Annual Nursing Competency Updated 2013
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Appropriate Hand Hygiene

Standard Precautions

Transmission-based Precautions

Wear PPE as appropriate

Respiratory Etiquette

Get recommended/required Vaccinations: includes
Influenza

Environmental cleanliness & appropriate waste
management

Proper cleaning, sterilization and disinfection of
patient care equipment

Aseptic Practices to prevent device related
infections
Utilize Resources which include Policies and
Procedures

2
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Healthcare workers can get 100s to
1000s of bacteria on their hands by
doing simple tasks like:
 pulling patients up in bed
 taking a blood pressure or pulse
 touching a patient’s hand
 rolling patients over in bed
 touching the patient’s gown or
bed sheets
 touching equipment like bedside
rails, over bed tables, IV pumps
Casewell MW et al. Br Med J 1977;2:1315
Ojajarvi J J Hyg 1980;85:193
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Hand Hygiene is performed on ungloved hands
using:

Hospital-approved hand sanitizer (foam or gel)
OR

Water and soap at sinks located throughout the
hospital.
Use soap and water when hands are visibly
dirty or contaminated with blood or body fluids.
Alcohol foam or gel is appropriate if your
hands are not visibly soiled.
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At DRaH, performance of hand
hygiene is measured at TWO
basic and important patient care
moments.
“Before Patient Interaction”
immediately before or at the time of
entering a patient room or area*
&
“After Patient Interaction”
immediately after or at the time of exiting
a patient room or area*
* i.e. PACU, radiology or ambulatory area
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Clean your hands:
 before
 donning sterile gloves or exam gloves
 inserting invasive devices into patients
 moving from a contaminated body site
to a clean body site
 eating or drinking
 touching your face
 after
 contact with patients’ intact skin
 contact with patient equipment, linen, supplies
 contact with body fluids, excretions, mucous membranes,
non-intact skin, and soiled dressings
 after removing gloves
 using the restroom
 coughing or blowing your nose
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 Soap & Water:
 Apply hospital-approved soap to hands
 Rub hands together vigorously, paying particular
attention to between fingers, under fingernails, and
backs of hands, for 15 seconds
 Rinse hands in a stream of warm water (avoid extreme
hot or cold water)
 Dry hands with paper towel
 Use towel to turn off water
 Alcohol Foams, Gels, & Liquid Alcohol Hand Rub
 Apply the manufacturer’s recommended amount of
alcohol-based product to palm of one hand (for foam
that’s about the size of a golf ball; for gels or liquids
that’s one push on the dispenser lever)
 Rub hands together, covering all surfaces of hands,
fingers, & wrist until hands are dry.
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Reminders :
 Alcohol Hand Rubs Are Not Indicated:



If hands are visibly dirty or contaminated with
blood, body fluids, or other material
After contact with patients with Clostridium
difficile (C. diff)
After exposure to known or suspected Bacillus
anthracis (anthrax)
Direct patient care
providers must keep
natural nail tips equal
to ¼ inch long or
less. No artificial
nails, gels, overlays
etc. for direct care
givers.
 The hands, including the nails and
surrounding tissue should be free from
infection and /or inflammation for
personnel having patient contact.
 Healthcare workers with dermatitis or
areas of broken, non-intact skin or
potential infection shall refrain from all
patient care activities.
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Before & After Hand Hygiene:
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
Require that blood, body fluids, secretions
and excretions(excluding sweat), mucous
membranes and non-intact skin of all patients
be treated as potentially infectious.

Requires putting the appropriate barrier (i.e.
gloves, gown, mask, eye protection) between
the healthcare worker and the blood or body
fluids of any patient.
“If it is wet and not yours, then use a barrier.”

