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Infection Prevention and Control (IPAC)

Infection prevention

KFL&A Public Health provides expert guidance for preventing the spread of infections in settings such as hospitals, long-term care homes, retirement and group homes, physicians' offices, dental practices, and clincis where allied health professionals practice.

Outbreaks

Note: diarrhea is defined as two or more unformed or watery stools within a 24 hour period that is not considered normal for the resident and is not associated with any recent bowel treatment, diet change or medication.

Enteric Outbreak Control Measures Checklist

This checklist is for use during institutional outbreaks of respiratory disease. It lists the actions you should take to limit the spread of disease during the outbreak.

Consult with KFL&A Public Health

Obtain outbreak number from KFL&A Public Health.
Begin an enteric line listing; fax to KFL&A Public Health.
Obtain stool samples from ill residents using enteric outbreak kits and send to Public Health Lab. On the weekend, consult with KFL&A Public Health on-call manager before obtaining stool samples.
After hours, store samples in refrigerator (not freezer) and deliver to the lab the next business day.

Notification

Call families and notify them of the outbreak.
Notify visitors - post signs on entrance doors to facility.
Notify the Ministry of Health and Long-Term Care compliance advisor.

Implement droplet and contact precautions

Increase hand hygiene. Alcohol-based hand rub containing at least 70% alcohol is preferred when hands are not visibly soiled.
Reinforce hand hygiene with staff, residents, visitors and volunteers. Assist residents with compliance.
Gloves - upon entry to room, discard after use, perform hand hygiene.
Gowns - for direct resident care; fluid resistant preferred.
Masks and eye protection for vomiting or explosive diarrhea.

Environmental controls

Increase cleaning frequency of high touch surfaces.
Increase cleaning and disinfection of washrooms and commodes to twice daily for rooms in isolation.
Dedicate resident care equipment to ill resident; if not dedicated, clean and disinfect between residents.
Handle linen and garbage carefully.
Ensure chemical concentration of the disinfectant meets manufacturer's instructions and the solutions are changed frequently; pay special attention to contact times.

Outbreak management team meeting

Form an outbreak management team with representation from each operational area of the facility, include those with decision-making authority and a representative from KFL&A Public Health.
Differentiate between a sporadic case and an outbreak-associated case when identifying the last outbreak-related resident and staff case.

Residents

Restrict cases to room for 48 hours after last episode of vomiting or diarrhea.
Medical and other appointments - if unable to reschedule, notify transfer service and infection control practitioner at the receiving hospital or facility regarding details of the outbreak (whether resident is a case).
Limit large group activities throughout facility.
Small group activities on affected unit - well residents only.
No communal activities with outside groups on affected unit.
Group activities on unaffected units may continue.

Staff and volunteers

Exclude ill staff and volunteers for 48 hours after last episode of vomiting or diarrhea.
Cohort staff - if possible dedicate staff for ill residents only or assign staff who have recovered from the illness.
Working at other facilities is not advised but will depend on individual facility policy.

Visitors

Visitors should not enter facility if they are ill; post signage.
Limit number of visitors while resident is in isolation; provide education on hand hygiene and use of personal protective equipment.

Admissions and transfers

New admissions - preferably to non-affected unit or floor; inform family, not currently ill
Re-admission - cases: provide appropriate isolation; non-cases: allowed.
Transfers to other long-term care homes - consult infection control practitioner at the home, advise transfer service.
Transfer to hospital - advise hospital and ambulance or transfer service and infection control practitioner at receiving hospital.

Ongoing monitoring

Conduct ongoing surveillance to identify new cases.
Monitor status of ill residents and staff.
Update line listings of residents and staff; fax daily to KFL&A Public Health (not on weekends).
Audit for compliance with control measures.

Declare outbreak over

Consult with KFL&A Public Health to determine when to declare outbreak over.
Review audits: Has there been sustained adherence to infection control outbreak measures including hand hygiene, use of personal protective equipment, environmental and equipment cleaning?

Respiratory Outbreak Control Measures Checklist

Consult with KFL&A Public Health

Obtain outbreak number from KFL&A Public Health.
Begin a respiratory line listing; fax to KFL&A Public Health.
Obtain swabs from ill residents using nasopharyngeal kits and send to Public Health Lab; on the weekend, consult with KFL&A Public Health manager on-call before obtaining samples.

