WIXLIB

Droplet transmissionDroplet transmission can occur when an infected person coughs, sneezes or talks, andduring certain procedures. Droplets are infectious particles larger than 5 microns in size.Respiratory droplets transmit infection when they travel directly from the respiratory tract ofthe infected person to susceptible mucosal surfaces (nasal, conjunctival or oral) of anotherperson, generally over short distances. Droplet distribution is limited by the force of expulsionand gravity and is usually no more than 1 metre.Airborne transmissionAirborne transmission may occur via particles containing infectious agents that remaininfective over time and distance. Small-particle aerosols (often smaller than 5 microns) arecreated during breathing, talking, coughing or sneezing and secondarily by evaporation oflarger droplets in conditions of low humidity. Aerosols containing infectious agents can bedispersed over long distances by air currents (e.g. ventilation or air conditioning systems) andinhaled by susceptible individuals who have not had any contact with the infectious person.These small particles suspended in the air are referred to as droplet nuclei and can transmitinfection into small airways of the respiratory tract.Figure 2 illustrates the different routes of transmission and their more specific ectHandsAirborneDroplet nuclei(Suspended in air)Equipment/environmentInjectionIngestionFigure 2. Transmission of infectious agentsClinical Educators Guide:Australian Guidelines for the Prevention and Control of Infection in Healthcare5

Standard and transmission-basedprecautionsStandard precautionsStandard precautions refer to those work practices that are applied during all instances ofpatient care, regardless of a perceived or confirmed infectious status. Implementing standardprecautions as a first-line approach to infection prevention and control in healthcare facilitiesminimises the risk of transmission of infectious agents from person to person, even inhigh‑risk situations.How standard precautions are implemented: hand hygiene, as consistent with the 5 Moments for Hand Hygiene the use of appropriate personal protective equipment (PPE) the safe use and disposal of sharps routine environmental cleaning reprocessing of reusable medical equipment and instruments respiratory hygiene and cough etiquette aseptic technique waste management appropriate handling of linen.Transmission-based precautionsAny infection prevention and control strategy should be based on the use of standardprecautions as a minimum level of control. Transmission-based precautions are recommendedas additional work practices in situations where standard precautions alone may beinsufficient to prevent transmission.Transmission-based precautions should be tailored to the particular infectious agent involvedand its mode of transmission. This may involve a combination of practices.Types of transmission-based precautions: Contact precautions are used when there is known or suspected risk of direct orindirect contact transmission of infectious agents that are not effectively contained bystandard precautions alone. Droplet precautions are used for patients known or suspected to be infected withagents transmitted over short distances by large respiratory droplets. Airborne precautions are used for patients known or suspected to be infected withagents transmitted person-to-person by the airborne route.Strategies for implementing transmission-based precautions: continued implementation of standard precautions dynamic risk assessment in the pre-admission setting to anticipate and communicatethe potential need for transmission-based precautions on patient arrivalClinical Educators Guide:Australian Guidelines for the Prevention and Control of Infection in Healthcare6

if patient has a suspected or confirmed infection, allocate a single room inclusive ofbathroom facilities and a door that can be closed (isolation) if the above strategy is not possible then place patients colonised or infected with thesame infectious agent in a room together (cohorting) wearing specific personal protective equipment providing patient-dedicated equipment using sodium hypochlorite, or an appropriate Therapeutic Goods Administration-listedhospital-grade disinfectant (with specific claims), daily on frequently touched surfacesand on general surfaces when visibly soiled or immediately after a spillage using specific air handling techniques restricting the movement of both patients and healthcare workers.Overview of riskmanagement in infectionprevention and controlIn the context of infection prevention and control in healthcare facilities, ‘risk’ is defined as thepossibility of microorganism colonisation or infection in patients or healthcare workers arisingfrom activities within a healthcare facility.Risk management is the basis for preventing and reducing harms arising from HAI.Infection control is a health and safety issue, which means that all those working in thehealthcare facility — managers, healthcare workers and support staff — are responsible forproviding a safe environment for patients and other staff.A successful approach to risk management occurs on many levels within a healthcare facility: Facility wide—for example, providing support for effective risk management through anorganisational risk-management policy, staff training, follow-up of outcomes, monitoring,reporting and enabling access to information systems that can be used to informrisk assessment. Ward or department based—for example, embedding risk management into all policies sothat risks are considered in every situation. Individual—for example, considering the risks involved in carrying out a specific procedureand questioning the necessity of the procedure as part of clinical decision-making,attending education sessions (e.g. hand hygiene or respirator fit testing).As healthcare facilities differ greatly in their day-to-day function, it is not possible to providea one size fits all approach to risk management. Even within a single setting (e.g. primarycare), increasingly complex care is delivered by a range of health professionals with diversequalifications and training. All healthcare facilities need to be able to determine the risks intheir own context and select the appropriate course of action. It is necessary for facilities toregularly conduct infection prevention risk assessments within their facility and ensure that allstaff understand their responsibility in managing these risks. In addition, healthcare facilitiesshould develop detailed protocols and processes for infection prevention and control specificto local settings.Clinical Educators Guide:Australian Guidelines for the Prevention and Control of Infection in Healthcare7

