TABLE OF CONTENTS. 1. Purpose of the WRHA Infection Prevention and Control Manual 2.1 and approval process

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1 TABLE OF CONTENTS Winnipeg Regional Health Authority Introduction Page Number 1. Purpose of the WRHA Infection Prevention and Control Manual 2.1 and approval process 2. WRHA Infection Prevention and Control Program Site Specific Infection Prevention & Control Program After Hours Coverage Chain of Infection Links in the Chain of Infection Breaking the Chain of Infection Transmission of Microorganisms 2.9 WRHA Infection Prevention and Control Policies & Operational Directives 1. Nursing Foot Care Infection Prevention & Control Management Routine Practices for Reducing the Risk of Infection Transmission Gels, Ultrasound and Medical Admission Screening of Patients for Antibiotic Resistant Organisms 3.13 (MRSA & VRE) 5. Cleaning of Non-Critical, Reusable Items Cleaning and Disinfection of Non-Critical Reusable Equipment/Items 3.18 for Patients in Hospital 7. Outbreak Management for Infection Prevention & Control in Hospitals, 3.26 Long Term Facilities and Personal Care Homes 8. Outbreak Management for Infection Prevention & Control in Hospitals Reporting of a Communicable Disease to Manitoba Health by Infection 3.37 Prevention & Control in Hospitals 10. Upper Extremity Supportive Devices 3.42 Routine Practices 1. Introduction Hand Hygiene Important Factors in Hand Hygiene When to Perform Hand Hygiene Agents Used for Hand Hygiene How to Perform Hand Hygiene Patient/Visitors

2 3. Personal Protective Equipment Gloves Gowns Masks Eye Protection Face Protection Respiratory Etiquette Patient Management Accommodation Equipment Environmental Control Specimen Collection Visitors Education Postmortem Care 4.12 Additional Precautions 1. Introduction Implementation of Additional Precautions Discontinuation of Additional Precautions Airborne Precautions Introduction Indications for Airborne Precautions Accommodation Healthcare Workers Hand Hygiene Personal Protective Equipment Patient Transport Patient/Family Visitors Contact Precautions Introduction Indications for Contact Precautions Accommodation Hand Hygiene

3 5.5 Personal Protective Equipment Patient Transport Equipment and Environment Patient/Family Visitors Droplet Precautions Introduction Indications for Droplet Precautions Accommodation Hand Hygiene Personal Protective Equipment Patient Transport Patient/Family Visitors Airborne/Contact Precautions Introduction Indications for Airborne/Contact Precautions Accommodation Healthcare Workers Hand Hygiene Personal Protective Equipment Patient Transport Equipment and Environment Patient/Family Visitors Droplet/Contact Precautions Introduction Indications for Droplet/Contact Precautions Accommodation Hand Hygiene Personal Protective Equipment Patient Transport Equipment and Environment Patient/Family Visitors 5.30 Clinical Presentation/Microorganism/Infectious Disease Table

4 Specific Disease Protocols-Alpha Listing Specific Disease Protocols 1. Antibiotic Resistant Organisms Extended Spectrum Beta Lactams (ESBLs) Methicillin-Resistance Staphlococcus Aureus (MRSA) Vancomycin Resistant Enterococci (VRE) Vancomycin-Resistant Intermediate Staphylococcus Aureus (VISA) 1.5 Vancomycin-Resistant Staphlococcus Aureus (VRSA) Diarrhea Bacterial Clostridium difficile associated diarrhea (CDAD) Other infectious microorganisms Viral Tuberculosis (TB) Varicella Zoster Virus (VZV) Chickenpox (Varicella) Shingles (Herpes Zoster) Influenza (Seasonal) Acquired Immunodeficiency Syndrome (AIDS) Human Immunodeficiency Virus Creutzfeldt-Jakob Disease (CJD) Group A Streptococcus Hepatitis Hepatitis A (HAV) Hepatitis B (HBV) Hepatitis C (HCV) Immunocompromised Condition Measles/Rubeola Meningitis

