Entire Infection Control Manual PDF

INFECTION
PREVENTION
&
CONTROL
MANUAL
Updated: November 2016
Infection Prevention and Control
Disclaimer
Disclaimer
The Interior Health Infection Prevention & Control Manual (the Manual) is intended as a reference document
only. The Manual represents Interior Health’s guidelines and does not imply directly or indirectly that non
Interior Health programs or facilities are bound by the guidelines. While non IH users are encouraged to
develop their own infection prevention and control guidelines, these individual groups may choose to adopt
the guidelines in the Manual as their iown provided all references to Interior Health are removed.
The most up-to-date version of the Manual is the electronic copy on the website. If a paper copy is being
maintained it is the responsibility of the users to ensure they have the most current best practise information
to guide their treatments and interventions.
The Manual (paper or electronic version) and all the information it contains is provided “as is” without
warranty of any kind, whether expressed or implied. All implied warranties, including, without limitation,
implied warranties of merchantability, fitness for a particular purpose, and non-infringement, are hereby
expressly disclaimed.
Limitation of Liabilities
Under no circumstances will the Interior Health Authority be liable to any person or business entity for any
direct, indirect, special, incidental, consequential, or other damages based on any use of the Manual,
including, without limitation, any lost profits, business interruption, or loss of programs or information, even if
the Interior Health Authority has been specifically advised of the possibility of such damages.
Summary of Changes to Infection Prevention and Control Manual
Summary of Changes to Infection Prevention & Control November

Manual 2016
 The Revised IH Infection Prevention & Control Manual is available on the InsideNet at Clinical
Resources or Policies & Procedures or Quality & Patient Safety and on the Internet at
http://www.interiorhealth.ca/AboutUs/QualityCare/Pages/InfectionControl.aspx
 All staff are expected to use the “on line” copy of the manual which contains the most up to date
information.
 There is one “hard copy” of the manual available at each Acute and Residential site in the event that the
electronic copy cannot be accessed.
 Please refer to the table below for: “New” and “Revised” guidelines that have been added to the manual.
The paper version of this manual requires updating with this information.
Section(S) Revised R= Revised N = New
Throughout the manual:

 The term “patient” is inclusive of patient, resident & client.
 There are links to signage and other tools on the InsideNet – Infection Prevention & Control Home page.
Section 03F – Routine Practices
Revisions include:
IF0100 Routine Practices R Donning and Doffing of PPE (personal protective equipment) photo instructions
for All Care Areas updated
IF0200 Hand Hygiene R 3.6 When Clostridium difficile infection is suspected or diagnosed:
 Wash hands with soap and water (preferred).
 If no sink is in close proximity, clean hands with alcohol hand rub and
wash with soap and water at first opportunity.
 Do not perform hand hygiene at a patient sink, as this may cause
recontamination of the health care provider’s hands. Use a dedicated staff
hand washing sink
Section 04H – Additional Precautions

Revisions Include:
IH0200 Airborne R Updated signs including Point of Care Risk Assessment, Airborne Precautions
Precautions and Airborne & Contact Precautions
IH0300 Droplet R Updated signs including Point of Care Risk Assessment, Droplet Precautions and
Precautions Droplet & Contact Precautions
IH0400 Contact R Updated signs including Point of Care Risk Assessment, Contact Precautions and
Precautions Contact Plus Precautions
Section 08S – Specific Diseases

Revisions Include:
IS0200 Clostridium R 3.2 Hand Hygiene
difficile  Wash hands with soap and water (preferred)
 If no sink is in close proximity clean hands with alcohol-based hand rub
(ABHR) and wash with soap and water at first opportunity
 Do not perform hand hygiene at a patient sink, as this may cause
contamination of the healthcare provider’s. Use a dedicated staff hand
washing sink
Table of Contents to Infection Prevention and Control Manual
 Assist patients with cleaning their hands, especially after toileting and
before meals
3.3 Patient Placement and Accommodation

 Brown Contact Precautions signage placed at entrance to the patient
room, cubicle or designated bed space (i.e.) Emergency Department
3.7 Cleaning of Patient Environment

 The brown Contact Precautions sign alerts Housekeeping staff of the
need for twice daily cleaning with a sporicidal disinfectant
Updated sign Contact Plus Precautions

Table of Contents to Infection Prevention and Control Manual
TABLE OF CONTENTS
MANUAL INTRODUCTION
IB0100: Interior Health Infection Prevention & Control Program
ROUTINE PRACTICES
IF0100: Routine Practices for All Care Areas
IF0200: Hand Hygiene Guidelines
IF0300: Waste Management
ADDITIONAL PRECAUTIONS
IH0100: Additional Precautions For
All Care Areas
IH0200: Airborne Precautions
IH0300: Droplet Precautions
IH0400: Contact Precautions
SPECIFIC DISEASES
IS0100: Reportable Communicable Diseases
IS0200: Clostridium difficile
IS0300: Antibiotic Resistant Organisms (ARO)
IS0300A: Carbapenemase Producing Organisms (CPOs)
IS0400: Scabies/Lice
IS0500A: Tuberculosis
IS0500B Tuberculosis Risk Screening – Residential Facilities
IS0600: Chickenpox (Varicella-Zoster) and Herpes Zoster (Shingles)
IS0700: Invasive Group A Streptococcal Infections (IGAS)
IS0800: Meningococcal Infection
IS0900: Creutzfeldt-Jakob Disease
IS1000: Respiratory Syncytial Virus (RSV)
IS1100: Rabies
IS1200 Measles
IS1300 Mumps
IS1400 Bed Bugs
IS1500 Pertussis
SURVEILLANCE AND OUTBREAKS

IV0100: Surveillance for Healthcare Associated Infections
IV0200: Definitions for Healthcare Associated Infections
IV0300: Surgical Site Infections (SSIs)
IV0400: Gastrointestinal Outbreak Guidelines
IV0500: Respiratory Infection (RI) Outbreak Guidelines
IV0600: Communicable Diseases in Employees
BEST PRACTICES
IX0100: Microbiology Specimen Collection
IX0200: Prevention & Control of Catheter Associated Urinary Tract Infections (CAUTI)
IX0300: Pneumococcal Vaccine for Residential Care
IX0400: Pet Therapy and Visitation
IX0500: Soiled Utility Rooms
IX0600: Equipment Cleaning
IX0700: Toy Management
IX0800: Personal Care Supplies Best Practice Guidelines
IX0900: Construction Projects
IX1000: Construction & Renovation Guidelines
Cross Reference to Infection Prevention and Control Manual
CROSS REFERENCE
A
Acute Care Plan for (ARO’s) IS0300 Acute Care Admission Screening Form #807910
Acute Care Plan for Clostridium difficile IS0200
Additional Precautions for all Care Areas IH0100
Table 6: Transmission
Characteristics and Empiric
Precautions by Clinical
Presentation: Recommendations
for Acute Care Centres
Table 7: Transmission
Characteristics and Precautions by
Specific Etiology:
Recommendations for Acute Care
Centres
Airborne Precautions IH0200  Airborne Precautions Sign #807900

 Airborne / Contact Precautions Sign
#807901
 Airborne Communicable Disease Algorithm
#807907
Antibiotic Resistant Organisms for Acute IS0300
Care
Antibiotic Resistant Organisms for IS0300

Residential Care
 Residential Care Plan
Antimicrobial Resistant Organisms (ARO) IS0300
Precautions for Community Care
Residential Care
C
CCARO (Community Care Antibiotic IS0300
Organisms)
Carbapenemase Producing Organisms IS0300A
Care Plan – Resident with CDI IS0200
Care Plan – Acute Care with CDI IS0200
Care Plan – Acute for AROs IS0300
Care Plan – Residential for AROs IS0300
Care Plan – Community for AROs IS0300
Chickenpox and Herpes Zoster (Shingles) IS0600
Catheter Associated Urinary Tract IX0200
Infections (CAUTI)
Clostridium difficile IS0200 Clostridium difficile Contact Precautions Sign
#807914
Clostridium difficile – Resident with CDI IS0200

Collection of Specimens in a IV0400
Gastroenteritis Outbreak
Common Agents and Illness – IV0400
Gastroenteritis (GI) Illness
Community Care Plan for AROs IS0300
Communicable Diseases in Employees IV0600
Construction Projects IX0900
Construction & Renovation Guidelines IX1000

Contact Precautions IH0400 Contact Precautions Sign #807902
Creutzfeldt-Jakob Disease IS0900
D
Definitions of Health Care Associated IV0200
Infections
Droplet Precautions for Acute Care IH0300  Droplet Precautions Sign #807903
 Droplet / Contact Precautions #807904
E
Equipment Cleaning
Exposure – Blood and Body Fluid
(see IH Policy AV0300)
G
Gastroenteritis Illness Outbreak guidelines IV0400
H
Hand Hygiene Guidelines IF0200
Herpes Zoster IS0600
HIV Exposure (see IH Policy AV0300)
I
Interior Health Infection Prevention & IB0100
Control Program
Influenza Immunization Policy for
Employees
(See IH Policy AV1300)
Influenza Like Illness Outbreak IV0500
Invasive Group A Streptococcal Infections IS0700

(IGAS)
L
Lice/Scabies IS0400
M
Meningococcal Infection IS0800
Microbiology Specimen Collection IX0100
N
Needlestick Exposure
(see IH Policy AV0300)
O
Outbreak Facility Sign IV0400  Form #807909
P
Personal Care Supplies Best Practice IX0800
Guideline
Pet Therapy and Visitation IX0400
Pneumococcal Vaccine for Residential IX0300
Care
Prevention & Control of Catheter IX0200
Associated Urinary Tract Infections
(CAUTI)
Q
Quick Reference Guide – Respiratory IV0500
Illness Outbreak
Quick Reference Guide for GI Outbreaks IV0400
R
Rabies IS1100
Reference guide – Respiratory Illness IV0500
Outbreak
Reference Guide for GI Outbreaks IV0400
Renovation Guidelines, Construction and IX0900
Reportable Communicable Diseases IS0100 Schedule A - List of Reportable Communicable
Diseases in BC
Residential Care Plan ARO IS0300
Residential Care Plan Clostridium difficile IS0200
Respiratory Infection (RI) Outbreak IV0500
Respiratory Syncitial Virus (RSV) IS1000
Routine Practices for all Care Areas IF0100
Routine Screening for Antibiotic Resistant IS0300
Organisms (AROs) form
S
Scabies/Lice IS0400
Schedule A (Reportable Communicable IS0100
Diseases)
Shingles IS0600
Soiled Utility Rooms IX0500
Specimen, Collection of Gastroenteritis IV0400
Outbreak
Specimen, Transport of IV0400
Surgical Site Infections IV0300
Surveillance of Health Care Associated IV0100
Infections
T
Toy Management IX0700
Transmission Characteristics and Empiric IH0100
Precautions by Clinical Presentation:
Recommendations for acute Care
Centres (Table 6)
Transmission Characteristics and IH0100
Precautions by Specific Etiology:
Recommendations for Acute Care
Centres (Table 7)
Transportation of Patients on Isolation or IH0100
Additional Precautions
Tuberculosis IS0500A
IS0500B
U
Urinary Tract Infections (Prevention of) IX0200
W
Waste Management IF0300
Introduction to Infection Prevention and Control Manual
MANUAL INTRODUCTION
1.0 PURPOSE
The Manual has been prepared to assist healthcare providers in implementing infection prevention
and control best practice strategies across the continuum of care. The principles and guidelines set
out in the Manual are based on published best practices, national and international, which have been
modified to reflect the specific needs of Interior Health (IH). The Manual will be updated as best
practices evolve, and the most current edition will be posted on the INFECTION PREVENTION &
CONTROL WEBSITE.
This document covers acute, residential, and community care settings and programs. Note: In this
document the term “patient” is inclusive of patient, resident & client. The implementation of
routine infection control principles applies to all healthcare providers and patients in all healthcare
settings all the time.
The goal of infection control practices is to reduce the risk of transmission of infectious
microorganisms in all healthcare settings by:
 Understanding the concepts of the chain of transmission;
 Understanding the concepts and application of Routine Practices (RP);
 Knowing why and when to use Additional Precautions (AP); and
 Appropriately using, applying and removing personal protective equipment (PPE) when indicated
for the protection of the patient or the healthcare provider.
2.0 DEFINITIONS
Aseptic Technique – refers to practices designed to render the patient’s skin, supplies and surfaces
maximally free from microorganisms. Such practices are required when performing procedures that
expose the patient’s normally sterile sites e.g., intravascular system, spinal canal, subdural space,
and urinary tract, in such a manner to keep them free of microorganisms.
Community- Acquired Infections – infections present or incubating at the time of admission to a

healthcare facility or program with no association to a recent hospitalization.
Health Care Associated Infection (HAI) – an infection that is not present or incubating at the time of
admission to a healthcare facility or program but is associated with admission to or a procedure
performed in a the facility or program.
Infection – occurs when microorganisms invade a body site, multiply in tissue and cause clinical
manifestations of local or systemic inflammation (e.g. fever, redness, heat, swelling, pain, etc.)
PPE – personal protective equipment are barriers used by healthcare providers to protect mucous
membranes, airways, skin and clothing from exposure to blood and body fluids.
3.0 GUIDING PRINCIPLES
Disclaimer for Figure 1 and

2
This was developed by
the Provincial Infectious
Diseases Advisory
Committee (PIDAC).
PIDAC is a
multidisciplinary
scientific advisory body
who provide to the Chief
Medical Officer of Health
evidence-based advice
regarding multiple
aspects of infectious
disease identification,
prevention and control.
PIDAC’s work is guided
by the best available
FIGURE 1 - The Chain of Infection – How Microorganisms are Spread evidence and updated
as required. Best
Practice documents and
tools produced by
PIDAC reflect
consensus positions on
what the committee
deems prudent practice
and are made available
as a resource to the
public health and health
care providers.
FIGURE 2 - An infection can be prevented by breaking any link in the chain of infection. Infection
control measures are designed to break the links and thereby prevent an infection from occurring.
Here are the six links in the chain of infection and how these links can be broken so an
infection does not occur:
1. Causative (infectious) agent including bacteria, viruses, fungi, prions and parasites
 Break the link by eliminating or inactivating the agent, preventing the agent from exiting the
reservoir, sterilizing surgical instruments, safe food practices, safe drinking water,
vaccinations, treating infectious individuals, practicing good hand hygiene.
2. Reservoir or “home” of the infectious agent including the human body, animals and the
environment (water, food)
 Break the link by treating infectious individuals, vaccination, handling and disposing of body
fluids appropriately, safe food practices, monitoring water for contamination.
3. Portal of exit is the path by which an infectious agent leaves the reservoir or “home” including
any break in the skin or any bodily fluid such as secretions, excretions and blood.
 Break the link by implementing safe practices such as covering coughs and sneezes,
handling body fluids with gloves, performing appropriate hand hygiene, and containing
draining wounds. Healthcare providers should not work if they have exudative (wet) lesions
or weeping dermatitis.
4. Mode of transmission – how the infectious agent travels from one place to another; the
mechanism for transfer of an infectious agent from a reservoir to a susceptible host. “Vector-
borne” diseases are spread by insects, rodents, birds and animals. Common vehicle
transmission refers to a single contaminated source such as food, multi-dose vials, intravenous
fluid or equipment which serves to transmit infection to multiple hosts. The primary modes of
transmission in healthcare include:
 Contact – direct contact which is person to person spread or indirect contact which is
contact with a contaminated surface or inanimate object to person spread.
 Droplet – where large particles are produced when an infected person sneezes, talks or
coughs and settle out on horizontal surfaces leading to indirect contact transmission or direct
contact onto another person’s mucous membranes; droplets can travel 1 - 2 metres.
 Airborne – where organisms are contained within droplet nuclei (five microns or smaller in
size) or dust particles in the air and the infectious agent is widely dispersed by air currents
and inhaled by a susceptible host (e.g. Tuberculosis).
 Break the link by ensuring transmission between objects or people does not occur;
use appropriate barriers, safe practices, spatial separation, engineering controls,
hand hygiene, environmental sanitation, and equipment disinfection/sterilization.
5. Portal of entry into a susceptible host via mucous membrane, GI, respiratory or broken skin. All
portals of entry have natural protective barriers. These barriers are normally effective but may
allow micro organisms to enter if the barriers are damaged or if they have been compromised by
invasive medical devices (e.g. catheters).
 Break the link by performing appropriate hand hygiene, using aseptic technique when
required, applying best practice techniques with wound and catheter care, wearing
appropriate PPE, eliminating invasive devices when safe to do so and providing safe food
and water.
6. Susceptible Host occurs when the normal balance between microorganisms and their host may
be disturbed by chronic diseases that cause an altered immune status e.g. diabetes , infancy, old
age, invasive procedures, drug therapy, poor nutrition, radiation, chemotherapy, burns, etc
 Break the link by ensuring hosts are not susceptible including measures such as
immunizations, good nutrition, recognition and treatment of high risk patients
BY UNDERSTANDING THE CHAIN OF INFECTION, THE PROCEDURES DESCRIBED IN THIS MANUAL CAN BE
APPLIED TO INTERRUPT MICROBIAL TRANSMISSION BETWEEN PATIENTS/RESIDENTS, VISITORS, AND
HEALTHCARE PROVIDERS.
2.0 REFERENCE
2.1 Routine Practices and Additional Precautions In all Healthcare Settings. Provincial Infectious
Diseases Advisory Committee (PIDAC), Ontario; November 2012.
2.2 Routine Practices and Additional Precautions for Preventing the Transmission of Infection in
Health Care Settings; Public Health Agency of Canada; 2013.
2.3 Infection Prevention and Control Manual. Vancouver Island Health Authority (VIHA);
2009.
2.4 APIC Text 2012.

