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Appendix 3: Standard & additional precautions

Page content: General | Standard precautions | Additional precautions | Outline of requirements for specified categories of additional precautions | Handwashing | Personal protective equipment | Environmental control | Further information

General

Infection control and prevention uses a risk management approach to minimise or prevent the transmission of infection. Standard and additional precautions principles and practice are based on the mode of transmission of an infectious agent.

Standard precautions are work practices required for the basic level of infection control. They include good hygiene practices, particularly washing and drying hands before and after patient contact, the use of protective barriers which may include gloves, gowns, plastic aprons, masks, eye shields or goggles, appropriate handling and disposal of sharps and other contaminated or clinical (infectious) waste, and use of aseptic techniques.

Standard precautions apply to all patients regardless of their diagnosis or presumed infection status, and in the handling of:

  • blood
  • all other body fluids, secretions and excretions (except sweat), regardless of whether they contain visible blood
  • non-intact skin
  • mucous membranes (mouth and eyes)
  • standard precautions also apply to dried blood and other body substances, including saliva.

Standard precautions should be considered minimum requirements for infection control. Implementing standard precautions minimises the risk of transmission of infection from person to person even in high-risk situations.

Standard precautions should be implemented at all times particularly when patients are undergoing invasive procedures, including catheterisation, cannulation or intubation. Health services that offer these procedures should provide detailed protocols for patient management in their infection control procedures manuals.

Additional precautions are work practices that should be applied in a health care setting for patients known, or suspected, to be infected or colonised with infectious agents that may not be contained using standard precautions alone.

Standard precautions

The use of standard precautions is essential as the primary strategy for the successful minimisation of transmission of health care associated infection because:

  • infectious patients may not show any signs or symptoms of infection that may be detected in a routine history and medical assessment
  • a patient’s infectious status is often determined by laboratory tests that may not be completed in time to provide emergency care
  • patients may be infectious before laboratory tests are positive or symptoms of disease are recognised (the window period of disease)
  • people may be placed at risk of infection from those who are asymptomatic but infectious.

Standard precautions for infection control in health care settings consist of the following work practices:

  • aseptic technique for all invasive procedures, including appropriate use of skin disinfectants
  • personal hygiene practices, particularly hand washing and drying before and after all significant patient contacts
  • the use of 70% alcohol-based chlorhexidine (0.5%) hand rub solutions as an adjunct to hand washing
  • use of personal protective equipment, which may include gloves, impermeable gowns, plastic aprons, masks/face shields and eye protection
  • appropriate handling and disposal of sharps and other clinical (infectious) waste
  • appropriate reprocessing of reusable equipment and instruments, including appropriate use of disinfectants
  • environmental controls, including design and maintenance of premises, cleaning and spills management including appropriate use of disinfectants
  • appropriate provision of support services such as laundry and food services.

Additional precautions

Additional Precautions are used for patients known or suspected to be infected or colonised with epidemiologically important or highly transmissible pathogens that can transmit/cause infection by the following means:

  • airborne transmission (e.g. pulmonary tuberculosis, chickenpox, measles)
  • droplet transmission of respiratory secretions (e.g. rubella, pertussis, influenza)
  • contact transmission (direct or indirect) with patients who may be disseminators of infectious agents of special concern (e.g. the dry skin of those colonised with Multi-resistant Staphylococcus aureus [MRSA], faecal contamination from carriers of vancomycin-resistant enterococci [VRE] or contaminated surfaces)
  • inherent resistance to standard sterilisation procedures or other disease-specific means of transmission where standard precautions are not sufficient (e.g. patients with known or suspected Creutzfeldt-Jakob disease)
  • any combination of these routes.

Additional precautions are designed to interrupt transmission of infection by these routes and should be used, in addition to standard precautions, when standard precautions alone might not contain transmission of infection. Additional precautions may be specific to the situation for which they are required, or may be combined where microorganisms have multiple routes of transmission.

Additional precautions should be tailored to the particular infectious agent involved and the mode of transmission, and may include one or any combination of the following:

  • allocation of a single room with ensuite facilities
  • a dedicated toilet (to prevent transmission of infections that are transmitted primarily by contact with faecal material, such as for patients with infectious diarrhoea or gastroenteritis caused by enteric bacteria or viruses)
  • cohorting (room sharing by people with the same infection) may be an alternative if single rooms are not available
  • special ventilation requirements (e.g. monitored negative air pressure in relation to surrounding areas)
  • additional use of personal protective equipment (e.g. health care workers attending to patients in respiratory isolation should wear a well-fitting mask: a 0.3-mm particulate filter mask (P2 or N95 mask) is recommended for tuberculosis)
  • rostering of immune health care workers to care for certain classes of infectious patients (eg chickenpox)
  • dedicated patient equipment
  • restricted movement of both patients and health care workers.

Additional precautions are not required for patients with bloodborne viruses, such as HIV, hepatitis B virus or hepatitis C virus, unless there are complicating infections, such as pulmonary tuberculosis.