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

Handle all blood/body fluid as if
infectious
Handle all items contaminated
with blood or body fluid as if
infectious

Follow appropriate Hand
Hygiene Practices

Follow Cough/Respiratory
Etiquette

Follow Safe Injection Practices

Use a surgical mask when
performing spinal
procedures(LP, epidural)

Handle all sharps with care

Discard sharps in rigid
containers

Wear appropriate PPE


Report exposures ASAP
Enforce designated eating
areas (in clinical setting to
prevent contamination of
food/beverages from blood or
body fluids)
Standard Precautions are designed to reduce
the risk of transmission
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Choose PPE appropriate for the
activity to prevent exposure,
PPE includes:

Gloves

Gowns

Face Masks

Eye Protection
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Standard Precautions Include:
Respiratory Etiquette
Instruct symptomatic
persons to:
 cover mouth/nose when
sneezing/coughing
 use tissues and dispose
immediately after use
 clean hands after contact
with respiratory secretions
 wear surgical mask if
tolerated or maintain
spatial separation, >3 feet
if possible.
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To prevent the transmission of infections in a healthcare
setting Safe Injection Practices require:

Use a sterile, single-use, disposable needle and syringe
for each injection given

Dispose of needle and syringe properly after one use

Whenever possible, use of single-dose vials is preferred
over multiple-dose vials

Do not use single bags or bottles of IV solution as a
common source for multiple patients
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
Do not recap, bend, break, or hand-manipulate
used needles.
 If recapping is required, use a one-handed scoop
technique only.

Use safety features when available and place
used sharps in an OSHA approved punctureresistant container.
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
All specimens of blood and body fluids
should be placed in a well constructed
DUHS approved container with a secure lid
to prevent leaking during transport.

A clean outer container / bag must be
utilized in transport to prevent exposure.
 This container / bag should be labeled with a
biohazard symbol for identification.
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
Follow established procedures for
routine care, cleaning, and disinfection
of environmental surfaces, especially
frequently touched surfaces in patientcare areas.


Only hospital approved cleaning products
should be used
Follow manufacturer directions for cleaning
equipment

Ensure all patient care items, bedside
equipment, and frequently touched
surfaces receive daily disinfection.

Privacy curtains are changed/cleaned
when visibly soiled, and at discharge for
Contact Isolation rooms.

Immediately clean spills of any blood or
body fluids with approved DRaH
disinfectant.
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Transmission-based
Precautions are designed for patients
with suspected or documented infection with microorganisms
that are highly transmissible.
Should
be used in addition to Standard Precautions.
Refer
to Standard & Transmission-based Precautions
Policy located on the DRAH Intranet
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In addition to the physician the RN can initiate transmission-based precautions
The patient’s physician is to be notified and an order written in the medical record
Contact Infection Prevention for assistance with isolation requirements
Educate the patient & their family on:
The reason for precautions
How to adhere to appropriate isolation practices
Don’t Forget…Document in the medical record that education was provided!

Place Signage on door or cubical entrance to patient’s environment

Enter order in Medical Record

Communicate isolation precaution at all levels of handoff between care givers

Signage should remain in place until room is cleaned at discharge or transfer
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Educate the patient & their family on:
The reason for precautions
How to adhere to appropriate isolation practices
Document in the medical record that education was provided

Patient Education is currently available on all units:

FAQs MRSA

FAQs VRE

FAQs Clostridium difficile

Understanding Isolation Precautions

Understanding Multi-drug Resistant Organisms

Hand Hygiene for Patients & Visitors
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


Patients on transmission-based (isolation) precautions should not
leave their room unless medically necessary (i.e. part of plan of care).
Whenever feasible, the patient’s procedure shall be done in the
patient’s room.
 If a procedure cannot be done in the patient’s room, then it is
preferred that the patient’s procedure be scheduled as the last
patient.
PPE is not to be worn in transport unless:
 healthcare worker transporting the patient is providing direct patient
care during transport.
 A second healthcare worker assists in transport, is considered
“clean” and shall not wear PPE.
 shall proceed ahead of patient and transport staff to open doors,
press elevator buttons, etc.
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When






ambulation/transport is necessary:
Upon leaving room, patient to perform hand hygiene.
A clean gown should be placed on the patient.
Clean linens shall be placed over the patient on the
stretcher or wheelchair to serve as a barrier.
Patients with draining wounds shall have a clean/dry
dressing.
Patients on Droplet or Airborne precautions shall
wear a surgical mask when outside their room.
Personnel in the receiving area shall be notified of the
isolation status of the patient prior to transport.
 Isolation status shall be communicated in patient
care handoff
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
Visitors who cannot comply with wearing of required PPE may not
visit with patient(s) on transmission-based (isolation) precautions.