Interior Health Infection Prevention and Control Program
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is
located on IHNET at the Policies & Procedures Home Page
EFFECTIVE DATE: September 2006

IB0100: Interior Health Infection Prevention
& Control Program REVISED DATE: November 2010
REVIEWED DATE: February 2015
1.0 PURPOSE
To protect patients, staff and visitors from infectious organisms within the healthcare environment the
Interior Health Infection Prevention & Control (IPAC) Program has three principle goals:
 Protect the patient.
 Protect the healthcare provider, visitors and others in the healthcare environment.
 Accomplish the previous two goals in a cost-effective manner whenever possible.
2.0 DEFINITIONS
Healthcare Associated Infections (HAIs) – infections that are not present or incubating at the time
of admission to the facility or program but are associated with admission to or a procedure performed
in a healthcare facility or program.
3.1 The IPAC Program functions in accordance with international, national and provincial
guidelines and best practices across the continuum of care.
3.2 The IPAC Program influences practice through direct actions including the following:
 Manages critical data including surveillance for infections and disseminates data to
appropriate stakeholders.
 Develops and recommends policies, procedures and best practices in IPAC including
but not limited to Routine Practices, Additional Precautions, asepsis, equipment
cleaning, disinfection and sterilization, product selection and evaluation, and
construction consultation as it pertains to IPAC.
 Intervenes directly to prevent infections and includes liaison and consultation with
community agencies and programs.
 Educates and trains healthcare providers, patients and nonmedical caregivers.
3.3 A multidisciplinary IPAC Committee with representation from across the continuum of care
including administration, clinical and ancillary staff acts as an advocate for the prevention and
control of HAIs, to promote patient safety and provide support that empowers the
implementation of best practices both at the local and corporate level of the organization.
3.4 Each multidisciplinary committee requires its own Terms of Reference that identifies its
purpose, responsibilities, membership and reporting expectations to ensure appropriate
dissemination of information and facilitates medical and administrative support for the IPAC
Program.
.
Interior Health Infection Prevention and Control Program
Page 2
3.5 The IPAC Program provides an Annual Report which clearly identifies the goals and priority
objectives of the program and the key improvements for monitoring infection prevention &
control practices that have influenced practices aimed at improving safety for patients and
staff and allocating IPAC resources appropriately.
.
Section 03F – IF0100 (Routine Practices for All Care Areas)
Page 1

IF0100: Routine Practices for All
Care Areas REVISED DATE: November 2010,
December 2012, November 2016
REVIEWED DATE:
1.0 PURPOSE
Routine Practices are infection prevention and control practices designed to reduce the risk of blood
and body fluid exposures to healthcare workers AND to prevent and control contamination and
transmission of microorganisms in all healthcare settings.
2.0 DEFINITIONS
See the glossary in Appendix A for definitions.

.
Routine Practices
Routine Practices are used by ALL healthcare providers

for ALL patients/residents/clients
in ALL settings
ALL of the time
3.1 Routine Practices must be incorporated into the culture of each healthcare setting and into
the daily practice of each healthcare provider.
3.2 Routine Practices apply to all BODY FLUIDS, NON-INTACT SKIN, MUCOUS MEMBRANES OR
EQUIPMENT CONTAMINATED WITH BLOOD, BODY FLUIDS OR TISSUES.
3.3 A Point of Care Risk Assessment must be done by healthcare providers before each
interaction with the patient or their environment to determine which interventions are
required to prevent transmission of microorganisms during that interaction.
 Choose patient placement or accommodation based on the risk assessment.
 Choose personal protective equipment (PPE) based on the risk assessment.
3.4 PPE is used to prevent transmission of infectious agents both from patient-to-patient and
from patient-to-healthcare provider. Healthcare settings must ensure sufficient supplies of,
and quick, easy access to PPE is provided.
Note: in this document the term “patient” is inclusive of patient, resident or client.
Page 2
3.5 Preventing transmission of microorganisms to other patients is a patient safety issue, and
preventing transmission to staff is an occupational health and safety issue. Healthcare
providers are accountable to practice safely to protect patients and themselves by following
organizational infection prevention and control guidelines.
Just because it ‘looks’ clean doesn’t mean it isn’t contaminated by bacteria or viruses
4.0 PROCEDURE
4.1 Point of Care Risk Assessment - to be done before each interaction with a patient or
their environment.
Assess the patient for high risk of contaminating environment:

 Uncontrolled diarrhea.
 Uncontained draining wounds or skin lesions.
 Uncontrolled respiratory symptoms.
 Symptoms – vomiting, fever, skin rash.
 Inability to clean hands or cover cough.
What type of environment is high risk for patient?

 Shared space (i.e.) multi-bed room, shared bathrooms.
 Crowded areas such as waiting rooms, hallways.
 Shared equipment.
4.2 Use avoidance procedures that minimize contact with droplets (e.g., sitting next to, rather
than in front of, a coughing patient when taking a history or conducting an examination).
4.3 Hand Hygiene Refer to IF0200 HAND HYGIENE GUIDELINE
Activity Best Practice
Hand Hygiene ▪ Before and after every patient/patient environment contact.

▪ After contact with blood or body fluids, soiled linen, equipment or garbage.
▪ Before and after glove use.
▪ Before performing aseptic procedures.
▪ Before handling food or medication.
▪ Before handling clean linen or supplies.
▪ After using the toilet or after toileting others.
▪ After changing an incontinence product or a child’s diaper.
▪ Prior to using computers and other electronic devices.
▪ Alcohol-based hand rub (ABHR) used routinely when hands are not visibly
soiled.
▪ Soap and water used when hands are visibly soiled.
▪ Assist patients with hand hygiene before eating, after toileting and when
hands are soiled.
▪ Educate visitors about hand hygiene.
Page 3
4.4 Personal Protective Equipment (PPE)

Determine the appropriate PPE to use that will decrease exposure risk and prevent
transmission of infectious agents: includes gloves, masks, N95 respirators, eye protection,
and gowns/aprons.
Gloves – non ▪ Wear for contact with blood or body fluids, mucous membranes, draining
sterile, single wounds or non-intact skin (open skin lesions or rash).
use, latex free ▪ Wear for handling items or surfaces potentially contaminated with blood or
body fluids.
▪ Gloves should be put on directly before the task for which gloves are
required.
▪ Gloves must be removed and discarded immediately after the activity for
which they were used.
▪ Hand hygiene must be done immediately prior to putting on gloves and
after removing gloves.
▪ Gloves are not required for routine care when in contact with intact skin (e.g.
bathing, dressing the patient, taking blood pressure).
▪ Gloves are not required to handle food trays and dishes.
▪ Change gloves after touching a contaminated body site and before touching
a clean body site or the environment.
▪ Do not wash or re-use single use gloves.
▪ Sterile gloves are worn to protect the patient during aseptic procedures.
▪ Disposable gloves are worn for tasks other than direct patient care (e.g.
laundry, working with chemicals, cleaners and disinfectants).
I.H. Facilities refer to the GLOVES, HAND HYGIENE AND YOU (NOT AVAILABLE TO
NON IH FACILITIES).
Masks and eye ▪ Wear to protect the mucous membranes of the nose, mouth and eyes during
protection procedures/activities likely to generate splashes of blood, body fluids,
secretions or excretions or within two metres of a coughing patient.
▪ Change mask if it becomes wet.
▪ Do not allow mask to hang or dangle around the neck.
▪ Remove mask by using ties or elastic and discard mask promptly after use.
▪ Remove and discard the eye protection after use if disposable; if re-usable,
clean with a disinfectant after each use.
▪ The outside of the mask and eye protection are considered contaminated.
▪ Clean hands after removing the mask and eye protection.
▪ Do not re-use disposable masks.
▪ Prescription eye glasses are not acceptable as eye protection.
N95 Respirators ▪ Must be fit tested prior to wearing N95 respirator.
▪ Wear when caring for patients on Airborne Precautions.
▪ A single-use N95 mask must only be worn once.
Gowns/aprons – ▪ Wear impermeable long sleeve gown to protect uncovered skin and prevent
single use soiling of clothing during activities likely to generate aerosolization of blood or
body fluids.
▪ The gown/apron should be put on immediately before the task and must be
worn properly, i.e., tied at top and around the waist.
▪ Gowns/aprons are SINGLE USE - remove promptly after use and discard in
appropriate receptacle. The outside of the gown/apron is considered
contaminated so hand hygiene must be done following removal.
Page 4
4.5 Environmental Controls

Measures implemented to reduce the risk transmission of infectious agents to patients and
healthcare providers; includes patient placement and transport, patient care equipment, cleaning
practices including laundry and dishes and engineering controls such as point-of-care sharps
containers and waste management.
Patient ▪ Options include single patient rooms, two patient rooms and multi-bed
Placement rooms/bays.
▪ Single room with dedicated bathroom and sink preferred when there is a
potential for transmission of an infectious agent (i.e.) patients with
uncontrolled diarrhea
▪ Maintain a spatial separation of at least 2 meters between coughing
patients and others in the room – draw the privacy curtain between beds.
▪ Cohorting a group of patients (with same disease/organism) in the same
area is an option if single rooms are not available.
Patient transport ▪ Patient’s gown/clothing is clean.
▪ Patient has clean hands prior to going to another department.
▪ Wounds are covered with clean, intact dressings.
▪ Incontinence products are in place and intact when required.
▪ Patients who are coughing need to wear a surgical/procedure mask.
Patient care ▪ ALL patient care equipment including transport equipment requires
equipment cleaning and disinfection after each use.
▪ Storage of contaminated equipment is to be in a designated area/container
– usually in a Soiled Utility Room.
▪ Gross soil must be removed before the item can be cleaned and
disinfected.
▪ Once items are cleaned and disinfected, they should be labeled as such,
and moved to a clean storage area.
▪ Dedicate bedpans and commodes for single patient use. Clean and
disinfect before use by another patient.
▪ Single use items are to be discarded, not reused.
▪ Procedures should be established for assigning responsibility for routine
cleaning of all healthcare equipment.
▪ Wear appropriate PPE when handling, cleaning and disinfecting soiled
equipment.
▪ Personal care supplies are single patient use items and are NOT to be
shared (i.e.) soap, lotions and creams.
REFER TO IX0800 PERSONAL CARE SUPPLIES GUIDELINE
▪ When using nursing bags in the Community settings, place soiled
equipment in impervious container and do not return it to the nursing bag.
Page 5
Environmental ▪ High touch surfaces in patient care areas are cleaned and disinfected with a
cleaning hospital-grade disinfectant (quaternary ammonium compound or hydrogen
peroxide product) daily and more frequently if the risk of environmental
contamination is higher.
▪ Floors are cleaned with a detergent product.
▪ No “re-dipping” (double dipping) of cleaning cloths in the cleaning solutions.
▪ Gloves should be worn during cleaning and disinfecting procedures.
▪ Containers for liquid soap and ABHR are disposable and should not be
‘topped up’.
▪ When a patient is discharged or transferred the room or bed space must be
cleaned and disinfected thoroughly before the next patient occupies the space.
▪ Do not apply cleaning chemicals by aerosol or trigger sprays.
▪ Tubs should be cleaned and disinfected after each use. Use cold water when
using the disinfectant and ensure contact time of the disinfectant with all
surfaces is for 10 minutes or as recommended by the manufacturer.
▪ Use gloves when handling waste/garbage.
▪ Place biohazardous waste (items saturated, dripping with blood) in appropriate
biomedical waste container in the soiled utility room.
▪ Items that are broken, torn, cracked or malfunctioning need to be replaced.
Dishes ▪ Use commercial dishwashers or wash with hot water and detergent for ALL
dishes, including those used by patients on Additional Precautions.
▪ Disposable dishes are not required.
▪ Gloves are not required when transporting dirty dishes.
▪ If Food Service Workers identify trays that contain bodily fluids or sharps, they
will bring this to the attention of the nursing staff.
Laundry ▪ ALL laundry is handled the same way, including those patients on Additional
Precautions.
▪ Wear appropriate PPE when handling soiled laundry (i.e. gloves and if
necessary disposable gown or apron).
▪ Position hamper/tote/laundry bag in room or as close to the room entrance as
possible.
▪ Ensure that laundry is free of sharps, instruments, and patient‘s personal
belongings.
▪ Excrement should removed manually, not by spraying with water.
▪ Roll laundry carefully into itself. Avoid shaking or fluffing.
▪ Dirty laundry is not to be placed on the bedside tables, floor or in the sink.
▪ Place soiled laundry into leak proof bags.
▪ Laundry bags should be tied securely and not over-filled.
▪ Remove PPE after handling soiled linen and perform hand hygiene before
handling clean laundry.
Sharps ▪ Sharps disposal containers must be readily available in all areas.
▪ Sharps must be discarded immediately after use, directly into a disposal
container at the point of use.
▪ Do not recap needles.
▪ Scalpel blades must be removed using forceps.
▪ Never fill a sharps disposal container more that ¾ full.
▪ Never leave a sharp protruding from the sharps disposal container.
Page 6
Activity BEST PRACTICE
Waste REFER TO IF0300 WASTE MANAGEMENT GUIDELINE

