This document help to hand hygiene; use of gloves, gown, mask, eye protection or face shield, depending on the anticipated exposure; and safe injection practices

1. Planning and Preparing
for Emerging Infectious
Diseases
AN EXERCISE BASED WORKSHOP FOR
RURAL AND CRITICAL ACCESS
HOSPITALS

2. Introductions and Welcome!
• Deb French
• Colorado Hospital Association, Hospital Emergency Preparedness
• Teri Hulett
• Infection Prevention Consultant
•Ashley Baker
• Colorado Hospital Association, Hospital Emergency Preparedness

3. Why a Workshop on Exercising Emerging
Infectious Disease for Rural Hospitals?
•Lessons learned from Ebola and other
infectious disease threats
•Unique challenges facing rural hospitals
•Best line of defense – testing and evaluating
capacity and capabilities for infectious
disease prevention

4. Why a Workshop on Exercising Emerging
Infectious Disease for Rural Hospitals?
•Required to test every three years.
 State Board of Health Rule 6 CCR 1009-5
Preparations for a Bioterrorist Event,
Pandemic Influenza, or an Outbreak by a
Novel and Highly Fatal Infectious Agent or
Biological Toxin

5. Objectives
•Review best practices for transmission-
based precautions
•Review exercise design made easy
concepts
•Identify positive planning aspects and/or
identify gaps in planning through tabletop
exercise

6. A Special Thank You!
•Linda Navrkal, Parkview Medical
Center
•Dee Ann Sierra, Rio Grand
Hospital
•Julie Zangari, St. Anthony
Summit Medical Center
•Laura Wilson, Southeast
Colorado Hospital District
•Mary Rasmusson, Montrose
Memorial Hosp
•Toni Foos, Colorado Hospital
Association
•Dave McGraw, Spanish Peaks
Regional Medical Center
•Mary Pancheri and Melissa
Miccio, Longmont United
Hospital
•Karri Knight, Denver Health
•Brigitte French, Penrose and St.
Francis Health Services
•ASPR, Colorado Department of
Public Health and Environment,
Hospital Preparedness Program
Grant

7. Infection Prevention:
Best Practices for
Transmission-Based
Precautions
TERI HULETT, RN, BSN, CIC, FAPIC
INFECTION PREVENTION CONSULTANT

8. Objectives
• Review the Chain of Infection
• Discuss Hand Hygiene Basics
• Identify Routes of Transmission
• Differentiate Categories of Transmission-
Based Precautions
• Discuss the role of Environmental Services
in Infection Prevention

9. Where do we start?

10. The Chain of Infection
Infectious Agent
Bacteria
Virus
Fungi
Reservoir
People
Environment
Equipment & Water
Portal of Exit
Excretion, secretions, skin, and
droplets
Means of Transmission
Direct/Indirect Contact
Inhalation
Airborne
Portal of Entry
Mucous Membranes
Respiratory & GI Tract
Broken Skin
Susceptible Host
Patient
Staff
Visitor
HCW

11. Breaking the chain of infection
Infectious Agent
Bacteria
Virus
Fungi
Reservoir
People
Environment
Equipment & Water
Portal of Exit
Excretion, secretions, skin,
and droplets
Means of
Transmission
Direct & Indirect Contact
Inhalation
Airborne
Portal of Entry
Mucous Membranes
Respiratory & GI Tract
Broken Skin
Susceptible Host
Patient
Staff
Visitor
HCW
Rapid identification, diagnosis,
and treatment
Education
Environmental Hygiene
Disinfection and
Sterilization
Hand Hygiene
Control of Excretions &
secretions
Proper attire
Hand Hygiene,
Personal Hygiene
Transmission Based Precautions
Aseptic Technique
Wound/catheter care
Hand Hygiene
Transmission based precautions
Environmental Hygiene
Recognition of high risk patients
Treatment of underlying disease
Immunizations

12. Three basic routes of transmission
 Contact
 Direct
 Indirect
 Droplet
 Larger; don’t travel long distances, not infective over time
 Spatial separation (≥ 3 feet)
 Airborne
 Smaller; infective over time and distance
https://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html

13. Hand Hygiene
“Hand Hygiene (HH) has been cited frequently as the single most important
practice to reduce the transmission of infectious agents in healthcare settings and
is an essential element of Standard Precautions.”
The term “hand hygiene” includes:
 Handwashing with soap and water
 Use of alcohol-based products that do not require the use of water (>60% alcohol)
 No artificial nails for those having contact with (high-risk) patients
“CDC/Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend that
artificial fingernails and extenders not be worn by healthcare personnel who have contact
with high-risk patients due to the association with outbreaks of gram-negative bacillus and
candida infections.”
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions:
Preventing Transmission of Infectious Agents in Healthcare Settings http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf

14. What are Transmission Based Precautions ?
Transmission-Based Precautions are designed
to supplement standard precautions in
patients/residents with documented or
suspected infection/colonization of highly
transmissible or epidemiologically important
pathogens.
http://www.mass.edu/mcncps/orientation/m2Transmission.asp

15. Transmission Based Precautions
• Hand Hygiene
• Gown
• Gloves
Contact Precautions
• Hand Hygiene
• Mask
Droplet Precautions
• Hand Hygiene
• Negative pressure room
• PAPR/N-95 Respirator mask
Airborne Precautions
https://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html