5 12.1 Hemophilus meningitis Meningococcal meningitis Pneumococcal meningitis Viral meningitis Mumps Pediculosis (Lice) Pertussis Rubella (German Measles) Scabies Severe Respiratory Illness Cimex Lectularius (Bed Bugs) Pandemic Influenza P1 Specific Infection Prevention and Control Practices 1. 4% Chlorhexidine to 2% Chlorhexidine for hand antisepsis and 8.1 cleansing. 2. Infection Prevention & Control Management of solution and equipment 8.3 for wound irrigation. 3. Reuse of electrical razors for personal hygiene Sharing of personal items String cords and call bells in patient care areas Infection Prevention & Control Wound Management Principles 8.11 Individual Site Specific Protocols, Policies & Information Refer to Table of Contents located in this section 1.5

6 Medical Device Reprocessing 1. Single-use Medical Devices Event Notification Process - Event Notification Process Sterilizer Quality Assurance Monitoring Endoscopes, Reprocessing (undergoing High Level Disinfection) Definitions 11.1 Appendix 1. Hand Hygiene Quick Reference Chart Hand Hygiene Procedure: Using an Alcohol-Based Hand Rub Hand Hygiene Procedure: Using Plain Soap or Antimicrobial Soap Personal Protective Equipment Criteria for Respiratory Infections Donning Personal Protective Equipment (PPE) Removing Personal Protective Equipment (PPE) Prior to Exiting 12.6 Patient Room 7. Removing Personal Protective Equipment (PPE) Immediately After 12.7 Exiting Patient Room 8. Air Changes for Removal of Airborne Contaminants Cover Your Cough 9.1 Cover Your Cough Pamphlet English Cover Your Cough Poster #1 English Cover Your Cough Poster #2 English Cover Your Cough Bilingual Additional Precautions Signs English 10.1 Airborne Precautions Sign Airborne/Contact Precautions Sign Contact Precautions Sign Droplet Precautions Sign Droplet/Contact Precautions Sign Additional Precautions Signs Bilingual

7 12. Patient and Family Information Sheets for Additional Precautions - English 12.1 Airborne Precautions Airborne/Contact Precautions Contact Precautions Droplet Precautions Droplet/Contact Precautions Patient and Family Information Sheets for Additional Precautions Bilingual 14. Hand Hygiene Signs 14.1 Wash Your Hands Sign 4.25 x Please Use the Hand Rub Provided Sign 4.25 x Please Use the Hand Rub Provided Sign 8.5 x Hand Hygiene Signs Bilingual Fact Sheets 15.1 Extended Spectrum Beta Lactamase (ESBL) Producing Bacteria Fact Sheet for Patient, Family & Visitors 15.2 Methicillin Resistant Staphylococcus aureus (MRSA) Fact Sheet for Patient, Family & Visitors 15.3 Vancomycin Intermediate Resistant Staphylococcus aureus (VISA) and Vancomycin Resistant Staphylococcus aureus (VRSA) Fact Sheet for Patient, Family & Visitors 15.4 Vancomycin-Resistant Enterococci (VRE) Fact Sheet for Patient, Family & Visitors 15.5 Extended Spectrum Beta Lactamase (ESBL) Producing Bacteria Fact Sheet for Healthcare Workers 15.6 Methicillin Resistant Staphylococcus aureus (MRSA) Fact Sheet for Healthcare Workers 15.7 Vancomycin Intermediate Staphylococcus aureus (VISA) and Vancomycin Resistant Staphylococcus aureus (VRSA) Fact Sheet for Healthcare Workers 15.8 Vancomycin-Resistant Enterococci (VRE) Fact Sheet for Healthcare Workers 15.9 Testing for Methicillin Resistant Staphylococcus aureus (MRSA) Fact Sheet for Patient & Family Testing for Vancomycin-Resistant Enterococci (VRE) Fact Sheet for Patient & Family 1.7

8 16. Infection Prevention & Control Signs 16.1 Price List Ordering Process References

