteriuria who has an indwelling urinary catheter; bacteria remain in the urine because the catheter is present, but resistant strains emerge. 10

11 ANTIBIOTIC (DRUG) RESISTANCE Healthcare settings also provide a fertile environment for drug-resistant germs. Close contact among sick patients may spread drug-resistant organisms and extensive use of antibiotics promotes bacterial resistance. 11

12 ANTIBIOTIC (DRUG) RESISTANCE A common misconception is that a person s body becomes resistant to specific drugs. In reality, microbes not people become resistant to the drugs. Any type of microbe can develop antimicrobial resistance. 12

13 ANTIBIOTIC (DRUG) RESISTANCE Drug resistance occurs when microbes develop ways to survive the use of medicines intended to kill or weaken them. If a microbe is resistant to many drugs, treating the infection it causes can become difficult or even impossible. 13

14 ANTIBIOTIC (DRUG) RESISTANCE Someone with an infection that is resistant to a particular antibiotic can pass that resistant infection to another person. In this way, a hard-to-treat illness can be spread from person to person. In some cases, the illness can lead to serious disability or even death. 14

15 ANTIBIOTIC (DRUG) RESISTANCE Increasingly, microbes that cause healthcare-acquired (nosocomial) infections are resistant to powerful antibiotics including methicillin and vancomycin. 15

16 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Staphylococcus aureus, often referred to simply as "staph," are bacteria commonly carried on the skin or in the nose of healthy people. Occasionally, staph can cause infections: Staph bacteria are among the most common causes of skin infections in the United States. 16

17 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Most of these infections are minor (such as pimples and boils), and most can be treated without antibiotics. However, staph bacteria can also cause serious infections such as surgical wound infections and pneumonia. 17

18 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) In the past, most serious staph bacteria infections were treated with dicloxacillin, nafcillin or methicillin. Over the past 50 years, treatment of these infections has become more difficult because staph bacteria have become resistant to various antibiotics, including penicillins, cephalosporins and aminoglycosides. 18

19 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) MRSA has been recognized as a problem in the healthcare setting for more than 20 years. MRSA is a strain of Staphylococcus aureus (S. aureus) that is resistant to methicillin (a type of penicillin). 19

20 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) VISA and VRSA are specific types of antimicrobial-resistant staph bacteria. Most staph bacteria are susceptible to the antimicrobial agent vancomycin; however, some have developed resistance. VISA and VRSA cannot be successfully treated with vancomycin because these organisms are no longer susceptible to the drug. 20

21 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Some common illnesses caused by Staphylococcus aureus: Skin infections Bone infections Joint infections Pneumonia Severe life-threatening bloodstream infections 21

22 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Identifying MRSA / VISA / VRSA Staph bacteria are classified as MRSA, VISA or VRSA based on laboratory tests. Laboratories perform tests to determine whether staph bacteria are resistant to antimicrobial agents that might be used for treatment of infections. 22

23 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) To identify VRSA, laboratories determine how much vancomycin is required to inhibit the growth of the organism in a test tube. The result of the test is usually expressed as a minimum inhibitory concentration (MIC) or the minimum amount of antimicrobial agent that inhibits bacterial growth in the test tube. 23

24 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Staph bacteria are classified as VISA if the MIC for vancomycin is 8 to 16 µg/ml, and classified as VRSA if the vancomycin MIC is >32 µg/ml. 24

25 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) To identify MRSA, a bacterial culture is obtained to determine antibiotic sensitivity of the suspected site of infection or colonization. To be identified as MRSA, the organism must have the following two characteristics: 25

26 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) 1. Be identified as Staphylococcus aureus or coagulase-positive staphylococcus, and 2. The antibiotic sensitivity test must show the organism resistant to commonly used antibiotics such as oxacillin, methicillin or nafcillin. 26

27 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Colonization vs. Infection Colonization occurs when staph bacteria are present in or on the body but are not causing illness. Approximately 25 to 30 percent of the population is colonized with staph bacteria inside the nose. 27

28 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Colonization also occurs on the skin surface, on wound or pressure ulcer surfaces, and in the sputum and urine. Infection occurs when staph bacteria are present and causing illness. 28