In most cases it is not necessary to undertake a complete risk assessment when performingroutine tasks, but it is essential for healthcare workers to be able to identify and analyse thepotential risks of transmission.Figure 3 below shows a risk management approach in the context of the chain ofinfection to ensure exposure to sources of infection is minimised for both the patient andhealthcare worker.Establish the contextAvoid risksIdentify risksCommunicateand consultMonitor andreviewAnalyse risksEvaluate risksTreat risksFigure 3. The risk management flowchartClinical Educators Guide:Australian Guidelines for the Prevention and Control of Infection in Healthcare8

Risk identification in theclinical contextThe following section demonstrates the decision-making steps behind identification,assessment and treatment of potential risks of transmission of infection during the delivery ofcare. Tables 1 and 2 provide clinical examples to illustrate this approach. This is based on thecontent in the 2019 Australian Guidelines for Prevention and Control of Infection in Healthcare.1. Establish the contextIdentify the basic parameters in which risk must be managed e.g. type of health facility,extent of and support for the facility’s infection prevention and control program.2. Avoid risksThe best way to manage a risk is to avoid it. It is valuable to consider the following beforeperforming a procedure: Is the planned task/intervention necessary? Are there alternative procedures that could eliminate or minimise any potentialexposure of the patient or yourself and others to infectious agents? For example:– Is it necessary to change the dressing today?– Does the patient still require an intravascular device, or can it be removed?3. Identify risksWhen approaching a clinical task or duty it is useful to consider the risks of HAI transmissionin terms of when/where/why and how they can occur. For example:What potential agents are involved? i.e. the source How are they transmitted? i.e. mode of transmission direct and indirect Who is at risk of infection? i.e. patient, healthcare worker or the patient care area?Table 2 provides prompts to assist in identifying the risks for HAI transmission and forconsidering what controls can be taken to interrupt the chain of infection.4. Analyse riskThe identified risks associated with the task/duty need to be analysed. This can be achievedby considering: How can transmission happen? i.e. what are the aspects of the duty/procedure thatcan transmit infection? What existing controls are in place to minimise the risk? i.e. are there sets ofprocedures or protocols in place that minimise the risk of transmission? What is the likelihood of transmission? What is the likelihood of associated morbidity or mortality associated with HAI? What is the likelihood of increased length of hospitalisation? What factors increase or decrease the risk?Clinical Educators Guide:Australian Guidelines for the Prevention and Control of Infection in Healthcare9

5. Evaluate riskThe next stage requires assessment of whether the level of risk is acceptable or not.Factors that influence this decision are: Is the risk so low that it is not considered a problem?– i.e. taking the blood pressure of a healthy individual is considered to have a low riskof transmission of infection Does the need to perform the task/duties outweigh the possible risk of HAItransmission?– e.g. delaying transfer to radiology due to infection may lead to further patientdeterioration What can be done to reduce or eliminate the risk?– e.g. develop a prioritised list of actions to break the chain of infection Can extra steps be taken to minimise or mitigate the risk?– e.g. using an aseptic technique to dress a wound or wearing gloves and gownswhen contacting a patient suspected to have MRSA Would this risk be acceptable/not acceptable in a different clinical setting?– i.e. are there special considerations required given the clinical environment,such as ICU versus outpatients, that will affect the actions taken to break the chainof infection?6. Treat the riskAt this step, all the information gathered from the analysis and evaluation on the risk ofHAI transmission is brought together to consider what actions should be taken. In orderto make this decision, consider how the level of risk will be affected by the proposedmitigation strategies.The choice in the course of action can include: Avoiding the risk: choosing an alternate lower risk procedure or task. Reducing the risk: can the likelihood be reduced through preventative measures, andexisting systems and controls i.e. are there policies and procedures in place to guide thebest way to perform the required task and minimise the risk? Transferring the risk: getting another individual or team to assist/perform the task who arebetter equipped or have more experience in undertaking the task. Retaining the risk and managing it: strategies include using PPE (see Table 1) and safetyengineered devices.The following questions assist in deciding what strategy should be adopted: What can be done to address the risk? i.e. from my analysis and evaluation will thetreatment of the risk lower the level of risk sufficiently? Who is responsible? e.g. some aspects of the risk mitigation strategy will involve othermembers of the HCF teamClinical Educators Guide:Australian Guidelines for the Prevention and Control of Infection in Healthcare10