Notification

Call families and notify them of the outbreak.
Notify visitors - post signs on entrance doors to facility.
Notify the Ministry of Health and Long-Term Care compliance advisor.

Implement droplet and contact precautions

Increase hand hygiene. Alcohol-based hand rub containing at least 70% alcohol is preferred when hands are not visibly soiled.
Reinforce hand hygiene with staff, residents, visitors and volunteers. Assist residents with compliance.
Gloves - upon entry to room, discard after use, perform hand hygiene.
Gowns - for direct resident care; fluid resistant preferred.
Masks and eye protection - fluid resistant surgical or procedure mask for direct resident care; discard after use; use within two meters of a coughing resident.

Environmental controls

Increase cleaning frequency of high touch surfaces.
Dedicate resident care equipment to ill resident; if not dedicated, clean and disinfect between residents.
Handle linen and garbage carefully.
Ensure chemical concentration of the disinfectant meets manufacturer's instructions and the solutions are changed frequently; pay special attention to contact times.

Outbreak management team meeting

Form an outbreak management team with representation from each operational area of the facility, include those with decision-making authority and a representative from KFL&A Public Health.
Differentiate between a sporadic case and an outbreak-associated case when identifying the last outbreak-related resident and staff case.

Residents

Restrict cases to room - for infectious period (usually five days) or until symptoms are completely resolved, whichever is shorter.
Restrict well residents to unit.
Antiviral treatment of all cases to start within 48 hours of symptom onset (confirmed influenza only).Antiviral prophylaxis recommended for all residents on affected unit (confirmed influenza only) to continue until outbreak is over.
Offer immunization and antivirals to unimmunized residents.
Medical and other appointments - if unable to reschedule, notify transfer service and infection control practitioner at the receiving hospital or facility regarding details of the outbreak (whether resident is a case).

Staff and volunteers

Exclude ill staff and volunteers for five days after onset of symptoms or until symptoms are completely resolved; whichever is shorter.
If influenza is suspected or diagnosed, the person must remain off work or placement until five days has passed.
Cohort staff - if possible dedicate staff to care for ill residents only.
Working at other facilities - if cause unknown, not recommended; if confirmed influenza, staff must be immunized and should change uniform before working at other facility.
If confirmed influenza, contact KFL&A Public Health Communicable Disease team for "Staffing during an Influenza Outbreak" algorithm.

Visitors

Visitors should not enter facility if they are ill; post signage.
Limit number of visitors while resident is in isolation; provide education on hand hygiene and use of personal protective equipment.

Admissions and transfers

New admissions - preferably to non-affected unit or floor; must be immunized, consider use of antivirals, and consult with KFL&A Public Health.
Re-admission: cases - allowed; non-cases - consult with KFL&A Public Health.
Transfers to other Long-Term Care Home - consult with KFL&A Public Health, permitted.
Transfer to hospital - advise hospital and ambulance or transfer service.

Ongoing monitoring

Conduct ongoing surveillance to identify new cases.
Monitor status of ill residents and staff.
Update line listings of residents and staff; fax daily to KFL&A Public Health (not on weekends).
Audit for compliance with control measures.

Declare outbreak over

Consult with KFL&A Public Health to determine when to declare outbreak over.
Review audits: Has there been sustained adherence to infection control outbreak measures including hand hygiene, use of personal protective equipment, environmental and equipment cleaning?

Reprocessing

Requirements for reprocessing rooms

Community health care settings that reprocess medical equipment must be configured with a separate area away from patient and clean areas to avoid cross contamination. If a physically separate reprocessing area is not possible, a room that spatially separates clean and dirty reprocessing areas and has a one-way work flow continually moving from dirty to clean is the minimum requirement. Activities in the reprocessing space must be restricted to reprocessing only. Preparation or processing of specimens (urine, stool, swabs, etc.) may not take place in the reprocessing space.

Please refer to the CSA standards and PIDAC best practice documents for a full listing of all requirements as this fact sheet does not detail an exhaustive list.