To minimise the exposure time of other people in office practices or hospital waiting rooms, people identified as ‘at risk’ of transmitting droplet or airborne diseases (e.g. a child with suspected chicken pox) should be subject to additional precautions including isolation and should be attended to before other people waiting for treatment.

An outline of the application of additional precautions for infections with airborne, droplet or contact transmission is shown in the following table.

Outline of requirements for specified categories of additional precautions

Requirement Additional precautions by transmission route
Item/Device Airborne Droplet Contact
Gloves Nil Nil For all manual contact with patient, associated devices and immediate environmental surfaces
Impermeable apron/gown Nil Nil When health care worker’s clothing is in substantial contact with the patient, items in contact with the patient, and their immediate environment

Respirator or mask.

Refer to AS 4381:2000 for additional information

P2/N95 particulate respirator for tuberculosis only. All others, use face mask suited to the purpose such as a mask that filters to o.1 microns and has a splash resistant shield. Yes —mask* Protect face if splash likely
Goggles/face-shields Protect face if splash likely Protect face if splash likely Protect face if splash likely
Special handling of equipment As per standard precautions As per standard precautions Single use or reprocess before reuse on next patient (includes all equipment in contact with patient)
Single room

Yes or Cohort patients with same infection.

Door closed.

Yes or Cohort patients with same infection.

Door closed.

If possible, or cohort with patient with the same infection (eg methicillin-resistant Staphylococcus
aureus)
Negative pressure Essential for pulmonary TB No No
Transport of patients

Appropriate mask* for patient

Notify area receiving patient

Appropriate mask* for patient

Notify area receiving patient

Notify area receiving patient
Other Encourage patients to cover nose and mouth when
coughing or sneezing and
wash their hands after blowing nose.
Provide one metre of separation between patients
in ward accommodation
Provide one metre of
separation between patients
in ward accommodation
Remove gloves and gown, and
wash hands before leaving
patient’s room

* Refer to Australian Standards:
AS 4381:2000 Single-use face masks for use in health care, for additional information
AS/NZS 1715 Selection, use and maintenance of respiratory protective devices
AS/NZS 1716:1994 Respiratory protective devices

Handwashing

  • Wash and dry hands after touching blood, body fluids, secretions, excretions and contaminated items such as equipment or instruments, regardless of whether gloves are worn or not.
  • Wash and dry hands immediately after gloves are removed, after significant patient contact such as contact with or physical examination, emptying drainage bags, undertaking venepuncture or delivery of an injection or going to the toilet.
  • Wash and dry hands following any activities that may transfer microorganisms to other patients or environments.
  • Use plain liquid soap for routine hand washing. Antimicrobial liquid soap solutions are required for invasive procedures and in some situations such as those patients with VRE and MRSA.
  • A 70% alcohol-based chlorhexidine (0.5%) hand rub solution may be used as an adjunct to handwashing and in situations where water is not readily available.

Personal protective equipment

The use of personal protective equipment (PPE) protects the health care worker and others from exposure to blood and body fluids/substances. PPE that complies with relevant Australian Standards should be readily available and accessible in all health services.

Gloves

  • Wear gloves (clean non sterile gloves are adequate) when touching blood, body fluids, secretions, excretions and contaminated items; put on clean gloves just before touching mucous membrane and non-intact skin. Sterile gloves are required for invasive procedures.
  • Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.
  • Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces and before going to another patient. Dispose of gloves in the clinical (infectious) waste or place in a plastic bag and tie before disposing of it in the general household waste.
  • Wash and dry hands immediately after removing gloves to avoid transfer of microorganisms to other patients or environments.

Gowns

  • Wear a gown (a clean non-sterile gown is adequate) to protect skin and prevent soiling of clothing during procedures and patient care activities that are likely to generate splashing or sprays of blood, body fluids, secretions, or excretions or cause soiling of clothing.
  • Select a gown (long- or short –sleeved) that is appropriate for the activity and the amount of fluid likely to be encountered.
  • Remove the used gown as promptly as possible using gloved hands, roll up carefully and place in a linen receptacle for laundering.
  • Wash and dry hands to avoid transfer of microorganisms to other patients and environments.

Masks, eye protection, faceshields

Wear a mask and eye protection or a faceshield to protect mucous membranes of the eyes, nose and mouth:

  • during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions
  • during cleaning activities.

Remove the mask by holding the ties only and dispose of the mask into a clinical waste bin.

Reusable face shields or goggles should be removed carefully and placed in a receptacle for cleaning.

Waterproof aprons

Wear waterproof aprons when splashes or sprays of blood or body fluids/substances are likely such as during cleaning activities.

Remove the used apron as promptly as possible using gloved hands, roll up carefully and place in a clinical waste bin.

Environmental control

Ensure that the health service has adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces and that these procedures are being followed. See Appendix 6 for cleaning and waste disposal.

Further information

  • Australian Government Department of Health and Ageing 2004, Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting (now rescinded)
    www.icg.health.gov.au/