Management
Blood/body fluid ▪ Wear appropriate PPE.
spills ▪ Absorb excess fluid with paper towels and discard in biohazardous waste
container.
▪ Clean area first, and then disinfect the area with an approved hospital
disinfectant.
▪ Notify Housekeeping of large spills.
4.6 Administrative/Source Controls
Activity BEST PRACTICE
Healthcare ▪ Ongoing education includes hand hygiene, Point of Care Risk Assessment,
Provider Routine Practices & Additional Precautions, cleaning & disinfection of the
Education environment and equipment and staff safety.
Patient Education ▪ Includes hand hygiene, respiratory hygiene and not sharing personal care
items.
Respiratory ▪ Post signs with instructions to patients and visitors on how to ‘cough/sneeze
Hygiene into your sleeve’, ‘cover your cough’ with a tissue and promptly dispose of
used tissue, or put on a mask if the symptoms are uncontrollable or person
cannot comply with instructions.
▪ Hand hygiene must be done following contact with respiratory secretions
including disposal of used tissues.
▪ Maintain spatial separation, ideally more than 2 meters (6 feet) between
persons with respiratory symptoms in common areas, such as waiting rooms.
▪ Healthcare providers to use and teach patients avoidance measures that
minimize contact with droplets when coughing or sneezing, such as: turning
the head away from others; covering the nose and mouth with tissue.
Visitors ▪ Should not enter the healthcare setting if they are sick or unable to comply
with hand hygiene and other precautions that might be required.
▪ Should be instructed to do hand hygiene when entering and exiting the
patient’s room.
▪ Encourage visitors to have annual influenza vaccine.
▪ Provide visitor with information pamphlets located on the INFECTION
PREVENTION & CONTROL WEBSITE. (NOT AVAILABLE TO NON IH FACILITIES).
Healthy ▪ Staff not to come into work when ill with symptoms that are of an infectious
Workplace origin.
Practices ▪ Provide appropriate immunizations to patients and healthcare providers
including annual influenza vaccine.
Aseptic ▪ Use for handling medications and for procedures such as intravenous
Technique catheterization, urinary catheterization, wound care, etc.
Aerosol- ▪ Only those needed to perform the procedure should be present in room.
Generating ▪ Use Routine Practices including hand hygiene and appropriate PPE based
Medical on the Point of Care Risk Assessment
Procedures
▪ Use Additional Precautions based on the Point of Care Risk Assessment and
potential for infectious disease diagnosis.
Page 7
Page 8
Page 9
Page 10
5.0 REFERENCES
5.1. Routine Practices and Additional Precautions for Preventing the Transmission of
Infection in Health Care; Public Health Agency of Canada; Sept 1, 2010 – Final Version.
5.2. Routine Practices and Additional Precautions In all Healthcare Settings. Provincial
Infectious Diseases Advisory Committee (PIDAC), Ontario; July 2011.
5.3. Best Practice for Environmental Cleaning for Prevention and Control of Infections in all
nd
Healthcare Settings. 2 Edition. Provincial Infectious Diseases Advisory Committee
(PIDAC), Ontario; May 2012.
APPENDIX A
Aerosol-generating medical procedures (AGMPS) - procedures that stimulate coughing and promote
generation of aerosols; examples include intubation and related procedures, manual ventilation, open
endotracheal suctioning, CPR, bronchoscopy, sputum induction, surgery, autopsy, and non-invasive
positive pressure ventilation (CPAP, BiPAP), high concentration oxygen therapy (50% or higher). For
diagnostic (but not therapeutic) bronchoscopy or sputum induction, use an N95 respirator, due to risk
from undiagnosed TB.
Aseptic Technique – preventative measures to reduce the risk of introduction of microorganisms

through a portal of entry including mucous membranes, intravenous catheterization, breaks in the skin,
urinary catheterization; methods of introduction include inhalation, injection, and puncture.
Cleaning – the physical removal of dirt, dust or foreign material. Cleaning usually involves soap and
water, detergents or enzymatic cleaners. Thorough cleaning is required before disinfection or
sterilization may take place.
Cohorting – the placement and care of patients in the same room, who are infected or colonized with the
same microorganism; or placing those who have been exposed together to limit risk of further
transmission.
Disinfection – removal and destruction of most pathogens (or disease-causing organisms) except
bacterial spores; requires friction (cleaning) and the use of a disinfectant product.
High touch areas/surfaces – are those that have frequent contact with hands and require more frequent
cleaning, particularly during outbreaks. Examples include doorknobs, elevator buttons, telephones, call
bells, bedrails, light switches, monitoring equipment, chair arms, faucet handles, over bed tables, hand
rails, flusher handle, soap and ABHR dispensers, paper towel holder and edges of privacy curtains.
Housekeeping Clean
 Terminal/Discharge Clean – refers to the process of cleaning and disinfection which is
undertaken upon discharge of a patient from a room. The patient room, cubicle, or bed space,
bed, bedside equipment, environmental surfaces, hand washing sink and bathroom should be
thoroughly cleaned before another patient is allowed to occupy the space.
 Isolation Terminal Clean – refers to the process of cleaning and disinfection which is
undertaken upon discharge of a patient from or discontinuation of any ‘Isolation Precautions’
(Additional Precautions). In addition to the Terminal/Discharge clean, privacy and shower
curtains are changed, toilet paper, paper towel, glove box and toilet brush should all be
discarded and replaced.
Page 11
Non-critical Medical Equipment – equipment in the patient care environment that is used between
patients (e.g. imaging equipment, electronic monitoring equipment, commode chairs); items that touch
only intact skin but not mucous membranes.
N95 Respirator – type of mask used to prevent inhalation of small particles that may contain infectious
agents transmitted via the airborne route.
Personal Protective Equipment (PPE) – barriers placed between the infectious source and one’s own
mucous membranes, airways, skin and clothing to prevent exposure to blood and body fluids.
Point of Care Risk Assessment – a dynamic process done before each interaction with a patient or
their environment in order to determine which interventions are required to prevent transmission of
microorganisms during the interaction considering the patient’s status can change.
Respiratory Hygiene – personal practices that help prevent the spread of microorganisms that cause
respiratory infections; applies to any person entering a healthcare facility who has signs of illness,
including cough, congestion, runny nose or increased production of respiratory secretions.
Routine Practices – based on the assumption that all blood and body fluids contain potentially infectious
organisms, the same safe standards of practice should be used routinely with all patients to prevent
exposure to blood, body fluids, secretions, excretions, mucous membranes, non-intact skin or soiled
items and to prevent the spread of microorganisms.
Sharps – are devices that can cause occupational injury to healthcare providers (e.g. laceration or
puncture the skin). Some examples of sharps include needles, lancets, blades and clinical glass.
Section 03F - IF0200 (Hand Hygiene Guidelines)
Page 1

IF0200: Hand Hygiene Guidelines
REVISED DATE: December 2012, November
2016
REVIEWED DATE: Sept 2014 July 2015
1.0 PURPOSE
Hand hygiene (hand cleaning) is the single most important procedure for preventing the spread of
healthcare associated infections.
2.0 DEFINITIONS
See the glossary in Appendix A for hand hygiene definitions.
3.1 Hand hygiene is known to reduce patient morbidity and mortality from healthcare associated
infections. It causes a significant decrease in the carriage of potential pathogens on the
hands.
Hand hygiene is the responsibility of ALL individuals involved in health care.
3.2 Hand sanitizing with an alcohol-based hand rub (ABHR) is the preferred method (when
hands are not visibly soiled) for cleaning hands.
3.3 There is standardized ABHR product placement in acute, residential and community areas
throughout IH :
 At entrances to facilities
 In waiting rooms
 At entrances to units
 In dining rooms
 At entrance to each patient room
 At entrance to soiled utility rooms, medication rooms, clean supply rooms
 At point-of-care, within 3 feet of the patient bed, unless there are safety concerns (e.g.
psychiatry, residential)
 Affixed to the mobile work carts such as vital sign carts, med carts, dressing carts, clean
linen carts, housekeeping carts, and others
 ABHR that is attached to the wall must not be installed directly over a source of ignition
(i.e. electrical outlets). The risk of fire related to the use of ABHR is very small
 Entrance to clean and soiled service rooms
 In any location where personal protective equipment is donned or doffed
Page 2
3.4 Hand hygiene infrastructure

 Sinks should be in adequate numbers and accessible to facilitate staff, patient and
visitor hand washing (CSA Z8000)
 Best Practices for Hand Hygiene facilities and Infrastructure in Healthcare Settings
Checklist for all new projects and renovations – this checklist should be completed for
each facility every three years. This should be done jointly between plant services,
capital planning and infection prevention and control
 Bar soaps are not recommended for use by healthcare providers
 Disposable paper towels are readily available for drying hands
 Healthcare workers will inform housekeeping if they see that the ABHR is empty
 Hand hygiene products must be dispensed in single-use dispensers and discarded
when empty; containers must not be “topped-up” or refilled - this practice is not
acceptable since it can result in contamination of the container and product
 ABHR’s should not be placed at, or adjacent to, hand washing sinks
 Place ABHR according to CSA Z8000 specifications
 Plain soap is used in all care settings for routine hand washing
3.5 The use of gloves is not a substitute for performing hand hygiene. Hand hygiene must be
performed before putting on gloves and after removing gloves.
3.6 When Clostridium difficile infection is suspected or diagnosed:

 Wash hands with soap and water (preferred)
 If no sink is in close proximity, clean hands with alcohol hand rub and wash with soap
and water at first opportunity
 Do not perform hand hygiene at a patient sink, as this may cause recontamination of
the health care provider’s hands. Use a dedicated staff hand washing sink
3.7 The fingernails are the area of greatest contamination. Short nails are easier to clean and are
less likely to tear gloves. Artificial nails and nail enhancements have been implicated in the
transfer of microorganisms.
 The areas of the hands that are often missed when performing hand hygiene are the
wrist creases, thumbs, fingertips, under the fingernails and under jewelry.
 Dry or damaged skin conditions of the hands show a higher bacterial load, which is
more difficult to remove than with healthy, intact skin.
3.8 Compatibility between lotions and hand hygiene products, and lotion‘s potential effect on
glove integrity should be considered (i.e. lotions should not be petroleum based).
Page 3
4.0 PROCEDURE
4.1 4 Moments for Hand Hygiene
Reference: Government of Ontario (2006)
THE 4 MOMENTS FOR HAND HYGIENE IN HEALTHCARE:
1. BEFORE initial patient/patient environment contact

2. BEFORE aseptic procedure
3. AFTER body fluid exposure risk
4. AFTER patient/patient environment contact
4.2 Additional Moments for Hand Hygiene

 Before initial contact with a patient or items in their environment; this should be done on
entry to the room or bed space, even if the patient has not been touched.
 Before putting on gloves.
 Before preparing, handling or serving food or medications to a patient.
 After care involving contact with blood, body fluids, secretions and excretions of a patient,
even if gloves are worn.
 Immediately after removing gloves and before moving to another activity.
 When moving from a contaminated body site to a clean body site during healthcare
activities.
 After contact with a patient or items in their immediate surroundings when leaving the
area, even if the patient has not been touched.
 After using the toilet or after toileting others.
 After changing an incontinence product or a child’s diaper.
 Prior to using computers and other electronic devices.
 And… whenever in doubt.
Page 4
4.3 Hand Hygiene Using Alcohol Based Hand Rub (ABHR)

 Use routinely when hands are not visibly soiled.
 Three steps for hand rub:
1. Apply product liberally to palms of hands.
2. Spread thoroughly over hands.
3. Rub until dry.
4.4 Hand Hygiene Using Soap and Water

 Use when hands are visibly soiled.
 Steps for hand washing with soap and water:
1. Wet your hands with warm running water.
2. Apply soap.
3. Lather for 15 seconds.
4. Rinse well with warm running water.
5. Pat hands dry with a paper towel.
6. Use the paper towel to turn off the taps.
 If hands are visibly soiled and running water is not available, perform hand hygiene
using ABHR then immediately find a sink to wash with soap and water.
4.5 Hand Hygiene for Patients

 Staff should encourage and assist patients to perform hand hygiene prior to eating,
when their hands are soiled, after toileting and before leaving their room or clinic area.
 ABHR is available for patients to use at point of care.
 It is okay for patients to ask their healthcare providers if they have performed hand
hygiene prior to providing direct care.
4.6 Surgical hand scrubs are performed in the operative setting

(http://inet.interiorhealth.ca/infoResources/clinresources/Documents/Surgical%20Scrub.pdf)
4.7 Hand Care

 Hand care for staff is a key component of improving effective and safe hand hygiene
practices.
 Provide staff education on the benefits of using ABHRs and appropriate hand hygiene
technique.
 Provide staff with appropriate hand moisturizing skin care products.
 To prevent skin damage from frequent hand hygiene, staff to moisturize hands
regularly by applying hand lotion from a pump dispenser
 If you have an existing skin condition and /or suspected new skin condition that is
interfering with performing hand hygiene look for hand care information on the InsideNet
under Employee Health & Safety
4.8 Nails, Jewelry and Clothing:

 Nails shall be kept clean and short (less than 3 mm) at all times - the nail shall not show
past the end of the finger.
 Nail polish shall not be worn.
 Artificial nails or nail enhancements shall not be worn by healthcare providers who
provide direct patient care.
 Hand/wrist jewelry shall not be worn by healthcare providers who provide direct patient
care.
 Watches shall be removed or pushed up above the wrist by healthcare providers who
provide direct patient care before performing hand hygiene.
 Long sleeves should not interfere with, or become wet when performing hand hygiene.
If long sleeves are worn, push sleeves back prior to doing hand hygiene.
Page 5
4.9 Other Impediments to Effective Hand Hygiene

 Upper extremity support devices such as casts and splints, or complex bandages on
hands and forearms of healthcare workers may impede effective hand hygiene.
 Staff that are unable to perform effective hand hygiene as per the 4 moments of hand
hygiene must report to their manager immediately – consultation with Workplace Health
and Safety may be necessary.
4.10 Education
 IH will provide staff hand hygiene education, training, and competency assessment and
inform all healthcare providers of the hand hygiene policy at the time of hiring and
during orientation (AH0700 Hand Hygiene Administrative Policy).
 The requirements to complete education/training are as follows:
Physicians – Yearly at the time of credentialing, physicians will complete the I-Learn
education module (course ID: module: 855, quiz: 856).
1. Direct Patient Care Staff – Education will be linked to performance rates of the
unit. Staff working on units with hand hygiene compliance less than 69% over a
one year period will be required to complete the I-Learn education module
(course ID: module:853, quiz: 854)
2. New Hires – At the time of their orientation.
3. Students – At the time of their orientation.
 Provide education for patients, families and visitors including instructions regarding
when and how to perform hand hygiene – use information brochures, posters.
 The hand hygiene pamphlet for patients, visitors, and families shall be at the bedside for
each new admission.
 Routinely monitor healthcare provider hand hygiene compliance and provide timely
feedback for each quarter that a unit has less than 69% compliance using an action
plan with the goal of improving patient safety by increasing hand hygiene compliance
rates.
5.0 REFERENCES
5.1 AH0700 – Interior Health Administrative Hand Hygiene Policy.
5.2 Best Practices for Hand Hygiene In All Healthcare Settings and Programs. British
Columbia Ministry of Health; July 2012.
th
5.3 Best Practices for Hand Hygiene In all Healthcare Settings – 4 Edition. Provincial
Infectious Diseases Advisory Committee (PIDAC), Ontario;(2010).
http://www.publichealthontario.ca/en/eRepository/2010-12%20BP%20Hand%20Hygiene.pdf
5.4 APIC Text 2009.
5.5 World Health Organization (WHO) World Alliance for Patient Safety. WHO Guidelines on
Hand Hygiene in Health Care
http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf
5.6 Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update
Source: Infection Control and Hospital Epidemiology, Vol. 35, No. 6 (June 2014), pp. 628-645
Page 6
APPENDIX A
Glossary
Alcohol-based Hand Rub (ABHR) – can be a liquid, gel, or foam formulation. ABHR’s are the preferred
method to routinely decontaminate hands in clinical situations when hands are not visibly soiled as they
provide for a rapid kill of most transient microorganisms, are less time-consuming than washing with soap and
water and are easier on skin. ABHR must contain between 70 - 90% alcohol. Can be used as a surgical
scrub.
Contamination: The presence of an infectious agent on hands or on a surface, such as clothing, gowns,
gloves, bedding, toys, surgical instruments, patient care equipment, dressings or other inanimate objects.
Direct Care: Provision of hands-on care (e.g. bathing, washing, turning patient, changing clothes, continence
care, dressing changes, care of open wounds/lesions, toileting).
Environment of the Patient: The immediate space around a patient that may be touched by the patient and
may also be touched by the healthcare provider when providing care. For example:
 In a single room, the patient environment is the room
 In a multi-bed room, the patient environment is the area inside the individual’s curtain and including
the curtain
 In an ambulatory setting, the patient environment is the area that may come into contact with the
patient within their cubicle
 In a nursery/neonatal setting, the patient environment includes the inside of the bassinette or isolette,
as well as the equipment outside the bassinette or isolette used for that infant (e.g. ventilator,
monitor)
Hand Care: Actions and products that reduce the risk of skin irritation. A hand care program for staff is a key
component of hand hygiene and includes hand care assessment, staff education and an occupational health
assessment.
Hand Hygiene: A general term referring to any action of hand cleaning. Hand hygiene relates to the removal
of visible soil and removal or killing of transient microorganisms from the hands. Hand hygiene for patient
care may be accomplished using an alcohol-based hand rub or soap and running water. Hand hygiene
includes surgical hand preparation.
Hand Hygiene Moment - points to a patient care activity during which hand hygiene is essential because the
risk of transmission of microorganisms is greatest. There may be several hand hygiene moments in a single
care sequence or activity.
Hand Washing: The physical removal of microorganisms from the hands using soap and running water.
Healthcare Provider (HCP): Any person working in the healthcare system. This includes, but is not limited
to, the following: emergency service workers, physicians, dentists, nurses, respiratory therapists and other
health professionals, personal support workers, clinical instructors, students, environmental and food
services, facility maintenance, contracted providers and home healthcare workers. In some settings,
volunteers might provide care and would be included as a healthcare provider.
Nail Enhancement: Nail enhancements refer to artificial nails, resin wraps, tips, acrylics, gems, sticker,
piercings or gels.
Occupational Health and Safety (OHS)/Workplace Health: Preventive and therapeutic health services in
the workplace provided by trained occupational health professionals, e.g. nurses, hygienists, and physicians.
Page 7
Patient: The term ‘patient’ in this document refers to any patient, clients and residents receiving care within a
healthcare setting.
Plain Soap: Detergents that do not contain antimicrobial agents or that contain very low concentrations of
antimicrobial agents that are present only as preservatives.
Point-of-Care: The place where three elements occur together: the patient, the healthcare provider and care
or treatment involving patient contact. Point-of-care products should be accessible to the healthcare provider,
within arm’s reach, without the provider leaving the zone of care.
Surgical hand preparation: The preparation of hands for surgery, using either antimicrobial soap and water
or an alcohol-based hand rub, preferably one with sustained antimicrobial activity.
Visibly Soiled Hands: hands on which dirt or body fluids can be seen.
Section 03F - IF0300 (Waste Management)
Page 1