16. Rationale
Transmission of infectious agents within a healthcare setting requires three
elements:
1. A source (or reservoir) of infectious agents
2. A susceptible host with a portal of entry receptive to the agent
3. A mode of transmission for the agent
https://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html

17. Breaking the chain of infection transmission
Equipment cleaning Hand Hygiene Compliance w/ Precautions

18. Contact Precautions
“Contact Precautions are intended to prevent transmission of
infectious agents, including epidemiologically important
microorganisms, which are spread by direct or indirect contact with
the patient or the patient’s environment.”
Healthcare personal caring for patients on contact precautions MUST wear an isolation gown and
gloves/personal protective equipment (PPE) for all interactions (that may involve contact with the
patient or potentially contaminated areas in the patients environment)
Donning (putting on) of PPE must occur immediately prior to entry
Doffing (removing) PPE must occur immediately prior to exiting
ANYONE ENTERING THE PATIENT ROOM MUST COMPLY WITH TRANSMISSION BASED PRECAUTIONS
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions:
Preventing Transmission of Infectious Agents in Healthcare Settings http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf

19. PPE Donning
file:///C:/Users/mhule/AppData/Local/Microsoft/Windows/INetCache/IE/E9B9P01K/PPE-Sequence.pdf
6) Added wording that will ensure the training
of staff on the personal protective equipment
purchased. Ensuring the safety of staff by
having sufficient supplies and by being
properly trained with those supplies. This
inconsistency has been witnessed with recent
Ebola response
State Board of Health Rule 6 CCR 1009-5
Preparations for a Bioterrorist Event, Pandemic
Influenza, or an Outbreak by a Novel and
Highly Fatal Infectious Agent or Biological Toxin

20. PPE Doffing
file:///C:/Users/mhule/AppData/Local/Microsoft/Windows/INetCache/IE/E9B9P01K/PPE-Sequence.pdf

21. What’s wrong with this picture?

22. Heightened level of precaution

23. Transport of patient on contact precautions

24. Droplet Precautions
Droplet Precautions are intended to prevent transmission of pathogens
spread through close respiratory or mucous membrane contact with
respiratory secretions.”
“Pathogens requiring droplet precaution do not remain infectious over long
distances in a healthcare facility and so do not require special air handling and
ventilation to prevent droplet transmission.”
• Don face mask (NOT N-95 respirator)prior to entering patient room
• Spacial separation ≥ 3 feet
• Place face mask on patient for transport outside of room
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation
Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf

25. Airborne Precautions
“Airborne Precautions prevent transmission of infectious
agents that remain infectious over long distances when
suspended in the air (measles, chicken pox, TB)”
Patient must be placed in an airborne isolation infection room (AIIR):
this is a single-patient room equipped with special air handling and
ventilation capacity that complies with specific regulatory guidelines:
• monitored negative pressure relative to the surrounding area
• 6 or 12 air exchanges/hour
• Air exhausted directly to the outside or
recirculated through a HEPA filtration system before return
• Door MUST remain closed
• Staff must wear N-95 respirator mask or PAPR
• Visitors entering must wear surgical mask
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions:
Preventing Transmission of Infectious Agents in Healthcare Settings http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf

26. But what’s missing in the discussion?
 Apply to all patients receiving care in hospitals,
regardless of their diagnosis or presumed infection
status
 Designed to reduce the risk of transmission of
microorganisms from both recognized and
unrecognized sources of infections
 Under standard precautions, blood and body
fluids of all patients are considered potentially
infectious
https://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
Standard Precautions

27. Standard Precautions
Standard Precautions combine the major features of Universal Precautions and Body
Substance Isolation and are based on the principle that all blood, body fluids,
secretions, excretions (except sweat), nonintact skin, and mucous membranes may
contain transmissible infectious agents. 2007 HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in
Healthcare Settings
“Standard Precautions include a group of infection prevention practices that apply to
all patients, regardless of suspected or confirmed infection status.”
• Hand Hygiene
• Use of gowns, gloves, face shields, eye protection
• Safe injection practices
https://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html

28. STATE BOARD OF HEALTH REGULATIONS PERTAINING TO PREPARATIONS
FOR A BIOTERRORIST EVENT, PANDEMIC INFLUENZA, OR AN OUTBREAK BY
A NOVEL AND HIGHLY FATAL INFECTIOUS AGENT OR BIOLOGICAL TOXIN
B) Having sufficient supplies, training
for staff using personal protective
equipment, and a process for the
provision of personal protective
equipment to employees who are
assigned to work in areas where they
may be exposed to ill and contagious
persons or to infectious agents and
waste.
Personal protective equipment shall,
at a minimum, be the equipment and
supplies used to achieve standard
precautions against bacterial and viral
infections;

29. Standard Precaution PPE

30. Food for thought….

31. References
CDCs Donning and Doffing Guidelines
file:///C:/Users/mhule/AppData/Local/Microsoft/Windows/INetCache/IE/4I0EW6R
G/PPE-Sequence.pdf
CDCs 2007 Isolation Guidelines
file:///C:/Users/mhule/AppData/Local/Microsoft/Windows/INetCache/IE/E9B9P01
K/Isolation2007.pdf
CDCs Guideline for Hand Hygiene in Health-Care Settings
file:///C:/Users/mhule/AppData/Local/Microsoft/Windows/INetCache/IE/E9B9P01
K/rr5116.pdf

32. Thank you