29 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Common sites of colonization: Surgical wounds Burns Respiratory secretions Sputum 29

30 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Intravenous (I.V.) catheters Indwelling urinary catheters Pressure ulcers Diabetic foot ulcers Blood 30

31 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Signs and Symptoms of any infection include: Fever Increased white blood cell count Purulence (pus) 31

32 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Swelling Redness Pain Heat at the site of infection 32

33 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Transmission S. aureus, including MRSA, VISA, and VRSA, can be spread by close contact with an infected person. S. aureus is almost always spread by direct physical contact and not through the air. 33

34 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Transmission may also occur through indirect contact by touching objects (e.g., towels, sheets, wound dressings, clothes or sports equipment) contaminated by the infected skin of a person with staph bacteria. 34

35 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Risk Factors There are several risk factors and conditions for both colonization and infections: Previous exposure to antimicrobial agents 35

36 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Underlying illness, diseases or conditions, particularly chronic renal disease, diabetes mellitus, peripheral vascular disease, dermatitis or skin lesions, invasive procedures such as dialysis, presence of indwelling devices (for example, dialysis catheters and indwelling urinary catheters) 36

37 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Repeated contact with healthcare workers and equipment Previous colonization with a multidrug-resistant organism Advanced age 37

38 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Treating MRSA The medication of choice to treat MRSA is vancomycin. Other antibiotics that have been used successfully to treat MRSA include rifampin and novobiocin for systemic use and bacitracin and mupirocin for topical application. 38

39 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) Residents who are only colonized with staph bacteria or MRSA usually do not need treatment. Colonization can be treated, but it can reoccur in a short period of time. 39

40 METHICILLIN/VANCOMYCIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA / VISA / VRSA) A resident with MRSA may be considered clear after two cultures are negative. Cultures must be taken at least 72 hours after antibiotic treatment has stopped and one week apart from each previously infected or colonized site from the anterior nares. 40

41 VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) Enterococci are normal inhabitants of the human gastrointestinal tract. Vancomycin is an antibiotic to which some strains of enterococci have become resistant. These resistant strains are referred to as VRE. 41

42 VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) Identifying VRE VRE are bacteria that have developed a resistance to most antibiotics commonly used for enterococcal infections. The antibiotics include vancomycin, aminoglycosides, and ampicillin. 42

43 VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) Colonization and Infection As with other drug-resistant organisms, residents can be either colonized or infected with VRE. Colonization is asymptomatic, while infection results in clinical signs and symptoms. 43

44 VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) Testing for infection involves obtaining cultures (where possible) of the suspected or identified site of infection. To test for colonization, a culture can be completed by using a special cotton swab and gently rubbing the skin outside the rectum. Test results are usually ready in two to three days. 44

45 VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) Transmission VRE usually is spread by direct contact with hands, environmental surfaces, or medical equipment that has been contaminated by the feces or tissue of an infected person. 45

46 VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) Enterococci are hardy organisms and they can live for a long time on hands, gloves, and environmental surfaces. For example, the bacteria have been found after five to seven days on countertops, twenty four hours on bedrails, and sixty minutes on telephone hand pieces. 46

47 VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) Risk Factors People who are more likely to become infected or colonized with VRE have the following characteristics: Severe illness with an underlying disease, such as cancer or immunosuppression (HIV/AIDS) Indwelling urinary or central venous catheters 47

48 VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) Recent abdominal or cardiothoracic surgery Prolonged hospital stay (particularly in ICU, oncology, or transplant unit) Recent treatment with vancomycin, cephalosporins, metronidazole or clindamycin, or multiple antimicrobial agents 48

49 VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) Occurrence Enterococcus is a common bacterium. In recent years, there has been a dramatic increase in the incidence of VRE. Although most outbreaks of VRE have occurred in acute-care settings (especially intensive care units), all healthcare institutions have the potential to be affected. 49

50 VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) VRE has been cultured from hospital equipment, doorknobs, bedrails and hands of hospital personnel. Anyone who frequents hospitals should be considered at risk for carrying VRE. 50