IF0300: Waste Management
REVISED DATE: November 2010,
December 2012, March 2013
REVIEWED DATE:
1.0 PURPOSE
To prevent the spread of infection, reduce the risk associated with waste disposal and ensure the safety
of the general public, patients and healthcare providers in regards to waste disposal processes.
2.0 DEFINITION
See the glossary in Appendix A for hand hygiene definitions.
3.1. Written procedures for the management of biomedical waste from healthcare settings should be
developed based on provincial and municipal regulations and legislation.
3.2. All staff handling waste or garbage will wear personal protective equipment
including protective gloves.
3.3. Waste should be segregated according to the categories listed in the table below. Waste
from several different categories should not be mixed in one bag. NOTE: Placing
regular waste that does not require special disposal will result in increased cost and may
incur penalties from collection agencies.
WASTE TYPE COLOUR-CODING STORAGE/DISPOSAL

Anatomical Red Commercial BioMedical Waste
waste – Disposal - incinerated
placentas,
human tissue,
organs and body
parts
Microbiology White Bucket Landfill
Laboratory
waste autoclaved
waste
Fluid waste - Yellow Commercial BioMedical Waste
pleurevacs, Disposal
hemovacs, blood
bags, suction
liners/containers *Contents of drainable devices
with visible can be emptied into the sewer.
blood, etc.
Page 2
Sharps – Yellow Commercial BioMedical Waste

needles, sutures, Commercial Disposal
lancets, blades, Sharps
trocars, Containers
contaminated
scissors, razors
or clinical glass
General waste - Black bag ** Landfill – Regular Garbage
disposable Disposal **
suction
containers with
no visible blood,
dressings,
sponges, diapers,
incontinent pads,
PPE, disposable
drapes, dialysis
tubing and filters,
empty IV bags
and tubing,
catheters, empty
specimen
containers,
disposable lab
coats and aprons
and pads that will
not release liquid
or semi-liquid
blood if
compressed, etc.
** FOLLOW LOCAL LANDFILL REGULATIONS.
3.4. Plastic waste holding bags are color coded and sturdy enough to resist puncture under conditions of
use and to the point of disposal. Use the Soiled Utility Room to gather together disposable
biomedical waste.
Safe Sharps Handling

Use safety engineered medical devices, such as needleless devices.
NEVER re-cap a used needle.
NEVER reach into waste or sharps containers.
Provision of rigid, puncture-resistant sharps containers at or near the point-of-use to permit

safe one-handed disposal required.
Handle laundry with care.
Educate staff about the risks associated with sharps, including safe disposal of sharps in
puncture-resistant containers if found in the environment (e.g. sharps in laundry, waste,
bedside, floor).
Page 3
4.0 PROCEDURE
4.1. Use appropriate PPE when handling waste/garbage including puncture resistant
gloves.
4.2. Ensure bags are not torn, are securely closed and no sharp objects are protruding
through.
4.3. It is not necessary to double bag garbage unless the first bag is leaking.
4.4. Human blood & body fluid waste can be disposed of from drainable devices into a sanitary sewer
and does not require special treatment before disposal. When handling these fluids care must
be taken to eliminate spills and the formation of aerosols.
4.5. Place all general waste into the regular garbage containers.
4.6. Place Biomedical waste into appropriate containers.
4.7. SHARPS
 Choose the correct size/shape of sharps container for the situation
(e.g.) small closable container for Home/Community care.
 Staff responsible for collecting and replacing sharps containers should
be trained in proper handling methods.
 All SHARPS containers must have an approved biohazard waste
label.
 Place all sharp items in an approved sharps container.
 DO NOT over fill sharps containers.
4.8. BLOOD & BLOODY BODY FLUID SPILLS
 Wear appropriate personal protective equipment to clean up spills (e.g.) gloves, gown and
face shield if there is a danger of splashing.
 Clean the area - gross soil must be removed prior to cleaning and disinfecting
o Use paper towels for small spills, mop for large spills.
o Used paper towels should be placed in biohazardous waste container.
o Mop heads should be placed in laundry bags.
 Disinfect area with approved hospital disinfectant.
 Cleaning equipment/reusable gloves are to be cleaned/discarded appropriately.
 Hands must be washed at the end of the procedure.
4.9. BIOMEDICAL WASTE DISPOSAL IN COMMUNITY CARE

 Follow Biomedical Waste Disposal – Community Care guidelines
http://inet.interiorhealth.ca/infoResources/clinresources/Documents/Biomedical%20Waste%2
0in%20Community%20Care.pdf
Page 4
APPENDIX A
Glossary
Anatomical Waste – placentas, human tissues, organs and body parts; does not include teeth, hair and
nails.
Biomedical waste – waste that requires additional precautions due to potential infectious nature;
includes anatomical waste, fluid waste, sharps, microbiology laboratory waste and sharps as defined in
APPENDIX A.
Drainable devices – any device that can have its liquid contents evacuated or drained out.
Fluid Waste – human fluid blood and blood products, items saturated or dripping with blood, body fluids
contaminated with blood and body fluids removed for diagnosis during surgery, treatment or autopsy;
does not include urine or feces.
General Waste – includes items such as dressings, sponges, diapers, incontinent pads, PPE,
disposable drapes, dialysis tubing and filters, empty IV bags and tubing, catheters, empty specimen
containers, disposable lab coats and aprons and pads that will not release liquid or semi-liquid blood if
compressed.
 Includes waste from Contact, Droplet and Airborne Precautions rooms.
 Includes waste from offices, kitchens, washrooms, public areas.
Microbiology Laboratory Waste - laboratory cultures, stocks or specimens of microorganisms, live or

attenuated vaccines, human or animal cell cultures used in research including laboratory material that
has come into contact with any of these.
Non drainable and/or Single Use devices – any device that is not able to have its liquid contents
drained out or are meant to be used once and then the device discarded.
Personal Protective Equipment (PPE) – barriers used by healthcare providers to protect mucous
membranes, airways, skin, and clothing from exposure to blood and body fluids. Can include gloves,
mask, eye protection or gown, as needed.
Sharps – items capable of cutting or puncturing the skin and that have come into contact with blood,
body fluids or microorganisms – items include all needles and devices containing needles or spikes,
broken medical glassware, contaminated scalpel blades, scissors, razors, lancets.
5.0 REFERENCES
5.1 Canadian Council of Ministers of the Environment (CCME) Guidelines for the Management of
Biomedical Waste in Canada. CCME-EPC-WM-42E. February 1992.
5.2 Best Practices for Environmental Cleaning for Prevention and Control of Infections In
All Health Care Settings - 2nd edition. Provincial Infectious Diseases Advisory Committee
5.3 City of Kelowna. (2012). Solid Waste Management Regulation Bylaw Number 10106.
February 13, 2012.
Section 04H – IH0100 (Additional Precaution for All Care Areas-Transmission Tables)
Page 1
IH0100: Additional Precautions For EFFECTIVE DATE: September 2006

All Care Areas
December 12, 2012, January 2015
Transmission Tables REVIEWED DATE:
1.0 PURPOSE
Additional Precautions are interventions used in addition to Routine Practices to prevent

transmission of certain microorganisms to patients and healthcare providers by interrupting
transmission of infectious agents that are suspected or identified in a patient.
Routine practices properly and consistently applied should prevent transmission by the contact and
droplet routes.
For certain situations that may result in extensive contamination of the environment or for
microorganisms with a very low infectious dose, additional precautions may be indicated. These
include contact, droplet and airborne precautions.
The Transmission Tables identify the transmission characteristics and precautions by

condition/clinical presentation or by a specific etiology. This information guides the healthcare
provider in determining when to implement and discontinue additional precautions – implementation
should occur as soon as disease or risk factors are suspected or identified. A confirmed diagnosis is
not necessary for additional precautions to be applied.
Table 9 identifies the additional precautions that should be used for conditions and/or clinical
presentations of patients.
Table 10 identifies the additional precautions that should be used for specific etiologies identified –
that is the causative microorganism has been identified.
2 | ROUTINE PRACTICES AND ADDITIONAL PRECAUTIONS FOR PREVENTING THE TRANSMISSION OF INFECTION IN HEALTHCARE
SETTINGS
PART C: TRANSMISSION CHARACTERISTICS AND PRECAUTIONS

Table 9: Transmission characteristics and precautions by condition/clinical presentation. Once
specific etiology is known, refer to Table 10
Condition/ Potential pathogens Precautions Infective material Route of Duration of Comments
clinical presentation transmission precautions
Abscess
See draining wound
Bronchiolitis RSV, human metapneumovirus Droplet and contact Respiratory secretions Large droplet and Duration of symptoms Patient should not share
parainfluenza virus, influenza, direct and indirect room with high-risk
adenovirus contact roommates
Burns, infected
See draining wound
Cellulitis H. influenzae type B in non- Droplet if Respiratory secretions Large droplet, direct Until 24 hours of
Draining: See draining immune child <2 years of age; H. influenzae type B contact appropriate
wound Streptococcus pneumoniae, is possible cause, antimicrobial therapy
Periorbital in child Group A Streptococcus, otherwise routine received or if
<5 years old without S. aureus, other bacteria practices H. influenzae type B
portal of entry ruled out
Cold Rhinovirus, RSV, human Droplet and contact Respiratory secretions Large droplet and Duration of symptoms Patient should not share
metapneumovirus, direct and indirect room with high-risk
parainfluenza, adenovirus, contact roommates
coronavirus
Conjunctivitis Adenovirus, enterovirus, Contacta Eye discharge Direct and indirect Until viral etiology ruled aRoutine if non-viral
chlamydia, Neisseria contact out; duration of
gonorrhea, other microbial symptoms, up to 14
agents days if viral
Cough, fever, acute Rhinovirus, RSV, human Droplet and contact Respiratory secretions Large droplet, direct Duration of symptoms Consider fever and
upper respiratory tract metapneumovirus and indirect contact or until infectious asthma in child <2 years
infection parainfluenza, influenza, etiology ruled out old as viral infection
adenovirus, coronavirus, Patient should not share
pertussis room with high-risk
roommates
SETTINGS

Cough, fever, pulmonary Mycobacterium tuberculosis Airborne Respiratory secretions Airborne Until infectious TB is TB in young children is
infiltrates in person at risk ruled out rarely transmissible
for TB Until patient has Assess visiting family
received 2 weeks of members for cough
effective therapy, and http://www.phac-
is improving clinically, aspc.gc.ca/tbpc-
and has 3 consecutive latb/pubs/tbstand07-
sputum smears eng.php
negative for acid fast
bacilli collected 8–24
hours apart
If multi-drug-resistant
TB, until sputum
culture negative
Croup Parainfluenza, influenza, human Droplet and contact Respiratory secretions Large droplet, direct Duration of symptoms Patient should not share
metapneumovirus, RSV, and indirect contact or until infectious cause room with high-risk
adenovirus ruled out roommates
Decubitius (pressure
ulcer, draining)
See draining wound
Dermatitis Many (bacteria, virus, fungus) Contact Pus Direct and indirect Until infectious etiology If compatible with scabies,
See draining wound contact ruled out take appropriate
precautions pending
diagnosis
Desquamation, extensive S. aureus Contact Pus Direct and indirect Until contained or
See draining wound contact infection ruled out
Diarrhea
See gastroenteritis
Acute diarrhea of likely
infectious cause
b
Draining wounds S. aureus, Group A Routine Pus Direct and indirect Duration of drainage Major: drainage not
Streptococcus, many other Contact:b Major contact contained by dressing
bacteria wound, dropletc c
Droplet for first 24 hours
of antimicrobial therapy if
invasive group A
streptococcal infection
suspected
Encephalitis Multiple microbial agents ADULT: Routined Feces, respiratory Direct and indirect Until specific etiology d
May be associated with
including herpes simplex virus PAEDIATRIC: secretions contact (fecal/oral) established or until other agents including
(HSV), enterovirus, arbovirus Contactd enterovirus ruled out measles, mumps,
(West Nile virus) varicella. If identified, take
appropriate precautions
for associated disease
SETTINGS

e
Endometritis Group A Streptococcus; many Routine unless signs Contact and droplet for
other bacteria of toxic shocke the first 24 hours of
antimicrobial therapy if
invasive group A
Streptococcus suspected.
Enterocolitis
See diarrhea
Epiglottitis H. influenzae type B; Droplet if Respiratory secretions Large droplet, direct Until 24 hours of
In child <5 years old Possible in non-immune H. influenzae type B contact appropriate
infant <2 years of age, group A is possible cause, antimicrobial therapy
Streptococcus, S. aureus otherwise routine received or until
H. influenzae type B
ruled out
Erysipelas Group A Streptococcus Routine
Draining: See draining
wound
Febrile respiratory illness Wide range of droplet-spread Contact and droplet Respiratory secretions Note: elderly people and
Usually present with respiratory infections, such as precautions people who are
symptoms of a fever colds, influenza, influenza-like immunocompromised may
greater than 38 °C and illness and pneumonia not have a febrile
new or worsening cough response to a respiratory
or shortness of breath infection
See Ontario Best
Practices for Preventing
Acute Respiratory
Infection in All Health
Care Settings
Fever without focus Enterovirus and other ADULT: Routinef Feces, respiratory Direct or indirect Duration of symptoms f
If findings suggest a
(acute, in children) pathogens PAEDIATRIC: secretions contact (fecal/oral) or until enteroviral specific transmissible
Contact infection ruled out infection, take precautions
for that infection pending
diagnosis
Food poisoning Bacillus cereus, Clostridium ADULT: Routineg Food; feces if Foodborne, or direct g
Consider contact
perfringens, S. aureus, PAEDIATRIC: Salmonella or and indirect contact precautions for incontinent
Salmonella, Vibrio Contact Escherichia coli O157 (fecal/oral) adults if stool cannot be
parahaemolyticus, Escherichia contained or for adults
coli O157, Listeria and others with poor hygiene who
contaminate their
environment
Contact precautions apply
to children who are
incontinent or unable to
comply with hygiene
Furuncles S. aureus
See draining wound
SETTINGS