Note: this document does not discuss occupational health and safety requirements.

Layout

Separate clean and dirty areas within the reprocessing area.
Create designated areas of adequate size for soiled receiving, cleaning, disinfection (if applicable), drying, packaging, sterilization, documentation and storage.
Create a one-way work flow moving from dirty to clean to prevent cross-contamination of the equipment.

Materials

Materials that are used in the reprocessing room for floors, walls, ceilings, surfaces, backsplash and countertops must:

Be easy to clean. Carpet must not be used.
Be made of a smooth material.
Be non-porous/impermeable.
Be seamless.
Be non-shedding (e.g., ceilings and walls).
Enclose all pipes and plumbing.
Not have open joints or crevices.
Note: laminate materials are not recommended.

Storage

Sterile items must be stored in a separate, enclosed, and limited access area that is protected from moisture. Sterile storage must also be separate from dirty items and away from where cleaning takes place. Shelving in the storage area must be non-porous and cleanable.

Wrapped sterilization pouches must be stored:

In a clean, dry, dust-free area
On closed shelving
Not at floor level
Away from debris, drains, moisture and sinks to maintain sterility until time of use.

If open shelving is used for storage of sterile medical items, shelving should be at least:

25 centimetres (10 inches) off the floor
46 centimetres (18 inches) from the ceiling
5 centimetres (2 inches) from an outside wall

Sinks

A dedicated hand washing sink must be readily accessible and located at the entrance/exit of the reprocessing room.
There must be at least one (preferably two) cleaning sink(s) that is separate from the hand washing sink.
Cleaning sinks must be large enough to soak the largest piece of equipment on-site. This will minimize aerosols during the cleaning process.
Cleaning sinks must be equipped with water ports for flushing of any instruments with lumens.
Sinks must not have an overflow as this can trap bacteria and is difficult to clean.

Temperature, humidity, and ventilation

Review manufacturer's instructions, PIDAC best practice documents, CSA standards and local municipal requirements to determine the appropriate number of air exchanges, temperature and humidity levels for the process/product being used.
Wherever chemical disinfection/sterilization is performed, air quality must be monitored when using products that produce toxic vapours and mists.
The reprocessing room must have ventilation systems appropriate to the process or product being used, to protect the staff and clients.

Miscellaneous

Lighting in the reprocessing room shall be in accordance with CSA Z8000.
Alcohol based hand rub (ABHR) must be located at all entrances to and exits from the reprocessing area.

Resources

Canadian Standards Association. User handbook for medical device reprocessing in community health care settings. SPE-1112-14. March 2014.
Canadian Standards Association. Medical device reprocessing - general requirements. Z314.0-13. March 2013.
Medical Device Reprocessing Association of Ontario
Public Health Ontario
PIDAC Best Practice Documents
PIDAC Best Practices for Cleaning Disinfection and Sterilization of Medical Equipment/Devices (May 2013)
PIDAC Infection Prevention and Control for Clinical Office Practice (April 2015)
PIDAC Best Practices for Environmental Cleaning for Prevention and Control of Infections
College of Physicians and Surgeons of Ontario (CPSO) Infection Control in the Physician's Office

Reprocessing in community health care settings

Following best practices for cleaning, disinfection and sterilization of reusable medical items can prevent the transmission of infection to clients/patients and healthcare providers.

The Provincial Infectious Diseases Advisory Committee (PIDAC) has produced provincial best practice documents that detail best practice requirements for all Regulated Health Professionals (RHP). These documents apply to all RHPs. RHPs include, but are not limited to, physicians, dentists, nurses, physiotherapists and chiropractors.

Integrating best practice standards into your daily practice will help to protect the health of your clients and staff.

Reusable medical items must be cleaned and then either disinfected or sterilized after each use unless labeled as a single use item. This is known as reprocessing. Items meant to be reprocessed are classified into three categories: critical, semi-critical, and non-critical. Critical items (items that enter sterile tissue or the vascular system) must be cleaned followed by sterilization after each use (e.g., biopsy forceps, tenaculums, dental hand pieces). Semi-critical items (items that come in contact with non-intact skin or intact mucous membranes) must be cleaned, followed by a minimum of high level disinfection; however, sterilization is preferred (e.g., metal specula, respiratory therapy equipment). Non-critical items (which contact intact skin only) must be cleaned, followed by a low-level disinfectant (e.g., blood pressure cuff, stethoscope).