9 Additional Precautions TABLE OF CONTENTS ALPHA LISTING Page Number Airborne Precautions 5.3 Introduction 5.3 Indications for Airborne Precautions 5.3 Accommodation 5.3 Healthcare Workers 5.4 Hand Hygiene 5.5 Personal Protective Equipment 5.5 Patient Transport 5.6 Patient/Family 5.6 Visitors 5.7 Airborne/Contact Precautions 5.18 Introduction 5.18 Indications for Airborne/Contact Precautions 5.18 Accommodation 5.18 Healthcare Workers 5.19 Hand Hygiene 5.19 Personal Protective Equipment 5.20 Patient Transport 5.21 Equipment and Environment 5.22 Patient/Family 5.23 Visitors 5.23 Contact Precautions 5.9 Introduction 5.9 Indications for Contact Precautions 5.9 Accommodation 5.10 Hand Hygiene 5.10 Personal Protective Equipment 5.10 Patient Transport 5.11 Equipment and Environment 5.11 Patient/Family 5.12 Visitors 5.12 Discontinuation of Additional Precautions 5.2 DATE ISSUED: REVISION DATE: 1.9

10 Droplet Precautions 5.13 Introduction 5.13 Indications for Droplet Precautions 5.13 Accommodation 5.13 Hand Hygiene 5.14 Personal Protective Equipment 5.14 Patient Transport 5.15 Patient/Family 5.15 Visitors 5.16 Droplet/Contact Precautions 5.25 Introduction 5.25 Indications for Droplet/Contact Precautions 5.25 Accommodation 5.25 Hand Hygiene 5.26 Personal Protective Equipment 5.26 Patient Transport 5.28 Equipment and Environment 5.28 Patient/Family 5.29 Visitors 5.30 Implementation of Additional Precautions 5.1 Introduction 5.1 Appendix Additional Precautions Signs English Airborne Precautions Sign Airborne/Contact Precautions Sign Contact Precautions Sign Droplet Precautions Sign Droplet/Contact Precautions Sign Additional Precautions Signs Bilingual Air Changes for Removal of Airborne Contaminants 12.8 ARO Fact Sheets - Extended Spectrum Beta Lactamase (ESBL) Producing Bacteria Fact Sheet for Patient, Family & Visitors Methicillin Resistant Staphylococcus aureus (MRSA) Fact Sheet for Patient, Family & Visitors Vancomycin Intermediate Resistant Staphylococcus aureus DATE ISSUED: REVISION DATE:

11 (VISA) and Vancomycin Resistant Staphylococcus aureus (VRSA) Fact Sheet for Patient, Family & Visitors Vancomycin-Resistant Enterococci (VRE) Fact Sheet for Patient, Family & Visitors Extended Spectrum Beta Lactamase (ESBL) Producing Bacteria Fact Sheet for Healthcare Workers Methicillin Resistant Staphylococcus aureus (MRSA) Fact Sheet for Healthcare Workers Vancomycin Intermediate Resistant Staphylococcus aureus (VISA) and Vancomycin Resistant Staphylococcus aureus (VRSA) Fact Sheet for Healthcare Workers Vancomycin-Resistant Enterococci (VRE) Fact Sheet for Healthcare Workers Testing for Methicillin Resistant Staphylococcus aureus (MRSA) Fact Sheet for Patient & Family Testing for Vancomycin-Resistant Enterococci (VRE) Fact Sheet for Patient & Family Cover Your Cough Cover Your Cough Pamphlet English 12.9 Cover Your Cough Poster #1 English Cover Your Cough Poster #2 English Cover Your Cough Bilingual Donning Personal Protective Equipment (PPE) 12.5 Hand Hygiene Procedure: Using an Alcohol-Based Hand Rub 12.2 Hand Hygiene Procedure: Using Plain Soap or Antimicrobial Soap 12.3 Hand Hygiene Quick Reference Chart 12.1 Hand Hygiene Signs Wash Your Hands Sign 4.25 x Please Use Alcohol-Based Hand Rub Sign 4.25 x Please Use Alcohol-Based Hand Rub Sign 8.5 x Hand Hygiene Signs Bilingual Infection Prevention & Control Signs - Infection Prevention & Control Signs Price List Infection Prevention & Control Signs Ordering Process DATE ISSUED: REVISION DATE:

12 Patient and Family Information Sheets for Additional Precautions - English Airborne Precautions Airborne/Contact Precautions Contact Precautions Droplet Precautions Droplet/Contact Precautions Patient and Family Information Sheets for Additional Precautions Bilingual Personal Protective Equipment Criteria for Respiratory Infections 12.4 Removing Personal Protective Equipment (PPE) Prior to Exiting 12.6 Patient Room Removing Personal Protective Equipment (PPE) Immediately After 12.7 Exiting Patient Room Clinical Presentation/Microorganism/Infectious Disease Table 6.1 Definitions 11.1 Individual Site Specific Protocols, Policies & Information Refer to Table of Contents located in this section Introduction After Hours Coverage 2.5 Breaking the Chain of Infection 2.8 Chain of Infection 2.6 Links in the Chain of Infection 2.6 Purpose of the WRHA Infection Prevention and Control Manual 2.1 Site Specific Infection Prevention & Control Program 2.3 Transmission of Microorganisms 2.9 WRHA Infection Prevention & Control Program 2.2 Medical Device Reprocessing Medical Device Reprocessing - Event Notification Process 10.5 Single-use Medical Devices 10.1 Sterilizer Quality Assurance Monitoring DATE ISSUED: REVISION DATE:

13 References 13.1 Routine Practices Hand Hygiene 4.3 Important Factors in Hand Hygiene 4.3 When to Perform Hand Hygiene 4.4 Agents Used for Hand Hygiene 4.5 How to Perform Hand Hygiene 4.5 Patient/Visitors 4.6 Introduction 4.1 Patient Management 4.9 Accommodation 4.9 Equipment 4.10 Environmental Control 4.11 Specimen Collection 4.11 Visitors 4.12 Education 4.12 Postmortem Care 4.12 Personal Protective Equipment 4.7 Gloves 4.7 Gowns 4.8 Masks 4.8 Eye Protection 4.8 Face Protection 4.9 Respiratory Etiquette 4.9 Specific Disease Protocols Acquired Immunodeficiency Syndrome (AIDS) Human Immunodeficiency Virus Antibiotic Resistant Organisms Extended Spectrum Beta Lactams (ESBLs) Methicillin-Resistance Staphlococcus Aureus (MRSA) Vancomycin Resistant Enterococci (VRE) Vancomycin-Resistant Intermediate Staphylococcus Aureus (VISA) Vancomycin-Resistant Staphlococcus Aureus (VRSA) DATE ISSUED: REVISION DATE:

14 Creutzfeldt-Jakob Disease (CJD) Diarrhea Bacterial Clostridium difficile associated diarrhea (CDAD) Other infectious microorganisms Viral Group A Streptococcus Hepatitis Hepatitis A (HAV) Hepatitis B (HBV) Hepatitis C (HCV) Immunocompromised Condition Influenza (Seasonal) Measles/Rubeola Meningitis Hemophilus meningitis Meningococcal meningitis Pneumococcal meningitis Viral meningitis Mumps Pandemic Influenza P1 Pediculosis (Lice) Pertussis Rubella (German Measles) Scabies Severe Respiratory Illness Tuberculosis (TB) DATE ISSUED: REVISION DATE:

15 Varicella Zoster Virus (VZV) Chickenpox (Varicella) Shingles (Herpes Zoster) Specific Infection Prevention and Control Practices 4% Chlorhexidine to 2% Chlorhexidine for hand antisepsis and 8.1 cleansing Infection Prevention & Control (IP & C) Wound Management Principles 8.11 Infection Prevention & Control Management of solution and equipment 8.3 for wound irrigation Reuse of electrical razors for personal hygiene 8.5 Sharing of personal items 8.7 String cords and call bells in patient care areas 8.9 WRHA Infection Prevention and Control Policies & Operational Directives Admission Screening of Patients for Antibiotic Resistant Organisms (MRSA & VRE) 3.13 Cleaning of Non-Critical, Reusable Items 3.15 Gels, Ultrasound and Medical 3.10 Nursing Foot Care Infection Prevention & Control Management 3.1 Routine Practices for Reducing the Risk of Infection Transmission DATE ISSUED: REVISION DATE:

Infection Prevention Highlights for the Medical Staff. Pamela Rohrbach MSN, RN, CIC Director of Infection Prevention

Infection Prevention Highlights for the Medical Staff. Pamela Rohrbach MSN, RN, CIC Director of Infection Prevention Highlights for the Medical Staff Pamela Rohrbach MSN, RN, CIC Director of Infection Prevention Standard Precautions every patient every time a. Hand Hygiene b. Use of Personal Protective Equipment (PPE)