Gas gangrene Clostridium spp.
Draining: See draining
wound
Gastroenteritis Diarrhea and/or vomiting due to ADULT: Contacth Feces Direct and indirect Duration of symptoms h
Use contact precautions
infection or toxin PAEDIATRIC: contact (fecal/oral) for C. difficile, until C. difficile, norovirus,
Contact norovirus, rotavirus rotavirus ruled out.
until ruled out. In Consider contact
pediatrics, until normal precautions for incontinent
stools or infectious adults if stool cannot be
etiology ruled out contained or for adults
with poor hygiene who
contaminate their
environment
to children who are
comply with hygiene
See Table 10 for specific
etiologies
Gingivostomatitis HSV, other causes including Contact if primary Mucosal lesions Direct contact While lesions present
radiation therapy, and extensive HSV
chemotherapy, idiopathic related.
(aphthous) Otherwise routine
i
Guillain-Barré syndrome Some cases associated with Take precautions as
infection (e.g., campylobacter)i appropriate for known or
suspected associated
infection
Hand, foot and mouth Enterovirus ADULT: Routine Feces, respiratory Direct and indirect Duration of symptoms Contact precautions apply
disease PAEDIATRIC: secretions contact (fecal/oral) to children who are
Contact incontinent or unable to
comply with hygiene
Hemolytic-uremic Some associated with E. coli ADULT: Routinej Feces Direct and indirect Until E. coli O157 ruled jConsider contact
syndrome O157 PAEDIATRIC: contact (fecal/oral) out precautions for incontinent
Contact adults if stool cannot be
contained or for adults
with poor hygiene who
contaminate their
environment
to children who are
comply with hygiene
SETTINGS

Hemorrhagic fever Ebola, Lassa, Marburg, Contact and droplet Blood and bloody body Direct and indirect Duration of symptoms Local public health
acquired in appropriate Crimean-Congo and others AGMPk fluids; respiratory contact; possibly or until hemorrhagic authorities should be
endemic or epidemic secretions; skin if Ebola aerosol if pneumonia fever virus ruled out notified immediately
k
area and urine if Lassa Lassa: Sexual contact If AGMP necessary, see
strategies to reduce
aerosol generation, see
Part B, Section IV,
subsection iii, 1b
Hepatitis of unknown Hepatitis A, B, C, E viruses, ADULT: Routinel Feces; blood and Mucosal or For 7 days after onset l
Consider contact
etiology Epstein-Barr virus and others PAEDIATRIC: certain body fluids percutaneous of jaundice or until precautions for incontinent
Contact exposure to infective hepatitis A and E adults if stool cannot be
body fluids epidemiologically contained or for adults
Sexual transmission excluded with poor hygiene who
Vertical; mother to contaminate their
child environment unless
Direct and indirect hepatitis A and E are
contact (fecal/oral) for epidemiologically
hepatitis A, E excluded
to children who are
comply with hygiene
Herpangina Enterovirus ADULT: Routine Feces, respiratory Direct and indirect Duration of symptoms Contact precautions apply
PAEDIATRIC: secretions contact (fecal/oral) to children who are
comply with hygiene
Impetigo Group A Streptococcus,
See draining wound S. aureus
Influenza-like illness Influenza, other respiratory Contact and droplet Respiratory secretions Large droplet, direct Duration of symptoms
viruses and indirect contact or until infectious
etiology ruled out
Kawasaki disease Unknown Routine Not known to be
(mucocutaneous lymph transmissible
node syndrome)
m
Meningitis Bacterial: Neisseria ADULT: Droplet until Respiratory secretions Large droplet, direct Until 24 hours of Pediatrics: precautions
meningitidis, H. influenzae Neisseria contact appropriate for both bacterial and viral
type B possible in non-immune meningitidis ruled antimicrobial therapy until etiology established.
infant <2 years of age, out, otherwise received Droplet if viral etiology
Streptococcus pneumoniae, routine established
Group B Streptococcus, Listeria PAEDIATRIC: Droplet Contact precautions apply
monocytogenes, E. coli and and contactm to children who are
other Gram-negative rods incontinent or unable to
comply with hygiene
Mycobacterium tuberculosis Routinen n
Rule out associated
respiratory TB
SETTINGS

Viral: enterovirus, arboviruses ADULT: Routineo Feces, respiratory Direct or indirect Until enterovirus ruled o
May be associated with
PAEDIATRIC: secretions contact out measles, mumps,
Contacto varicella, HSV. If
identified, take
appropriate precautions
for associated disease
Fungus Routine
Necrotizing enterocolitis Unknown, probably many Routinep Duration of symptoms p
Unknown if transmissible
organisms Take precautions if
outbreak suspected
Osteomyelitis H. influenzae type B possible in ADULT: Routine Until 24 hours of
non-immune infant <2 years of PAEDIATRIC: Droplet effective antimicrobial
age, S. aureus, other bacteria if H. influenzae therapy or until
type B possible; H. influenzae type B
otherwise routine ruled out
Otitis, draining
See draining wound
Paroxysmal cough, Bordetella pertussis, Bordetella Droplet Respiratory secretions Large droplets Until pertussis ruled out Close contacts (household
suspected pertussis parapertussis or 3 weeks after onset and HCWs) may need
of paroxysmals if not chemoprophylaxis and/or
treated or until 5 days immunization
of antimicrobial therapy If HCWs immunization not
received up to date, refer to OH
and/or delegate Refer to
Canadian Immunization
Guide 7th Ed., 2006 for
specific information
available at:
http://www.phac-
aspc.gc.ca/publicat/cig-
gci/index-eng.php
Pharyngitis Group A Streptococcus, viral, Droplet and contact Respiratory secretions Direct and indirect Duration of symptoms; If diphtheria suspected,
Corynebacterium diphtheriae contact; large droplets if Group A see Table 10.
Streptococcus until 24
hours of antimicrobial
therapy received
Pleurodynia Enterovirus ADULT: Routine Feces, respiratory Direct and indirect Duration of symptoms Contact precautions apply
PAEDIATRIC: secretions contact (fecal/oral) to children who are
comply with hygiene
SETTINGS

Pneumonia Viruses, pertussis, ADULT: Routineq Respiratory secretions Large droplets, direct Until etiology q
Routine for adults unless
Mycoplasma, Streptococcus PAEDIATRIC: Droplet and indirect contact established, then as for clinical, epidemiologic or
pneumoniae, H. influenzae and contact specific organism; no microbiologic data to
type B, S. aureus, group A special precautions for necessitate contact and
Streptococcus, Gram-negative pneumonia unless droplet precautions (i.e.,
enteric rods, Chlamydia, ARO, then use Contact on contact and droplet for
Legionella, Pneumocystis, other viral etiologies)
fungi; other agents Minimize exposure of
immunocompromised
patients, patients with
chronic cardiac or lung
disease, neonates
Pseudomembranous C. difficile Contact Feces Direct and indirect Duration of symptoms Until 72 hours after stool is
colitis contact (fecal/oral) normal.
Rash compatible with Sarcoptes scabiei Contact Mites Direct and indirect If confirmed, until 24 For typical scabies,
scabies contact hours after initiation of routine (use gloves and
appropriate therapy gown for direct patient
contact only)
See scabies, Table 10
Rash (maculopapular) Measles Airborne Respiratory secretions Airborne If confirmed, until 4 See measles, Table 10
with fever and one of days after onset of rash
coryza, conjunctivitis or
cough
Rash (petechial/purpuric) Neisseria meningitidis Droplet if N. Respiratory secretions Large droplets, direct Discontinue if Neisseria
with fever meningitidis contact meningitidis ruled out
suspected, otherwise If N. meningitidis
routine confirmed, until 24
hours of appropriate
antimicrobial therapy
received
Rash (vesicular) with Varicella Airborne and contact Respiratory secretions, Airborne, direct and If confirmed, until all See varicella, Table10
fever skin lesion drainage indirect contact lesions are dry
Rash, vesicular/pustular Smallpox, disseminated Contact, droplet and Lesions and respiratory
in appropriate vaccinia, monkeypox airborne secretions
epidemiologic context (monkeypox)
until smallpox, Skin lesion exudate,
disseminated vaccinia oropharyngeal
and monkeypox ruled out secretions (smallpox,
disseminated vaccinia)
Reye’s syndrome May be associated with viral Precautions for known or

infection, especially influenza, suspected associated viral
varicella infection
Scalded skin syndrome Routine
(Ritter`s Disease)
SETTINGS

Septic arthritis H. influenzae type B possible in ADULT: Routine Respiratory secretions Large droplet, direct Until 24 hours of
non-immune infant <2 years of PAEDIATRIC: Droplet for H. influenzae type B contact H. influenzae appropriate
age; S. aureus, Streptococcus if H. influenzae type B antimicrobial therapy
pneumoniae, group A type B possible; received or until
Streptococcus, N gonorrhoea, otherwise routine H. influenzae type B
other bacteria ruled out
Severe respiratory illness
See febrile respiratory
illness
Skin infection
See cellulitus
Toxic shock syndrome S. aureus, Group A Dropletr r
Droplet for first 24 hours
Streptococcus Routine of antimicrobial therapy if
invasive group A
streptococcal infection
suspected
See draining wound if
drainage or pus
Urinary tract infection Many Routines s
Contact if ARO
Vincent’s angina, Trench Multiple bacteria Routine
mouth
Wound infection
See draining wound
SETTINGS
Table 10: Transmission characteristics and precautions by specific etiology(15;492;497)

Microorganism Clinical Precautions Infective Route of Incubation Period of Duration of Comments
presentation material transmission period communicability precautions
Actinomycosis Cervicofacial, Routine Variable Not person to Normal flora; infection usually
(Actinomyces sp.) thoracic or person secondary to trauma.
abdominal
infection
Adenovirus Respiratory tract Droplet and Respiratory Large droplets; 1–10 days Shortly before Duration of Different strains responsible for
Respiratory strains infection contact secretions direct and and until symptoms respiratory and gastrointestinal
(pneumonia) indirect contact symptoms cease disease
Patient should not share room with
high-risk roommates
Minimize exposure of
immunocompromised patients,
patients with chronic cardiac or lung
disease, neonates.
Symptoms may be prolonged in
immunocompromised patients
Conjunctivitis Contact Eye discharge Direct and 5–12 days Late in Duration of Careful attention to aseptic technique
indirect contact incubation period symptoms, up and reprocessing of ophthalmology
until 14 days to 14 days equipment to prevent epidemic
after onset keratoconjunctivitis
a
Adenovirus Diarrhea ADULT: Feces Direct and 3–10 days Until symptoms Duration of Consider contact precautions for
Enteric strains Routinea indirect contact cease symptoms incontinent adults if stool cannot be
PAEDIATRIC: (fecal/oral) contained or for adults with poor
Contact hygiene who contaminate their
environment
Contact precautions apply to children
who are incontinent or unable to
comply with hygiene
b
Amebiasis Dysentery and ADULT: Feces Direct and 2–4 weeks Duration of cyst Duration of Consider contact precautions for
(Entamoeba liver abscess Routineb indirect contact excretion symptoms incontinent adults if stool cannot be
histolytica) PAEDIATRIC: (fecal/oral) contained or for adults with poor
environment
comply with hygiene
Anthrax Cutaneous, Routine 1–7 days; Not person-to- Acquired from contact with infected
(Bacillus pulmonary maybe up to person animals and animal products
anthracis) 60 days Inhalation anthrax may occur as a
result of occupational exposure to
anthrax spores or as a result of
bioterrorism
Decontamination and postexposure
prophylaxis necessary for exposure to
aerosols in laboratory exposures or
biological terrorism
SETTINGS

Antimicrobial- Infection or Contactc Infected or Direct and Variable Variable As directed by c
Contact precautions for acute care
resistant colonization colonized indirect contact ICP (for the purpose of this document,
organisms (AROs) (i.e., secretions, acute care includes ambulatory care
Includes MRSA, asymptomatic) excretions settings such as hospital emergency
VRE,-resistant of any body site departments, and free-standing or
Gram-negative facility-associated ambulatory (day)
rods and other surgery or other invasive day
organisms, as per procedures (e.g., endoscopy units,
ICP hemodialysis, ambulatory wound
clinics)
When symptomatic, precautions
should be determined on a case by
case basis as per ICP
When asymptomatic, precautions not
necessary in LTC, ambulatory,
prehospital and home care
See Appendix VI, 2. ARO
See IP&C Measures for HCWs in All
Healthcare Settings –
Carbapenaemase-resistant Gram-
negative bacilli at:
http://www.phac-aspc.gc.ca/nois-
sinp/guide/pubs-eng.php
d
Arthropod borne Encephalitis, Routine Blood, tissues Vector-borne 3–21 days Not person to Over 100 different viruses, most
virusd fever, rash, (spread by (varies with person except limited to specific geographic areas
(arboviruses) arthralgia, mosquitoes, different rarely by blood In North America: West Nile is most
meningitis ticks) arboviruses) transfusion or common; others include California,
organ St. Louis, Western equine, Eastern
transplantation equine, Powassan, Colorado tick,
Snowshoe hare, Jamestown Canyon
Ascariasis Usually Routine Not person to Ova must hatch in soil to become
(Ascaris asymptomatic person infective.
lumbricoides)
(roundworm)
Aspergillosis Skin, lung, Routine Not person to Spores in dust; infections in
(Aspergillus spp.) wound or central person immunocompromised patients may
nervous system be associated with construction
infection
Avian influenza
See influenza
SETTINGS

e
Astrovirus Diarrhea ADULT: Feces Direct and 3–4 days Duration of Duration of Consider contact precautions for
Routinee indirect contact symptoms symptoms incontinent adults if stool cannot be
environment
comply with hygiene
Babesiosis Routine Blood Tick borne Not person to
person, except
rarely by blood
transfusion from
asymptomatic
parasitaemic
donors
Bacillus cereus Food poisoning Routine Foodborne
Nausea,
vomiting,
diarrhea,
abdominal
cramps
Bed bugs Allergic Routine Not known to transmit disease
(Cimex lectularius) reactions and If necessary, consult professional
itchy welts. pest control for infestation
For information see:
http://www.cdc.gov/nceh/ehs/publicati
ons/bed_bugs_cdc-
epa_statement.htm
Blastomycosis Pneumonia, skin Routine Not person to Acquired from spores in soil
(Blastomyces lesions person
dermatitidis)
Bocavirus Droplet and May cohort if infected with same virus
Respiratory tract contact Patient should not share room with
infection high-risk roommates
Botulism Flaccid Routine Foodborne Not person to
(Clostridium paralysis; cranial person
botulinum) nerve palsies
Brucellosis Systemic Routine Weeks to Not transmitted Acquired from contact with infected
(Brucella sp.) bacterial months person to person, animals or from contaminated food,
Undulant, Malta or disease of acute except rarely via mostly dairy products
Mediterranean or insidious banked Brucella is hazardous to laboratory
fever onset spermatozoa and workers. Notify laboratory if diagnosis
sexual contact is suspected
Prophylaxis necessary following
laboratory exposure
SETTINGS

f
Draining lesions MINOR: Drainage from Possibly direct Duration of MAJOR: Contact precautions
Routine open lesions contact drainage necessary only if wound drainage
MAJOR: cannot be contained by dressings
Contactf
Burkholderia Exacerbation of Contactg Until organism B. cepacia can result in respiratory
cepacia chronic lung cleared as tract colonization or infection in
disease in directed by patient with cystic fibrosis
g
patients with ICP If other cystic fibrosis patients are on
cystic fibrosis the unit
All interactions with other cystic
fibrosis patients should be avoided
Caliciviruses
See Noroviruses
h
Campylobacter Gastroenteritis ADULT: Contaminated Direct and 2–5 days Duration of Duration of Consider contact precautions for
Routineh food, feces indirect contact excretion symptoms adults if stool cannot be contained or
PAEDIATRIC: (fecal/oral) Person–to- for adults with poor hygiene who
Contact person contaminate their environment
uncommon Treatment with effective antimicrobial
shortens period of infectivity
comply with hygiene
Candidiasis Many Routine Normal flora
(Candida sp.)
Cat scratch Fever, Routine 16–22 days Not person to Acquired from animals (cats and
disease lymphadenopath person others)
(Bartonella y
henselae)
Chancroid Genital ulcers Routine Sexual 3–5 days Until healed and
(Haemophilus transmission as long as
ducreyi) infectious agent
persists in the
original lesion
Chickenpox
See varicella
Chlamydia Urethritis, Routine Conjunctival Sexual Variable As long as
trachomatis cervicitis, pelvic and genital transmission organism present
inflammatory secretions Mother to child in secretions
disease; at birth
neonatal Trachoma:
conjunctivitis, direct/indirect
infant contact
pneumonia;
trachoma
Chlamydia Pneumonia Routine Respiratory Unknown Unknown Unknown Rare outbreaks of pneumonia in
pneumoniae secretions institutionalized populations
SETTINGS