Children less than 12 years old should not visit patients on
transmission-based (isolation) precautions due to potential
inappropriate PPE use.
 Exceptions may apply for special circumstances with Infection
Prevention input and physician approval.

Visitors of patients on Airborne Precautions should be limited to
immediate adult household members who have had recent contact
with the patient
 Visitors shall wear a N95 respirator while in the patient’s room.
 Visitors are not fit-tested for the N95; however, healthcare staff
shall demonstrate how to wear the N95 respirator. (Refer to
Patient Care Manual: Tuberculosis Control Plan attachment for
fitting a respirator).

Provide education and document completion
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 Contact- Wear gown and gloves. Used for patients with known
or suspected MRSA, VRE, ESBLs, RSV, Bedbugs, Shingles, etc.
 Contact /Special Enteric- Wear gown and gloves. Used for
patients with known or suspected Clostridium difficile,
Norovirus, etc. (soap and water only for Hand Hygiene)
 Droplet- Wear Surgical mask. Used with patients with known or
suspected Meningitis, Influenza, Pertussis, etc.
 Airborne- Wear N95 mask or PAPR. Used for patients with TB or
r/o TB, active Chickenpox, Measles, etc.
 Special Airborne/Contact-Wear gown, gloves, mask(N95 or
PAPR). Used for patients with emerging infectious agent of
unknown cause/origin
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

Contact Precautions are used
for patients who are suspected
or known to be infected with
organisms that can be
transmitted by:
 direct contact with the patient (hand
or skin-to-skin contact that occurs
when performing patient care
activities that require touching the
patient’s dry skin)
 indirect contact with environmental
surfaces or patient-care items in the
patient’s environment.

This isolation category
requires the use of gloves and
gown to enter the room
regardless of patient contact.
Examples:
 MRSA
 VRE
 Rashes
 ESBLs
(Extended-spectrum Beta-lactamase resistance)
 KPC
(Klebsiella pneumoniae Carbapenem-resistance)
 Varicella (Chicken Pox)
 Scabies
 Bedbugs
 Draining Wounds
 Shingles (non disseminated)
Use in addition to Standard
Precautions!
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

Special Enteric Precautions are
designed to reduce
transmission of organisms that
can easily survive in the
environment once shed from
the human body.
Special Enteric Precautions
include Contact Precautions
plus hand hygiene by soap
and water.

Examples:
 Clostridium difficile (C.diff)
 Norovirus
 Hand hygiene with soap and
water must be used when
leaving the patient’s room /
environment in order to remove
the organism and/or spores.
Use in addition to Standard
Precautions!
31


Droplet Precautions are for
known or suspected infections
with microorganisms transmitted
by droplets (large-particle
droplets greater than 5 µm in
size).
Droplets are generated by the
patient during:





Coughing
Sneezing
Talking
Performance of procedures involving
the respiratory tract.

Examples:
 Meningitis
 Influenza
 Mumps
 Pertussis
Transmission can occur by:
 direct contact with droplets
 contact with objects recently
contaminated with respiratory
secretions.
Use in addition to Standard
Precautions!
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

Airborne Precautions are used
for known or suspected
infections with microorganisms
transmitted by airborne droplet
nuclei (small particle residue of 5
µm or less in size).
Place the patient in a private
room that has monitored
negative air pressure in relation
to the surrounding areas.
 If negative air pressure room in
unavailable, portable HEPA filter units
should be used.

Examples:
 Mycobacterium
Tuberculosis (TB)
 Varicella (Chicken Pox)
 Measles
 HEPA should remain in use in the room
for 40 minutes after patient discharge
and before admitting another patient
(CDC TB Guideline, 2005).

