drainage, incontinence, or other body fluid drainage that cannot be contained and has the potential for environmental contamination. The recommended PPE is a gown and gloves for all interactions involving contact with the patient or potentially contaminated areas in the patient’s environment/room. To contain pathogens within the room, don PPE upon room entry and discard it before exiting the patient’s room. Enhanced barrier precautions Knowing if a individual has an MDRO is often determined through an apparent infection, and culture can confirm the MDRO. A random sample of residents in 18 long-term care facilities (LTCF) in southern California were screened for an MDRO, and it was determined that 65% had an MDRO (McKinnell et al., 2019). The most common MDROs were MRSA and extended-spectrum beta-lactamase–producing organisms (ESBL). Contact precautions are implemented if there is an active infection with an MDRO; otherwise, the resident remains in standard precautions, and a silent spread of pathogens may occur. Contact precautions are challenging for LTCF to implement due to balancing the residents’ quality of life and keeping a home-like environment using PPE and room restrictions. The Healthcare Infection Control Practices Advisory Committee (HICPAC) working group reviewed and provided input for a new guideline for skilled nursing facilities: Consideration of the use of Enhanced Barrier Precautions (EBP) in Skilled Nursing Facilities (CDC, 2021). Enhanced barrier precautions are a balanced approach that reduces the risk of transmission without the restrictions of contact precautions. When contact precautions do not apply, EBP are implemented for residents known to: ● Be infected or colonized with an MDRO. ● Have wounds that require a dressing change (not a skin tear with a bandage strip). Have indwelling medical devices. Gown and gloves are recommended during high-contact activities such as: ● Dressing. ● Bathing/showering. ● Transferring. ● Providing hygiene. ● Changing linens. ● Changing briefs or assisting with toileting. ● Device care or use (central line, urinary catheters, feeding tube, tracheostomy/ventilator). ● Wound care that requires a dressing change (not intended for a skin tear requiring a bandage strip). Another study highlighted how unaware HCWs are of patients colonized with an MDRO. In a large prospective surveillance study among nursing home residents (n = 651) in Michigan, more than 50% were colonized with at least one MDRO at admission and discharge (Mody et al., 2018). The pathogens the residents were colonized with at admission were MRSA (16%), VRE (33%), and resistant gram-negative bacilli ( E. coli , Klebsiella , Enterobacter , Pseudomonas ; 32%). Body sites with more significant colonization of MDROs were hand (25%), groin (25%), and rectum (44%). After a prolonged hospital stay, colonization of the body sites grew, with MDRO on hands (55%), groin (39%), and rectum (68%). Elderly residents in long-term care facilities risk becoming colonized or infected with an MDRO. The risk increases with frequent hospitalizations and more risk factors. Based on these results, Mody and colleagues (2018) suggested performing predischarge surveillance cultures to identify patients colonized with MDROs. Using EBP instead of contact precautions, residents in nursing homes would not be restricted to their rooms or from group activities. These precautions are intended for long-term implementation (i.e., during the resident’s stay or until wounds
resolve or the device is discontinued). In contrast, contact precautions should be time limited (i.e., during the infectious period) (CDC, 2022). Protective environment A protective environment prevents infectious pathogens from spreading to an immunocompromised patient (e.g., stem cell transplants and oncology settings; CDC, 2022). A protective environment involves positive pressure (relative to the corridor). Special ventilation requirements and high-efficiency particulate air (HEPA) filtration ensure clean air enters the room. Additional infection prevention measures include prohibiting dried and fresh flowers as well as potted plants in patient rooms. Patient placement A private room is preferred for a patient on TBP (CDC, 2022). There are not always private rooms available depending on the healthcare setting; therefore, assess the risk of transmission to other patients when considering patient placement. Ideally, patients with draining wounds, stool incontinence, or uncontained body fluids are prioritized for a private room. Cohorting is the practice of grouping patients together that are colonized or infected with a like pathogen. Cohorting minimizes the risk of transmission of pathogens to other patients in the facility. Ambulatory settings (e.g., outpatient clinics and provider clinics) are encouraged to implement strategies to prevent the transmission of respiratory pathogens (CDC, 2022). Examples are screening patients at the front desk and posting signs educating the public about when to report specific symptoms. Infectious patients can be placed in a room right away or offered a mask and separated from other patients. In home healthcare settings, patients could limit visitors and, if able, separate infected patients from others. Transportation of patients Four critical principles for acute care and residential care settings include: ● Limit transport to essential purposes (e.g., diagnostic or therapeutic procedures) if they are unable to be performed at the bedside. ● If the transport is necessary, use appropriate barriers on the patient (e.g., wear a mask, wear a clean gown, cover wounds with clean dressings). ● Notify receiving department personnel of patient transport and inform them of appropriate PPE. ● If the patient is being transported outside the facility, notify the receiving facility and alert them to the type of precautions followed (airborne, droplet, contact). Environmental measures Cleaning and disinfecting are essential to standard precautions because they prevent the transmission of pathogens. Cleaning and disinfecting procedures do not need to change for most pathogens (CDC, 2022). However, special cleaning and disinfecting procedures are implemented for important epidemiological pathogens such as C. difficile , norovirus, and certain MDROs. There should be policies and procedures for HCWs regarding cleaning and disinfecting patient rooms and equipment. They should specify who is responsible and the appropriate products to use based on manufacturer recommendations. Textiles and laundry Textiles and laundry (i.e., bedding, towels, clothing) should be handled to minimize the transmission of pathogens. Three fundamental principles are (1) do not shake the items to minimize dispersal, (2) avoid contact with soiled items, and (3) contain soiled items in a laundry bag or bin to minimize dispersal (CDC, 2022). Additional guidance can be found in the CDC’s 2003 Guidelines for Environmental Infection Control in Healthcare Facilities (CDC, 2019).
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Book Code: RPTTX2024
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