Chlamydia Pneumonia, Routine Infected birds 7–14 days Not person to Acquired by inhalation of desiccated
(Chlamydophila) undifferentiated person droppings, secretions and dust of
psittaci fever infected birds
(Psittacosis,
Ornithosis)
i
Cholera Diarrhea ADULT: Feces Direct and 2–3 days Duration of Duration of Consider contact precautions for
(Vibrio cholerae Routinei indirect contact shedding symptoms adults if stool cannot be contained or
01, 0139) PAEDIATRIC: (fecal/oral) for adults with poor hygiene who
Contact contaminate their environment
comply with hygiene
Clostridium Diarrhea, Contact Feces Direct and Variable Duration of Duration of Bacterial spores persist in the
difficile pseudo- indirect contact shedding symptoms environment
membranous (fecal/oral) Ensure scheduled environmental
colitis cleaning
During outbreaks, special attention
should be paid to cleaning;
hypochlorite solutions may be
required if continued transmission
See Appendix VI. 3. Viral
Gastroenteritis
Dedicate patient care equipment
Relapses are common
Clostridium Food poisoning Routine Foodborne 6–24 hours Not person to
perfringens person
Gas gangrene, Routine Variable Not person to Found in normal gut flora, soil;
abscesses, person infection related to devitalized tissue
myonecrosis
Coccidioido- Pneumonia, Routine 1–4 weeks Not person to Acquired from spores in soil, dust in
mycosis draining lesions person endemic areas
(Coccidioides
immitis)
Colorado tick fever Fever Routine Tick-borne 3–6 days Not person to
See Dengue Fever person
(Arbovirus)
Congenital rubella
See Rubella
Coronavirus (CoV) Common cold Droplet and Respiratory Direct and 2–4 days Until symptoms Duration of May cohort if infected with same virus
(other than SARS- contact secretions indirect contact cease symptoms Patient should not share room with
CoV) Possible large high-risk roommates
For SARS CoV, see droplet
Severe acute
respiratory
syndrome
SETTINGS

Coxsackievirus
See Enteroviral
infections
Creutzfeldt-Jakob Chronic Routinej Contaminated j
PHAC guidelines for precautions for
disease (CJD) encephalopathy neurosurgical surgery and other procedures may be
instruments; accessed at:
tissue grafts http://www.phac-aspc.gc.ca/nois-
from infected sinp/guide/pubs-eng.php
donors
Notification of a suspected or
diagnosed case of CJD should be
made to the CJD surveillance system
(1-888-489-2999)
Crimean-Congo
fever
See Viral
hemorrhagic
fevers
Cryptococcosis Pneumonia, Routine Unknown Not person to
(Cryptococcus meningitis, person
neoformans) adenopathy
k
Cryptosporidosis Diarrhea ADULT: Feces Direct and 1–12 days From onset of Duration of Consider contact precautions for
(Cryptosporidium Routinek indirect contact symptoms until symptoms incontinent adults if stool cannot be
parvum) PAEDIATRIC: (fecal/oral) several weeks contained or for adults with poor
Contact after resolution hygiene who contaminate their
environment
comply with hygiene
Cysticercosis T. solium larval Routine Ova in feces Direct contact Months to While eggs Transmissible only from humans with
(Taenia solium cysts in various (fecal/oral) years present in feces T. solium adult tapeworm in
larvae) organs gastrointestinal tract (autoinfection
occurs)
Cytomegalovirus Usually Routine Saliva, genital Directl Unknown Virus is excreted No additional precautions for
asymptomatic; secretions, Sexual in urine, saliva, pregnant HCWs
l
congenital urine, breast transmission; genital Close direct personal contact
infection, milk, vertical mother secretions, necessary for transmission
retinitis, transplanted to child in breast milk for Disease is often due to reactivation in
mononucleosis, organs or stem utero, at birth many months; the patient rather than transmission of
pneumonia, cells, blood or through may persist or be infection
disseminated products breast milk episodic for life
infection in Transfusion,
immuno- transplantation
compromised
host
SETTINGS

Dengue Fever, Routine Mosquito- 3–14 days Not person to
(arbovirus) arthralgia, rash borne person
Dermatophytosis
See Tinea
m
Diphtheria Cutaneous Contact Lesion Direct or 2–5 days If untreated, Until 2 Cultures should be taken at least 24
(Corynebacterium (characteristic drainage indirect contact 2 weeks to culturesm from hours apart and at least 24 hours
diphtheriae) ulcerative several months skin lesions after cessation of antimicrobial
lesion) are negative therapy.
Close contacts should be given
antimicrobial prophylaxis, as per most
recent NACI recommendations
available at:
http://www.phac-
aspc.gc.ca/publicat/cig-gci/index-
eng.php
n
Pharyngeal Droplet Nasopharynge Large droplets, 2–5 days; If untreated, Until 2 Cultures should be taken at least 24
(adherent al secretions 2 weeks to culturesn from hours apart and at least 24 hours
greyish several months both nose and after cessation of antimicrobial
membrane) throat are therapy
negative Close contacts should be given
antimicrobial prophylaxis
Ebola
See Viral
hemorrhagic fever
Echinococcosis Cysts in various Routine Months to Not person to Acquired from contact with infected
(hydatidosis) organisms years person animals
(E. granulosis,
E. multilocularis)
Echovirus
See Enterovirus
Enterobiasis Perianal itching Routine Ova in stool, Direct, indirect Life cycle As long as gravid Direct transfer of infective eggs by
Oxyuriasis, perianal region contact requires 2–6 females hand from anus to mouth of the same
pinworm weeks discharge eggs or another person; indirectly through
(Enterobius on perianal skin; clothing, bedding or other
vermicularis) eggs remain contaminated articles
infective indoors Close household contacts may need
about 2 weeks treatment
Enterococcus
species
(vancomycin-
resistant only)
See Vancomycin-
resistant
enterococci
SETTINGS

Enteroviral Acute febrile ADULT: Feces, Direct and 3–5 days Duration of Contact precautions apply to children
infections symptoms, Routine respiratory indirect contact symptoms who are incontinent or unable to
Echovirus, aseptic PAEDIATRIC: secretions (fecal/oral) If poliovirus, comply with hygiene
Coxsackievirus A meningitis, Contact see
Coxsackievirus B encephalitis, Poliomyelitis
Enterovirus pharyngitis,
Poliovirus - See herpangina,
poliomyelitis rash,
pleurodynia,
hand, foot and
mouth disease
Conjunctivitis Contact Eye discharge Direct and 1–3 days Duration of
indirect contact symptoms
Epstein-Barr virus Infectious Routine Saliva, Direct 4–6 weeks Prolonged;
mononucleosis transplanted oropharyngeal pharyngeal
organs or stem route via excretion may be
cells saliva; intermittent or
transplantation persistent for
years
Erythema
infectiosum
See Parvovirus
B19
o
Escherichia coli Diarrhea, food ADULT: Feces Direct and 1–8 days Duration of Duration of Consider contact precautions for
(enteropathogenic poisoning, Routineo indirect contact shedding symptoms incontinent adults if stool cannot be
and hemolytic- PAEDIATRIC: (fecal/oral) If hemolytic- contained or for adults with poor
enterohemorrhagic uremic Contact Foodborne uremic hygiene who contaminate their
strains) syndrome, syndrome: environment
thrombotic until 2 stools Contact precautions apply to children
thrombocytopeni negative for who are incontinent or unable to
c purpura E. coli comply with hygiene
O157:H7 or 10
days from
onset of
diarrhea
Fifth disease
See Parvovirus
German measles
See Rubella
SETTINGS

p
Giardia Diarrhea ADULT: Feces Direct and 3–25 days Entire period of Duration of Consider contact precautions for
(Giardia lamblia) Routinep indirect contact infection; often symptoms incontinent adults if stool cannot be
PAEDIATRIC: (fecal/oral) months contained or for adults with poor
environment
comply with hygiene
Granuloma Painless genital Routine Sexual Unknown; Unknown;
inguinale ulcers, inguinal transmission probably probably for the
(Donovanosis) ulcers, nodules between 1 and duration of open
(Calymmatobacteri 16 weeks lesions on the
um granulomatis) skin or mucous
membranes
Haemophilus Pneumonia, ADULT: Respiratory Large droplets, Variable Most infectious in Until 24 hours Close contacts <48 months old and
influenzae type B epiglottitis, Routine secretions direct contact the week prior to of appropriate who are not immune may need
(invasive meningitis, PAEDIATRIC: onset of antimicrobial chemoprophylaxis
infections) bacteremia, Droplet symptoms and therapy has Household contacts of such children
septic arthritis, during the been received should also receive prophylaxis
cellulitis, symptoms until
osteomyelitis in treated
a child
Hand foot and
mouth disease
See Enteroviral
infections
Hansen’s disease
See Leprosy
Hantavius Fever, Routine Rodent excreta Presumed A few days to 6 Not well defined, Infection acquired from rodents
(Hantavirus pneumonia aerosol weeks person to person
pulmonary transmission is rare (person to
syndrome) from rodent person
excreta documented for
South American
strains)
Helicobacter pylori Gastritis, Routine Probable 5–10 days Unknown
duodenal ulcer ingestion of
disease organisms;
presumed
fecal/oral/oral/o
ral
SETTINGS

q
Hepatitis A, E Hepatitis, ADULT: Feces Direct and A: 28–30 days A: 2 weeks 1 week after Consider contact precautions for
anicteric acute Routineq indirect contact E: 26–42 days before to 1 week onset of incontinent adults if stool cannot be
febrile PAEDIATRIC: (fecal/oral) after onset of jaundice; contained or for adults with poor
symptoms Contact jaundice duration of hygiene who contaminate their
Shedding is hospitalization environment
prolonged in the if newborn Contact precautions apply to children
newborn who are incontinent or unable to
E: not known; at comply with hygiene
least 2 weeks Postexposure prophylaxis indicated
before onset of for non-immune household contacts
symptoms with significant exposure to
hepatitis A if within 2 weeks of
exposure
Refer to Canadian Immunization
Guide for specific information:
http://www.phac-
eng.php
Outbreaks of HAV in HCWs have
been associated with eating and
drinking in patient care areas
Hepatitis B, C, D, G Hepatitis, often Routine Blood, genital Mucosal or B: 2–3 months B: all persons Refer to Canadian Immunization
viruses asymptomatic; secretions, and percutaneous C: 2 weeks–6 who are hepatitis Guide 7th Ed., 2006 for specific
cirrhosis, certain other exposure to months B surface- information, available at:
hepatic cancer body fluids infective body D: 2–8 weeks antigen- http://www.phac-
fluids positive are aspc.gc.ca/publicat/cig-gci/index-
Sexual infectious eng.php
transmission; C: indefinite Contact OH or delegate if HCW has
Vertical mother D: indefinite percutaneous, non-intact skin or
to child mucous membrane exposure.
Refer to CDC dialysis
recommendations available at:
http://www.cdc.gov/mmwr/preview/m
mwrhtml/rr5005a1.htm
Herpes simplex Encephalitis ADULT:
virus Routine
PEDS:
Contact
Neonatal Contact Skin or Direct contact Birth to 6 Duration of Contact precautions are also
mucosal weeks of age symptoms indicated for infants delivered vaginally
lesions; (or by C-section if membranes have
possibly all been ruptured more than 4–6 hours) to
body women with active genital HSV
secretions and infections, until neonatal HSV infection
excretions has been ruled out
SETTINGS

Mucocutaneous: Contact Skin or Direct contact 2 days–2 While lesions Until lesions
disseminated or mucosal weeks present are dry and
primary and lesions crusted
extensive Sexual
(gingivostomatiti transmission
s, eczema Mother to child
herpeticum) at birth
Recurrent Routine
Herpes zoster
See Varicella
zoster
Histoplasmosis Pneumonia, Routine 3–17 days Not person to Acquired from spores in soil
(Histoplasma lymphadenopath person
capsulatum) y, fever
Hookworm Usually Routine Percutaneous; Few weeks to Not person to Larvae must hatch in soil to become
(Necator asymptomatic fecal/oral many months person infectious
americanus,
Ancyclostoma
duodenale)
Human
herpesvirus 6
(HHV-6)
See Roseola
Human immuno- Asymptomatic; Routine Blood, genital Mucosal or Weeks to From onset of Contact OH or delegate immediately
deficiency virus multiple clinical secretions, percutaneous years infection if HCW has percutaneous, non-intact
(HIV) presentations breast milk and exposure to skin or mucous membrane exposure
certain other infective body
body fluids fluids
Sexual
transmission,
vertical mother
to child
Human meta- Respiratory tract Droplet and Respiratory Large droplets 3–5 days Duration of May cohort if infected with same virus
pneumovirus infection contact secretions Direct and symptoms Patient should not share room with
indirect contact high-risk roommates
Human T-cell Usually Routine Breast milk, Vertical mother Weeks to Indefinite
leukemia virus, asymptomatic, blood and to child; years
human T- tropical spastic, certain other mucosal or
lymphotrophic paraperisis, body fluids percutaneous
virus (HTLV-I, lymphoma exposure to
HTLV-II) infective body
fluids
Infectious
mononucleosis
See Epstein-Barr
virus
SETTINGS

Influenza Respiratory tract Droplet and Respiratory Large droplets, 1–3 days Generally 3–7 Duration of If private room is unavailable,
Seasonal infection contact secretions direct and days from clinical symptoms consider cohorting patients during
indirect contact onset outbreaks
Prolonged Patient should not share room with
shedding may high-risk roommates
occur in immuno- Consider antiviral for exposed
compromised roommates
individuals. See Guidance: IP&C Measures for
HCWs in Acute Care and Long-term
Care Settings at:
For further information for all types of
influenza see:
http://www.phac-
aspc.gc.ca/influenza/index-eng.php
Pandemic Respiratory tract Pandemic As seasonal As seasonal Unknown; Unknown, Duration of See Canadian Pandemic Plan Annex
Novel influenza infection influenza possibly 1–7 possibly up to 7 symptoms F, Infection Prevention and Control
viruses precautionsr days days and Occupational Health and Hygiene
guidelines during Pandemic Influenza
in Existing and Temporary Healthcare
Settings, available at:
http://www.phac-
Refer to PHAC website for specific
guidance documents. Available at
Avian Respiratory tract Droplet and Excreta of sick For current information on Avian
infection, contact birds, possibly influenza, see
conjunctivitis human Human Health Issues Related to
respiratory Domestic Avian Influenza in Canada,
tract secretions available at"
http://www.phac-
http://www.phac-
aspc.gc.ca/publicat/daio-enia/9-
eng.php
Lassa fever
See Viral
hemorrhagic fever
Legionella Pneumonia, Routine 2–10 days; Not person to Acquired from contaminated water
(Legionella spp.) Legionnaires’ person sources (inhalation not ingestion)
Legionnaires’ disease, Pontiac
disease fever
SETTINGS