Manufacturer instructions

It is important to always follow the manufacturer's instructions for maintenance and use of medical equipment. Have the manufacturer's instructions on-site and review these instructions for all equipment in your office in order to understand how to reprocess each item.

The manufacturer's instructions will detail:

Minimum sterilization time, temperature and pressure requirements
Packaging instructions for items to be sterilized
Safe operating instructions
Maintenance requirements and frequency

Tips to consider when reprocessing (note: this is not an exhaustive list of requirements):

A designated area must be used to reprocess equipment
Cleaning must always take place prior to disinfection or sterilization
A separate and dedicated cleaning sink must be used for cleaning items. A hand washing sink must not be used.
Cleaning brushes must be single use or cleaned and disinfected after each use.
Never reuse or reprocess an item labeled "for single use only" or "disposable".
Disassemble equipment according to manufacturer's instructions.
Hinged instruments must be reprocessed in the open and unlocked position.
Biological indicators (spore tests) must be run every day the sterilizer is used (or every load if using implantable devices).
Staff must log each sterilization cycle including date, time, temperature, pressure, item(s) sterilized, and staff initials for every load.
Items run through a sterilizer must be wrapped in approved sterilization package (wrap or pouch).
Internal chemical indicators must be placed inside every sterilization package as per current PIDAC best practice.
External chemical indicators must be used with every packaged item to indicate that the item has been sterilized.
A Bowie-Dick test (air removal test) must be completed on pre-vacuum sterilizers every day the sterilizer is used.

Biological indicators (spore testing)

The sterilization process must be monitored to ensure the integrity of the process. Spore test vials or strips must be run in the sterilizer every day it is used (or every load if using implantable devices). Once the spore test is run it must be incubated for a specified period of time before the results can be read.

Run a control test in addition to the spore test and at the same frequency.
Additional spore testing may be required (i.e. repairs, relocation of machine). See PIDAC best practice documents for more information.
It is important that a process be in place in the event of a failed spore test.

Labeling sterilization pouches

Labeling sterilization pouches will help your office track and rotate sterilized items. This is particularly helpful when there is a spore test failure and items must be tracked and held pending further testing.

Sterile packaged items must be labeled and include:

Date reprocessed
Load and lot number
Item(s) in the pouch
Staff member's initials

Remember to write on the plastic side of the pouch only and not the paper side as this could allow the ink to penetrate the pouch and render it not sterile.

Note: Review PIDAC and CSA documents for temperature, humidity, and ventilation requirements.

Resources

For more information on reprocessing and the minimum standards in Ontario please review the following documents and links:

Reproduced with the permission of Wellington-Dufferin-Guelph Public Health.

Cleaning, disinfection, and sterilization of reusable medical items

Never reuse or reprocess an item intended for single use.
Follow manufacturer's instructions for the use, maintenance and reprocessing of medical items.
Reprocess medical items in a separate designated area.
Disassemble items according to manufacturer's instructions.
Reprocess hinged instruments in the open and unlocked position.
Use a dedicated sink to clean items (not a handwashing sink).
Always clean items prior to disinfection or sterilization.
Items must be sterilized in approved packaging (wrap or pouch).
Put an internal chemical indicator inside the sterilization package.
External chemical indicators must be used on the sterilization package.
Label sterilization package with date, items, lot number and staff initials (do not write on paper side of package).
Log the sterilizer cycle including date, item, time, temperature, pressure and staff initials.
Clean and disinfect reusable cleaning brushes after every use.
Do spore testing every day the sterilizer is used (see PIDAC document for additional requirements).

Note: This is not an exhaustive list of requirements. Follow the applicable Canadian Standards Association (CSA) and Provincial Infectious Diseases Advisory Committee (PIDAC) documents that detail best practice requirements for all Regulated Health Professionals (RHP) for cleaning, disinfection and sterilization.

Reproduced with the permission of Wellington-Dufferin-Guelph Public Health.