Keep the room door closed
and the patient in the room.
Use in addition to Standard
Precautions!
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
This isolation category requires the use of
respiratory protection:
 Positive Air Purifying Respirator (PAPR) or
 N95 mask that has been fit-tested on the user for
entry into the patient’s room.
 Remember, you must be fit-tested ANNUALLY
for the N95 mask.

A Seal Check should be performed to ensure
a proper fit once N95 applied).
 If a proper fit cannot be achieved, do NOT enter the
area requiring respiratory protection.

In the case of varicella or measles, the
individual does not require a PAPR/N95 if
immunity is documented.
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Pathogen/Disease
New Diagnosis
Arrived with
Clostridium Difficile Infection
Contact isolation along with
Contact isolation along with special
(CDI)
special enteric precautions should
enteric precautions should be
be continued in all hospitalized continued in all hospitalized patients
Note: DUHS guidelines
patients with known CDI until the
with known CDI until the time of
differs from current
time of hospital discharge.
hospital discharge.
CDC recommendations
(i.e. is stricter than CDC)
Patients hospitalized longer than 2 Patients hospitalized longer than 2
weeks following resolution of
weeks following resolution of
symptoms and treatment of CDI symptoms and treatment of CDI may
may be removed from contact
be removed from contact isolation
isolation and special enteric
and special enteric precautions with
precautions with Infection
Infection Prevention approval when
Prevention approval when there
the patient has no signs and
are no signs and symptoms of
symptoms of CDI.
CDI.
***** Refer to DRAH
Standard & Transmission
Precautions Policy for
complete list of
discontinuation criteria.
The patient’s room is then
The patient’s room is then terminally
terminally cleaned (may need to
cleaned (may need to transfer
transfer patient to new room).
patient to new room).
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Pathogen/Disease
New Diagnosis
Arrived with
Methicillin Resistant Patients with a NEW (+) positive culture for MRSA or Patients arriving with or readmitted with a
previous culture-positive for MRSA (< 1 year ago)
Staph Aureus (MRSA) a positive culture (+) within the past year are to
remain on contact precautions until they:
should be placed on contact isolation until the
criteria for discontinuation of isolation is met.
Are discharged from our facility or they are shown
to be MRSA negative by meeting ALL of the
following criteria:
Are discharged from our facility or they are shown
to be MRSA negative by meeting ALL of the
following criteria:
•
•
•
•
•
***** Refer to DRAH
Standard & Transmission
Precautions Policy for
complete list of
discontinuation criteria.
Off all antibiotics for 24 hours
Have three (3) consecutive negative nasal
swabs, each one obtained no less than a
week apart (i.e., swabs must be at least 7
days apart).
Have three (3) consecutive negative cultures
from the original site, each one obtained no
less than a week apart. If unable to obtain
culture from original site, this is not necessary.
•
Off all antibiotics for 24 hours
Have three (3) consecutive negative nasal
swabs, each one obtained no less than a
week apart (i.e., swabs must be at least 7
days apart)
Have three (3) consecutive negative cultures
from the original site, each one obtained no
less than a week apart. If unable to obtain
culture from original site, this is not necessary
Note: Most patients infected or colonized with MRSA Patients with a (+) positive MRSA culture > 1
remain colonized with MRSA for months after initial year ago should be placed on contact isolation until
infection despite treatment; thus routine cultures to they are shown to be MRSA negative by meeting
demonstrate resolution of colonization are generally ALL of the following criteria:
not advisable. These patients should automatically
• The patient must be off antibiotics
be placed on contact isolation.
active against MRSA.
• One (1) negative culture from nares.
• All signs of the original site of infection
have resolved, and if possible obtain
culture from original site.
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
Central Line Associated Infections
(CLABSI)

Catheter Associated Urinary Tract Infections
(CAUTI)

Surgical Site Infections
(SSI)
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CRUSH
CLABSI
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COUNTER
CAUTI
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SILENCE
SSI
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Perform proper
HAND HYGIENE
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Infection Prevention & Control Department:
John Engemann, MD
Connie Clark BSN, RN, CIC (x3166)
Brittain Wood BSN, RN (x3076)
Please feel free to contact us 24/7!
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