Leprosy Chronic disease Routine Nasal Direct contact 9 months to 20 Transmitted between persons only
(Hansen’s disease) of skin, nerves, secretions, years with very prolonged extensive close
(Mycobacterium nasopharyngeal skin lesions personal contact
leprae) mucosa Household contacts should be
assessed and may be given
prophylaxis
Leptospirosis Fever, jaundice, Routine 2–30 days Direct person to Acquired from contact with animals
(Leptospira sp.) aseptic person
meningitis transmission is
rare
Lice (pediculosis) Scalp or body Routine, plus Louse Head and body 6–10 days Until effective Until 24 hours Apply pediculicides as directed on
Head itch, itchy rash gloves for lice: direct and treatment to kill after label. If live lice found after therapy,
Body direct patient indirect contact lice and ova application of repeat
Pubic (crab) contact only Pubic lice: appropriate Head lice: wash headgear, combs,
(Pediculus capitas, usually sexual pediculicide; pillowcases, towels with hot water or
Pediculus contact applied as dry clean or seal in plastic bag and
corporis, Pediculus directed store for 10 days.
humanus, Phthirus Body lice: as above, for all exposed
pubis) clothing and bedding
Listeriosis Fever, Routine Foodborne; mean 21 days; Pregnant women and

(Listeria meningitis Vertical mother 3–70 days immunocompromised persons should
monocytogenes) Congenital or to child in utero following a avoid cheese made with
neonatal or at birth single unpasteurized milk, cold cuts and
infection exposure to an uncooked meat products, including
implicated food hot dogs
product Listeria grows well at low
temperatures and is able to multiply in
refrigerated foods that are
contaminated
Nosocomial outbreaks reported in
newborn nurseries due to
contaminated equipment or materials
Lyme disease Fever, arthritis, Routine Tickborne To initial rash: Not person to
(Borrelia rash, meningitis 3–32 days; person
burgdorferi) mean 7–10
days
Lymphocytic Aseptic Routine Urine of 6–21 days Not person to Acquired from contact with rodents
choriomeningitis meningitis rodents person
virus
Lympho- Genital ulcers, Routine Sexually Range of 3–30
granuloma inguinal transmitted days for a
venereum adenopathy primary lesion
(C. trachomatis
serovars L1, L2,
L3)
SETTINGS

Malaria Fever Routine Blood Mosquito- Variable; 9–14 Not normally Can be transmitted via blood
(Plasmodium sp.) borne; rarely days for P. person to person transfusion
transplacental falciparum
from mother to
fetus; blood
transfusion
Marburg virus
See Viral
haemorrhagic
fever
Measles Fever, cough, Airborne Respiratory Airborne 7–18 days to 5 days before 4 days after Only immune HCWs, caretakers and
(Rubeola) coryza, secretions onset of fever; onset of rash (1– start of rash; visitors should enter the room
conjunctivitis, rarely as long 2 days before duration of Respirator needed for non-immune
maculopapular as 21 days onset of initial symptoms in persons who must enter
skin rash symptoms) until immuno- Precautions should be taken with
4 days after compromised neonates born to mothers with
onset of rash patients measles infection at delivery
(longer in Immunoprophylaxis is indicated for
immuno- susceptible contacts
compromised Refer to Canadian Immunization
patients) Guide 7th Ed., 2006 for specific
information available at:
http://www.phac-
eng.php
Susceptible Airborne Respiratory Airborne Potentially From 5 days Only immune HCWs, caretakers and
contact secretions communicable after first visitors should enter the room
during last exposure Respirator needed for non-immune
2 days of through 21 persons who must enter
incubation period days after last Precautions should be taken with
exposure neonates born to mothers with
regardless of measles infection at delivery
postexposure Immunoprophylaxis is indicated for
prophylaxis susceptible contacts
Melioidosis Pneumonia, Routine Contaminated Variable Organism in soil in Southeast Asia
(Pseudomonas fever soil Person-to-person has not been
pseudomallei) proven
Meningococcus Rash Droplet Respiratory Large droplet, Usually 2–10 Until 24 hours Close contacts may need
(Neisserria (petechial/purpu secretions direct contact days of effective chemopropylaxis as per most recent
meningitidis) ric) with fever antimicrobial NACI recommendations available at:
Meningococcem therapy has http://www.phac-
ia meningitis, been received aspc.gc.ca/publicat/cig-gci/index-
pneumonia eng.php and http://www.phac-
aspc.gc.ca/publicat/cig-gci/p04-meni-
eng.php
SETTINGS

Methicillin-
resistant
Staphylococcus
aureus (MRSA)
See ARO
Molluscum Umbilicated Routine Contents of Direct contact 2 weeks to 6 Unknown Close direct personal contact needed
contagiosum papules papules months for transmission
Monkeypox Resembles Contact,s Lesions and Contact with s
Contact: until Transmission in hospital settings is
smallpox; droplet and respiratory infected all lesions unlikely. See
lymphadenopath airborne secretions animals; crusted http://www.cdc.gov/ncidod/monkeypo
y is a more possible x for current recommendations
predominant airborne
feature transmission
from animals to
humans
Mucormycosis Skin, wound, Routine Fungal spores Inhalation or Unknown Not person to Unknown Acquired from spores in dust, soil
t
(phycomycosis; rhinocerebral, in dust and soil ingestion of person Infections in immunocompromised
zygomycosis) pulmonary, fungal spores patients
(Mucor, gastrointestinal,
Zygomycetes) disseminated
infectiont
Mumps Swelling of Droplet Saliva Large droplets, Usually 16–18 Viral excretion Until 5 days Droplet precautions for exposed
salivary glands, direct contact days; range highest 2 days after onset of susceptible patients/HCWs should
orchitis, 14–25 days before to 5 days parotitis begin 10 days after first contact and
meningitis after onset or continue through 26 days after last
parotitis exposure
For outbreaks, see:
http://www.phac-
aspc.gc.ca/publicat/ccdr-
rmtc/10pdf/36s1-eng.pdf
Mycobacterium Lymphadenitis; Routine Unknown Not person to Acquired from soil, water, animal,
non-TB (atypical) pneumonia; person reservoirs
disseminated
disease in
immuno-
compromised
host
SETTINGS

Mycobacterium Confirmed or Airborneu Respiratory Airborne Weeks to While organisms Until deemed TB in young children is rarely
tuberculosis suspected secretions years is viable in no longer transmissible; due to lack of cavitary
including M. respiratory sputum infectious disease and weak cough
tuberculosis (including If confirmed, Assess visiting family members for
subsp. canetti, M. pleural, until patient cough
bovis, M. bovis laryngeal) has received 2 Canadian Tuberculosis Standards,
BCG, M.africanum, weeks of http://www.phac-aspc.gc.ca/tbpc-
M. caprae, M. effective latb/pubs/tbstand07-eng.php uAGMP,
microti and M. therapy, and is see strategies to reduce aerosol
pinnipedii improving generation Part B, Section IV,
clinically, and subsection iii, 1b
has 3
consecutive
sputum
smears
negative for
acid fast
bacilli,
collected 8–24
hours apart
with at least 1
early morning
specimen
If multi-drug-
resistant TB,
until sputum
culture
negative
Nonpulmonary: Routine Most patients with nonpulmonary
meningitis, bone disease alone are noncontagious; it is
or joint infection important to assess for concurrent
with no drainage pulmonary TB
v
Nonpulmonary: Routine, Aerosolized While viable Airborne precautions if procedures
skin or soft Airbornev wound micro that may aerosolize drainage are
tissue draining drainage organisms are being performed
lesions in drainage
PPD skin test Routine Non
positive with no communicable
evidence of
current
pulmonary
disease
Mycoplasma Pneumonia Droplet Respiratory Large droplets 1–4 weeks Unknown Duration of
pneumoniae secretions symptoms
SETTINGS

Neisseria Urethritis, Routine Sexual 2–7 days May extend for
gonorrhoeae cervicitis, pelvic transmission months if
inflammatory Mother to child untreated
disease, at birth
arthritis, Rarely:
ophthalmia direct/indirect
neonatorum, contact
conjunctivitis
Neisseria
meningitidis
See
Meningococcus
Nocardiosis Fever, Routine Unknown Not person to Acquired from organisms in dust, soil
(Nocardia sp.) pulmonary or person
CNS infection or
disseminated
disease
Noroviruses Nausea, Contact Feces Direct and Usually 24–48 Duration of viral 48 hours after During outbreaks, special attention
(Norwalk-like vomiting, indirect contact hours; range of shedding; usual resolution of should be made to cleaning;
agents, diarrhea (fecal/oral) 10–50 hours 48 hours after illness hypchlorite solutions may be required
caliciviruses) diarrhea resolves if continued transmission
See Appendix VI 3. Viral
Gastroenteritis
Orf Skin lesions Routine Generally 3–6 Not person to Acquired from infected animals.
(poxvirus) days person
Parainfluenza virus Respiratory tract Droplet and Respiratory Large droplets, 2–6 days 1-3 weeks Duration of May cohort if infected with same virus
infection contact secretions direct and symptoms Patient should not share room with
indirect contact high-risk roommates
Parvovirus B-19 Erythema Routine: fifth Respiratory Large droplets, 4–21 days to Fifth disease: no Aplastic or
Human parvovirus infectiosum (fifth disease secretions direct contact onset of rash longer infectious erythrocytic
disease), Droplet: Vertical mother by the time the crisis: 7 days
aplastic or aplastic crisis to fetus rash appears Chronic
erythrocytic or chronic Aplastic crisis: up infection in
crisis infection in to 1 week after immuno-
immuno- onset of crisis compromised
compromised Immuno- patient:
patient compromised duration of
with chronic hospitalization
infection: months
to years
Pediculosis
See lice
SETTINGS

Pertussis Whooping Droplet Respiratory Large droplets Average 9–10 To 3 weeks after To 3 weeks Close contacts (household and
(Bordetella cough, non- secretions days; range 6– onset of after onset of HCWs) may need chemoprophylaxis
pertussis, specific 20 days paroxysms if not paroxysms if and/or immunization
Bordetella respiratory tract treated not treated; or If HCWs immunization not up to date,
parapertussis) infection in until 5 days of refer to OH and/or delegate
infants, appropriate Refer to Canadian Immunization
adolescents and antimicrobial Guide 7th Ed., 2006 for specific
adults therapy information available at:
received http://www.phac-
eng.php
Pinworms
See Enterobius
Plague Bubonic Routine Rodents and 1–7 days
(Yersinia pestis) (lymphadenitis) their fleas
Pneumonic Droplet Respiratory Large droplets 1–4 days Until 48 hours of Until 48 hours Close contacts and exposed HCWs
(cough, fever, secretions appropriate of appropriate may need prophylaxis
hemoptysis) antimicrobial antimicrobial
therapy received therapy
received
Pneumocystis Pneumonia in Routine Unknown Unknown Ensure roommates are not
jiroveci (carinii) immuno- immunocompromised
compromised
host
Poliomyelitis Fever, aseptic Contact Feces, Direct and 3–35 days Virus in the Until 6 weeks Most infectious during the days
Infantile paralysis meningitis, respiratory indirect contact throat for from onset of before and after onset of symptoms
flaccid paralysis secretions approximately symptoms or Close contacts who are not immune
1 week and in until feces viral should receive immunoprophylaxis
feces for 3–6 culture
weeks negative
Prion disease
See Creutzfeldt-
Jakob disease
Psittacosis
See Chlamydia
psittace
Q Fever Pneumonia, Routine Infected Direct contact 14–39 days Not person to Acquired from contact with infected
(Coxiella burnetii) fever animals, milk with infected person animals or from ingestion of raw milk
animals; raw
milk
Airborne from
aerosolized
contaminated
dust
SETTINGS

Rabies Acute Routine Saliva Mucosal or Usually 3–8 Person-to-person Acquired from contact with infected
encephalomyeliti percutaneous weeks, rarely transmission is animals
s exposure to as short as theoretically Postexposure prophylaxis is
saliva; corneal, 9 days or as possible, but rare recommended for percutaneous or
tissue and long as 7 years and not well mucosal exposure to saliva of rabid
organ documented animal or patient
transplantation
Rat bite fever Fever, arthralgia Routine Saliva of Rodent bite, A. moniliformis Not person-to- A. moniliformis: rats and other
Actinobacillus infected ingestion of days 3–10 person animals, contaminated milk
(formerly rodents; contaminated days, rarely S. minus: rats, mice only
Streptobacillus contaminated milk longer;
moniliformis) milk S. minus 1–3
Spirillum minus weeks
Relapsing fever Recurrent fevers Routine Vector-borne Not person to Spread by ticks or lice
(Borellia person
recurrentis, other
Borellia species)
Respiratory Respiratory tract Droplet and Respiratory Large droplets, 2-8 days Shortly before Duration of May cohort if infected with same virus
syncytial virus infection contact secretions direct and and for the symptoms Patient should not share room with
(RSV) indirect contact duration of active high-risk roommates
disease
Rhinovirus Respiratory tract Contact and Respiratory Direct and 2–3 days Until symptoms Duration of May cohort if infected with same virus
infection, droplet secretions indirect cease symptoms Patient should not share room with
common cold contact, high-risk roommates
possibly large
droplets
Rickettsialpox Fever, rash Routine Mite-borne 9–14 days Not person to Transmitted by mouse mites
(Rickettsia akari) person
Ringworm
See Tinea
Rocky Mountain Fever, petechial Routine Tick-borne 3–14 days Not transmitted
spotted fever rash, from person to
(Rickettsia encephalitis person, except
rickettsia) rarely through
transfusion
Roseola infantum Rash, fever Routine Saliva Direct contact 10 days Unknown Close direct personnel contact
(HHV-6) needed for transmission
Rotavirus Diarrhea Contact Feces Direct and 1–3 days Duration of viral Duration of
indirect contact shedding symptoms
(fecal/oral)
Roundworm
See Ascariasis
SETTINGS

Rubella, acquired Fever, Droplet Respiratory Large droplets, 14–21 days For about 1 week Until 7 days Only immune HCWs, caretakers and
maculopapular secretions direct contact before and after after onset of visitors should enter the room
rash onset of rash. rash Pregnant HCWs should not care for
rubella patients, regardless of their
immune status
If it is essential for a non-immune
person to enter the room, facial
protection should be worn
Droplet precautions should be
maintained for exposed susceptible
patients from 7 days after first contact
through to 21 days after last contact
Administer vaccine to exposed
susceptible non-pregnant persons
within 3 days of exposure
Refer to Canadian Immunization
Guide 7th Ed., 2006 for specific
information available at:
http://www.phac-
eng.php
Exclude susceptible HCWs from duty
from day 7 after first exposure to
day 21 after last exposure, regardless
of postexposure vaccination
Rubella, congenital Congenital Droplet and Respiratory Direct and Prolonged Until one year As per Rubella, acquired
rubella contact secretions, indirect shedding in of age, unless
syndrome urine contact; large respiratory tract nasopharynge
droplets and urine; can be al and urine
up to one year cultures done
after 3 months
of age are
negative
Rubeola
See Measles
w
Salmonella Diarrhea, enteric ADULT: Feces Direct and 6–72 hours Variable Duration of Consider contact precautions for
(including fever, typhoid Routinew indirect contact symptoms incontinent adults if stool cannot be
Salmonella Typhi) fever, food PAEDIATRIC: (fecal/oral); contained or for adults with poor
poisoning Contact foodborne hygiene who contaminate their
environment
comply with hygiene
SETTINGS