Monitoring and review is an essential component of the risk-management process.This ensures that: new risks are identified analysis of risk is verified against real data, if possible risk treatment is implemented effectively.Thinking exerciseHow would you put into practice the following scenarios to minimise the risk of infection?Scenario 1: a child with chickenpox in an antenatal clinic waiting roomScenario 2: a patient with MRSA sharing a room with three patients without MRSAIn each scenario, consider: who is at risk what is the risk why is it a risk what steps are needed to treat the risk.Organisational supportFor infection prevention and control to be effective at the clinical level, much organisationalsupport is required. This includes embedding infection control into governance andmanagement structures, initiating procedures (e.g. immunisation programs) to ensure thathealthcare workers are protected, instituting processes for surveillance that feed into theoverall quality control program, implementing systems for ongoing staff education andtraining, and incorporating infection control into planning for facility design and maintenance.Organisational support should aim to ensure that clinical work practices provide patientcentred care—this is not only essential from a safety and quality perspective, but out ofconsideration for patient preferences. This may require consultation with patients and relevantconsumer groups in the development of healthcare services.Table 1: Summary of Personal Protective Equipment maskEyeprotectionGown -----Routineobservations (e.g.blood pressuremeasurement) -----General medicalexamination - If splashrisk likelyIf splashrisk likelyIf splashrisk likelyProcedureActivities of dailyliving(e.g. washing,toilet)For contactwith brokenskin/ rash/mucousmembraneClinical Educators Guide:Australian Guidelines for the Prevention and Control of Infection in Healthcare11

ctionGownWoundexamination/dressing For contactwith bodysubstancesFor directcontactwith woundFor woundFor woundFor grosslyirrigation if irrigation if infectedsplash likely splash likely woundsBlood glucoseand haemoglobinmonitoring ----Vaginal delivery - - Intravenouscannula insertion -- -Intravascularaccess deviceinsertion Intravascularaccess device care - - -Surgical aseptictechniqueprocedure e.g.lumbar puncture - Insertion of urinarycatheter - If exposurerisk likelyIf exposurerisk likelyIf exposurerisk likelyUrinary cathetercare - WhenemptyingdrainagebagIf exposurerisk likelySuctioning:endotracheal tube,tracheostomy Major dentalprocedures - Routine intra-oraldental procedures - ProcedureIf splashrisk likely- Where max.barrierprecautionsare used -- Dominanthand (opensuctionsystem)If exposurerisk likelyIf exposurerisk likelyClinical Educators Guide:Australian Guidelines for the Prevention and Control of Infection in Healthcare12

Table 2: Decision Making on Risk ManagementClinical TasksIdentify the RiskTreat the RiskDoes theactivityinvolve Who is atrisk?What is theHow is itpotential source transmitted?of the infectiousagent?What can I do to break thechain of infection?(see also Table 1)Directphysicalcontact with:PatientContaminated Standard precautionsHealthcareworkerHealthcareworkers’ handsPatient careareaDirectphysicalcontact with:Broken skin ’ handsMedicaldevices/Patient careequipmentareaBlood or bodysubstancesPatientHealthcareworkers’ handsPoor techniqueContaminatedequipmentDirect andindirectcontacttransmissionContact Clean surfaces withappropriate solution beforeand after useEvaluation of Risk – is the level of risk acceptable? What else can be done?Medicaldevices/equipment Perform hand hygieneAnalysis of Risk – determine the level of risk, i.e. the likelihood and consequence?Intact skinDirect andindirectcontacttransmission Standard precautions Perform hand hygiene Appropriate use of PPE e.g.gloves, gown , eye protection Clean surfaces withappropriate solution beforeand after use Aseptic technique Standard precautions Perform hand hygiene Appropriate use of PPE e.g.gloves, gown , eye protection Clean surfaces withappropriate solution beforeand after use Aseptic technique Employ correct technique Single use equipment Has the device beappropriately reprocessed? Note: Instruments used oncritical sites are requiredto be sterile. Semi-criticalinstruments require high-leveldisinfection.Clinical Educators Guide:Australian Guidelines for the Prevention and Control of Infection in Healthcare13

Clinical TasksIdentify the RiskTreat the RiskDoes theactivityinvolve Who is atrisk?What can I do to break thechain of infection?(see also Table 1)Handling ofsharp rkerBodythroughsubstancesneedle stickinjuryWhat is theHow is itpotential source transmitted?of the infectiousagent?Contact Standard precautions Correct use and disposal ofsingle use sharps at point ofcare where possible Correct transport of reusablesharps Correct techniqueand trainingMucosalsecretions,includingPatient caredroplets fromareacoughs andsneezesAerosolscreated by theproceduresPhysicalcontact withclinical wastee.g. dressingsHealthcareworkerPhysicalcontactwith humanwaste orcontaminatedlaundry,clothing, orequipmente.g. handlingof soiledlinen, orassisting withtoiletingHealthcareworkerBlood and bodysubstancesAirborne(such as TBand measles)Droplet (suchas influenza)Indirectcontact viacontaminationof patientcare area bydropletsContactPatient careareaPatient careareaBlood and bodysubstancesContact Airborne precautions requirethe use of a P2 respirator Droplet precautions requirethe use of a surgical maskEvaluation of Risk – is the level of risk acceptable? What else can be done?HealthcareworkerAnalysis of Risk – determine the level of

legal code for the CC BY 4.0 International licence. Attribution Creative Commons Attribution 4.0 International Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The NHMRC's preference is that you attribute this publication (and any