51 VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) Treating VRE VRE infections are no more virulent than other enterococcal infections, but infections caused by VRE are very difficult, if not impossible, to treat because the range of antibiotics available for treatment is limited and predicting which antibiotics will be effective is difficult. 51

52 VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) By comparison, those people found to be harmlessly colonized by VRE in their gastrointestinal tract or elsewhere need no special treatment. Over time, many of these people become spontaneously clear of VRE. 52

53 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS To help prevent the transmission of disease, the prudent use of antibiotics, ongoing education programs about infectious diseases, and the implementation of appropriate infection control measures are needed to prevent person-to-person spread. 53

54 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS The following are recommended for prevention of VRE and MRSA / VISA / VRSA for facilities who suspect an outbreak: Obtain stool cultures or rectal-swab cultures of roommates of residents infected or colonized with VRE. Obtain nasal cultures from roommates of residents infected or colonized with MRSA. 54

55 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS The staff and physician should consider contact or isolation precautions on a case-by-case basis, depending on risks for transmission such as: Uncontrolled secretions Fecal incontinence Draining wounds Diarrhea Total dependence for activities of daily living. 55

56 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Consider discontinuing restrictions such as contact precautions on a case-by-case basis after considering either: The absence of active infection or draining wounds, the lack of evidence of a resident/patient risk of transmission, and residual colonization without persistent risk factors for transmission; or Three consecutive negative cultures, 56 taken approximately a week apart from the original positive culture site.

57 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS To help prevent the control of healthcareacquired infections, the CDC recommends Isolation Precautions, which identify how diseases are spread and what actions can be taken to prevent that spread. Isolation precautions can be divided into two types: Standard precautions. These precautions are intended for the care of all residents regardless of their diagnosis or presumed infection status. 57

58 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Transmission-based precautions. These precautions are intended for the care of residents known or suspected to be infected by pathogens for which additional precautions beyond Standard Precautions are needed to interrupt transmission in a healthcare setting. Contact Precautions are transmissionbased precautions used for multi drugresistant microorganisms, among other situations. 58

59 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS STANDARD PRECAUTIONS Standard Precautions combine the major features of Universal (blood and body fluid) Precautions (designed to reduce the risk of transmission of bloodborne pathogens) and Body Substance Isolation (designed to reduce the risk of transmission of pathogens from moist body substances). 59

60 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Standard Precautions apply to the following: Blood All body fluids Secretions and excretions, except sweat, regardless of whether they contain visible blood Nonintact skin Mucous membranes 60

61 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Standard precautions are basic infectioncontrol guidelines that must be applied at all times when working with residents. The purpose is to prevent the spread of disease by identifying and eliminating common practices that spread disease. 61

62 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS To prevent the spread of bloodborne diseases, the following guidelines should be used: All residents specimens should be considered biohazardous. Change gloves after contact with each resident. Do not reuse disposable gloves. 62

63 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Handle sharps carefully to prevent accidental injury. Do not recap, bend, or break used needles; place the puncture-resistant containers as close as practical to the use area. Locate resuscitation and ventilation equipment in areas where resuscitation is likely to occur, to minimize the need for emergency mouth-to-mouth resuscitation. 63

64 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Healthcare workers who have exudative lesions or weeping dermatitis should refrain from all direct resident contact and handling of resident equipment until the condition resolves. Report all sharps injuries and mucosal splashes immediately to the supervisor. Use appropriate barrier precautions: gloves, gown, mask, and eye protection 2005 as MED-PASS, appropriate. Inc. All Rights Reserved 64

65 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Wash hands immediately, using proper technique, after gloves are removed. Wash hands thoroughly, using proper technique, if contaminated with blood or other body fluids. Clean up blood spills immediately, wearing gloves. Use an EPAapproved solution, such as a 1:10 dilution of bleach and water. 65

66 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Handwashing Handwashing is often called the single most important step in preventing communicable disease. Hands should be washed as follows: Immediately after touching blood, body fluids, or intact skin (even though gloves have been worn) Before and after each resident contact Immediately after glove removal 66

67 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Personal Protective Equipment (PPE) Personal protective equipment (PPE) is used to reduce exposure to blood or body fluids. The use of each item will depend upon the procedure or task being performed: Gloves Gowns Masks 67

68 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Face shields Eye protection Lab coats Mouth pieces (airways) Resuscitation bags Mask for CPR 68

69 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS PPE is considered effective only if it does not permit blood or other potentially infectious materials to pass through or to reach employees work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use for the duration of time the protective equipment will be used. 69

70 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Personal protective equipment must be: Provided at no cost to the employee. Accessible at the work site. Of appropriate size and type to prevent exposure (this includes hypoallergenic gloves, cotton liners or other similar alternatives to those employees that have an allergy or sensitivity to latex gloves). 70

71 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Cleaned, laundered, repaired, replaced, or discarded as appropriate. Removed before leaving the work area and after a garment becomes contaminated. Disposed of in designated containers. Replaced if torn, punctured, contaminated, or other barrier function is compromised (never wash or decontaminate disposable gloves for reuse). 71

72 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Note: In places where no handwashing facilities exist, workers must be provided with either appropriate antiseptic hand cleaner in conjunction with clean cloth/paper towels or antiseptic towelettes. 72

73 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Gloves In addition to handwashing, gloves play an important part in preventing the spread of infections. Gloves are worn for three important reasons: To provide a protective barrier for the hands To prevent the spread of germs from the hands of caregivers to residents To prevent the spread of germs from one resident to another 73

74 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Gloves should be worn whenever there is a possibility of coming into contact with body fluids, nonintact skin, mucus membranes, or contaminated items. When wearing gloves, care must be taken to: Always change gloves between residents. Change gloves after contact with contaminated material such as feces, blood, or wound drainage. Remove gloves promptly after use. 74

75 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS TRANSMISSION-BASED PRECAUTIONS Contact Precautions Contact transmission occurs when infection is spread through contact with infected skin or surfaces. Direct contact transmission occurs when a pathogen is passed from a source to a host by direct touch. 75

76 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS When the infection is transmitted by touching an intermediate object that has been infected by the source, this is known as indirect contact transmission. Examples of infections that can be spread by contact include multi drug-resistant bacteria, hepatitis, and skin and wound infections. 76

77 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS To prevent contact transmission, the following guidelines should be used: Residents under contact precautions should be placed in private rooms. If a private room is unavailable, a resident may be placed with another individual who has an active case of the same disease. Gloves are extremely important in preventing contact-borne infections. 77

78 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Always change gloves and wash hands after touching an infected area of the resident. Never touch mucous membranes or nonintact skin on the resident immediately after touching an infected area; touching these two areas one after another can spread the infection to healthy parts of the resident s body. 78

79 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Only transport residents when absolutely necessary and with the resident using a facemask. Remove gloves when leaving the resident s room, and always use an antimicrobial agent or waterless antiseptic immediately. 79

80 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Once gloves are off and hands are washed, avoid touching any surfaces in the resident s room that might be contaminated with the infection. Follow facility procedure for excreta: feces, urine and body fluids. 80

81 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Wear a gown if clothing will contact the resident, his or her environment, or objects in his or her room to avoid contamination. Remove the gown before leaving the resident s room and make sure that personal clothing does not touch contaminated surfaces. 81

82 PREVENTION AND/OR CONTROL OF TRANSMISSION OF PATHOGENS Remember that intermediate objects can also pass contact-borne infections, so be sure to clean and disinfect everything that may have touched the resident s infection. 82

83 SUMMARY Antibiotic use promotes development of antibiotic-resistant bacteria. A key factor in the development of antibiotic resistance is the ability of infectious organisms to adapt quickly to new environmental conditions. Increasingly, healthcare-acquired infections are resistant to the most powerful antibiotics available, methicillin and vancomycin. 83

84 SUMMARY Basic infection control practices are key to preventing the spread of MDROs, especially to susceptible individuals. CDC guidelines provide recommendations for prevention and control of many healthcareassociated diseases and infections including infections with MDROs. 84

85 SUMMARY No guideline can address all the needs of healthcare facilities. It is important that you understand your facility protocols and follow them. 85