Scabies Itchy skin rash Contact Mite Direct and Without Until mites and Until 24 hours Apply scabicide as directed on label.
(Sarcoptes scabiei) indirect contact previous eggs are after initiation Wash clothes and bedding in hot
exposure, 2–6 destroyed by of appropriate water, dry clean or seal in a plastic
weeks; 1–4 treatment, therapy bag, and store for 1 week
days after re- usually after 1 or Household contacts should be treated
exposure occasionally 2
courses of
treatment, 1
week apart
Scarlet fever
See Group A
Streptococcus
Schistosomiasis Diarrhea, fever, Routine Not person to Contact with larvae in contaminated
(bilharziasis) itchy rash person water.
(Schistosoma sp.) Hepatospleno-
megaly,
hematuria
x
Shigella Diarrhea ADULT: Feces Direct and 1–3 days Usually 4 weeks Duration of Consider contact precautions for
Routinex indirect contact if not treated symptoms incontinent adults if stool cannot be
environment
comply with hygiene
Treatment with effective antimicrobial
shortens period of infectivity
y
Severe acute Malaise, Contact and Respiratory Droplet, direct 3–10 days Not yet 10 days AGMP, see strategies to reduce
respiratory myalgia, droplet y secretions, and indirect determined; following aerosol generation, see Part B,
syndrome (SARS headache, fever, AGMP stool contact suggested to be resolution of Section IV, subsection iii, 1b
coronavirus) respiratory Aerosols less than 21 days fever if May cohort if infected with same virus
symptoms during AGMP respiratory Patient should not share room with
(cough, symptoms high-risk roommates
increasing have also
shortness of resolved
breath),
pneumonia,
acute respiratory
distress
syndrome
Shingles
See Herpes zoster
SETTINGS

Smallpox Fever, Droplet, Skin lesion Airborne, direct 7–10 days Onset of mucosal Until all scabs Immunization of HCWs was stopped
(variola virus) vesicular/pustula contact and exudate, and Indirect lesions, until all have crusted in 1977
Generalized r in appropriate airborne oropharyngeal contact skin lesions have and separated Refer to Canadian Immunization
vaccinia, eczema epidemiologic secretions crusted (3–4 weeks) Guide 7th Ed., 2006 for information
vaccinatum context regarding vaccine,
See Vaccinia for http://www.phac-
management of aspc.gc.ca/publicat/cig-gci/index-
vaccinated eng.php
persons NACI Statement on Smallpox
Vaccination, http://www.phac-
rmtc/02vol28/28sup/acs1.html
Care preferably should be provided
by immune HCWs; non-vaccinated
HCWs should not provide care if
immune HCWs are available
Respirator for all regardless of
vaccination status
Sporotrichosis Skin lesions, Routine Variable Rare person to Acquired from spores in soil, on
(Sporothrix disseminated person vegetation
schenckii)
z
Staphylococcus Skin (furuncles, MINOR: Drainage, pus Direct and Variable As long as Until drainage MAJOR: drainage not contained by
aureus impetigo) wound Routine indirect contact organism is in resolved or dressings
(if methicillin- or burn infection; MAJOR: the exudates or contained by
resistant, see also abscess; Contactz drainage dressings
ARO) scalded skin
syndrome,
osteomyelitis
Endometritis Routine
Food poisoning Routine Foodborne
Pneumonia ADULT: Respiratory Large droplets, Variable Until 24 hours
Routine secretions direct contact of appropriate
PAEDIATRIC: antimicrobial
Droplet therapy
received
Toxic shock Routine
syndrome
Streptobacillus
moniliformis
disease
See Rat-bite fever
Streptococcus Pneumonia, Routine Variable Normal flora
pneumoniae meningitis and
other
SETTINGS

aa
Streptococcus, Skin (e.g., MINOR: Drainage, pus Direct and 1–3 days, As long as Until 24 hours MAJOR: drainage not contained by
Group A erysipelas, Routine indirect contact rarely longer organism of appropriate dressings
(Streptococcus impetigo), MAJOR: is in the exudatesantimicrobial
pyogenes) wound or burn Contactaa or drainage therapy
infection received
Scarlet fever, ADULT: Respiratory Large droplets, 2–5 days 10–21 days if not Until 24 hours
pharyngitis, in Routine secretions treated of appropriate
children PAEDIATRIC: antimicrobial
Contact and therapy
droplet received
Group A Routine
Streptococcus
endometritis
(puerperal fever)
Group A Droplet and Respiratory Large droplets, Until 24 hours Chemoprophylaxis may be indicated
Streptococcus contact secretions, direct or of appropriate for close contacts of patients with
toxic shock, wound indirect contact antimicrobial invasive disease or toxic shock
invasive disease drainage therapy syndrome
(including received For further information see:
necrotizing http://www.phac-
fasciitis, aspc.gc.ca/publicat/ccdr-
myositis, rmtc/06pdf/32s2_e.pdf
meningitis,
pneumonia)
Streptococcus, Group B Routine Mother to child Early onset: 1– Normal flora
Group B Streptococcus at birth 7 days of age;
(Streptococcus newborn sepsis, late onset: 7
agalactiae) pneumonia, days to 3
meningitis months of age
Stronglyoides Usually Routine Larvae in feces Unknown Rarely Infective larvae in soil
(Stronglyoides asymptomatic transmitted May cause disseminated disease in
stercoralis) person to person immuno-compromised patient
Syphilis Genital, skin or Routine Genital Direct contact 10–90 days; When moist
(Treponema mucosal lesions, Gloves for secretions, with infectious usually 3 muco-cutaneous
pallidum) disseminated direct contact lesion exudates or weeks lesions of
disease, with skin exudates lesions primary and
neurological or lesions Sexual secondary
cardiac disease; transmission, syphilis are
latent infection Intrauterine or present
intrapartum
from mother to
child
SETTINGS

Tapeworm Usually Routine Larvae in food Foodborne Variable Not transmissible Consumption of larvae in raw or
(Taenia saginata, asymptomatic person to person undercooked beef or pork or raw fish;
Taenia solium, larvae develop into adult tapeworms
Diphyllobothrium in gastrointestinal tract
latum) Individuals with T. solium adult
tapeworms may transmit cysticercosis
to others
Tapeworm Usually Routine Ova in rodent Direct contact 2–4 weeks While ova in
(Hymenolepsis asymptomatic or human (fecal/oral) feces
nana) feces
Tetanus Tetanus Routine 1 day to Not person to Acquired from spores in soil which
(Clostridium tetani) several months person germinate in wounds, devitalized
tissue
Tinea Ringworm (skin, Routine Organism in Direct skin-to- Variable; 4–14 While lesion May be acquired from animals,
(Dermatophytosis) beard, scalp, skin or hair skin contact days present shared combs, brushes, clothing,
(Trichophyton sp., groin, perineal hats, sheets, shower stalls
Microsporom sp., region); athletes
Epidermophyton foot; pityriasis
sp., Malassezia versicolor
furor)
Toxic shock
syndrome
See S. aureus,
Group A
Streptococcus
Toxocariasis Fever, wheeze, Routine Ova in dog/cat Unknown Not person to Acquired from contact with dogs, cats
(Toxocara canis, rash, feces person
Toxocara cati) eosinophilia
Toxoplasmosis Asymptomatic, Routine Intrauterine 5–23 days Acquired by contact with infected
(Toxoplasma fever, transmission felines or soil contaminated by
gondii) lymphadenopath from mother to felines, consumption of raw meat,
y; retinitis, foetus; contaminated raw vegetables or
encephalitis in transplantation contaminated water
immuno- of stem cells or
compromised organs
host; congenital
infection
Trachoma
See Chlamydia
trachomatis
Transmissible
spongiform
encephalopathy
See Creutzfeld-
Jacob disease
SETTINGS

Trench fever Relapsing Routine Feces of Louse-borne 7–30 days Not person to
(Bartonella fevers, rash human body person in the
quintana) lice absence of lice
Trichinosis Fever, rash, Routine Infected meat Food-borne 5–45 days Not person to Acquired from consumption of
(Trichinella diarrhea person infected meat
spiralis)
Trichomoniasis Vaginitis Routine Sexually 4–20 days Duration of
(Trichomonas transmitted infection
vaginalis)
Trichuriasis Abdominal pain, Routine Unknown Not person to Ova must hatch in soil to be infective
(whipworm) diarrhea person
(Trichuris
trichiura)
Tuberculosis (TB)
See
Mycobacterium
tuberculosis
Tularemia Fever, Routine 1–14 days Not person to Acquired from contact with infected
(Francisella lymphadenopath person animals
tularensis) y, pneumonia F. tularensis is hazardous to
laboratory workers; notify laboratory if
diagnosis is suspected
Typhoid/
paratyphoid fever
See Salmonella
Typhus fever Fever, rash Routine Rat fleas Flea borne From 1–2 Not transmitted
(Rickettsia typhi) weeks, person to person
Endemic flea- commonly 12
borne typhus days
Rickettsia Fever, rash Routine Human body Louse borne 1–2 weeks Person-to-person through close
prowazekii louse personal contact, not transmitted in
Epidemic louse- absence of louse
borne fever
SETTINGS

Vaccinia Range of Contact Skin exudates Direct and 3–5 days Until all skin Until all skin Vaccinia may be spread by touching
adverse indirect contact lesions resolved lesions dry a vaccination site before it has healed
reactions to the and scabs and crusted or by touching bandages or clothing
smallpox separated and scabs that may have been contaminated
vaccine (e.g., separated with live virus from the smallpox
eczema vaccination site.
vaccinatum, Immunization of HCWs was stopped
generalized or in 1977.
progressive Refer to Canadian Immunization
vaccinia, other) Guide 7th Ed., 2006 for information
regarding vaccine,
http://www.phac-
eng.php
NACI Statement on Smallpox
Vaccination, http://www.phac-
rmtc/02vol28/28sup/acs1.html
Vancomycin- Infection or Contact Infected or Direct and Variable Duration of As directed by Enterococci persist in the
resistant colonization of colonized indirect contact colonization ICP environment; pay special attention to
enterococci (VRE) any body site secretions, cleaning
excretions See Appendix VI, 2. ARO
Vancomycin- Infection or Contact Infected or Direct and Variable Duration of As directed by Local public health authorities should
resistant S. aureus colonization of colonized indirect contact colonization ICP be notified immediately
(VRSA) any body site secretions, See Appendix VI, 2. ARO.
Theoretical; to excretions
date, not reported
Varicella zoster Fever with Airborne and Skin lesion Airborne, direct 10–21 days 1–2 days before Until all HCWs, roommates and caregivers
virus vesicular rash contact drainage, and indirect rash and until lesions have should be immune to chickenpox
Varicella respiratory contact skin lesions have crusted and No additional precautions for
(chickenpox) secretions crusted dried pregnant HCWs
May be Respirators for non-immune persons
prolonged in that must enter
immuno- Susceptible high-risk contacts should
compromised receive varicella zoster
patients immunoglobulin as soon as possible,
latest within 96 hours of exposure
Varicella zoster immunoglobulin may
extend the incubation period to 28
days
Refer to Canadian Immunization for
specific information, available at:
http://www.phac-
eng.php
SETTINGS

Herpes zoster Vesicular skin Airborne and Vesicle fluid, Airborne, direct Until all lesions Until all HCWs, roommates and caregivers
(shingles), lesions Contact respiratory and indirect have crusted and lesions have should be immune to chickenpox
disseminated secretions contact dried crusted and Respirators for non-immune persons
dried that must enter
Susceptible high-risk contacts should
receive varicella zoster
immunoglobulin as soon as possible,
days
Herpes zoster, Vesicular skin Airborne and Vesicle fluid Direct and Until all lesions Until 24 hours Localized zoster may disseminate in
localized Immuno- lesions in contact indirect have crusted and after antiviral immunocompromised host if not
compromised host dermatomal contact, dried and therapy treated
distribution airborne disseminated started; then HCWs, roommates and caregivers
infection is ruled as for should be immune to chickenpox
out localized Susceptible high-risk contacts should
zoster in receive varicella zoster
normal host immunoglobulin as soon as possible,
days
bb
Herpes zoster, Vesicular skin Routine Vesicle fluid Direct and Until all lesions Until all Consider contact and airborne for
localized lesions in Contactbb and indirect have crusted and lesions have cases of extensive localized zoster
Normal host dermatomal airborne contact, dried crusted and that cannot be covered, in situations
distribution possibly dried where there are varicella susceptible
airborne patients/HCWs.
Varicella or herpes Susceptible Airborne Respiratory Airborne 10–21 days Potentially From 8 days Airborne precautions should be taken
zoster contact contact secretions communicable after first with neonates born to mothers with
during last 2 contact until varicella onset <5 days before
days of 21 days after delivery
incubation period last contact HCWs, roommates and caregivers
with rash, should be immune to chickenpox
regardless of
postexposure
vaccination
(28 days if
given varicella
zoster
immuno-
globulin)
Variola
See smallpox
SETTINGS

Vibrio Diarrhea, food Routine Contaminated Foodborne Between 12
parahaemolyticus poisoning food, and 24 hours;
enteritis especially range from 4–
seafood 30 hours
Vincent’s angina Routine
(trench mouth)
Viral hemorrhagic Hemorrhagic Contact and Blood and Direct and Lassa: 1–3 Unknown, Until Local public health authorities should
fevers fever droplet bloody body Indirect contact weeks possibly several symptoms be notified immediately.
(Lassa, Ebola, AGMPcc fluids, Lassa: Sexual Ebola: 2–21 weeks resolve cc
AGMP necessary: see strategies to
Marburg, Crimean- respiratory contact days Lassa virus may reduce aerosol generation, see Part
Congo viruses) secretions be excreted in B, Section IV, subsection iii, 1b
Lassa: urine urine for 3–9
weeks after
onset
West Nile virus
See Arboviruses
Whipworm
See Trichuriasis
Whooping cough
See Pertussis
dd
Yersinia Diarrhea, ADULT: Feces Direct and 3–7 days, Duration of Duration of Consider contact precautions for
enterocolitica; Y. mesenteric Routinedd indirect contact generally excretion in stool symptoms incontinent adults if stool cannot be
pseudotuberculosi adenitis PAEDIATRIC: (fecal/oral); under 10 days contained or for adults with poor
s Contact foodborne hygiene who contaminate their
environment
comply with hygiene
Zoster
See Varicella
(Herpes zoster)
Zygomycosis
(Phycomycosis)
See Mucormycsis
.
Section 04H-1H0200 (Airborne Precautions)
Page 1

IH0200: Airborne Precautions
REVISED DATE: April 2011, January 2015,
November 2016
REVIEWED DATE:
1.0 PURPOSE
Airborne Precautions refer to infection prevention and control interventions to be used in addition
to Routine Practices to prevent transmission of airborne particles that remain suspended in the air,
travel on air currents and are then inhaled by others who are nearby or who may be some distance
away from the source patient, in a different room or ward (depending on air currents) or in the same
room that a patient has left, if there have been insufficient air exchanges. Common microorganisms
transmitted by the airborne route are Mycobacterium tuberculosis (TB), varicella virus (chickenpox
virus) and measles virus.
2.0 DEFINITIONS
Airborne Precautions – measures used for diseases that are spread by airborne transmission. This
primarily occurs through dissemination of microorganisms by aerosolization. Organisms are
contained in droplet nuclei which are small airborne particles, less than 5 microns in size that result
from evaporation of large droplets. Organisms can also be contained in debris in dust particles that
remain suspended in the air for long periods of time. These microorganisms are then widely
dispersed by air currents and can be inhaled by susceptible hosts who may be some distance away
from the source patient. Control of airborne transmission is the most difficult, as it requires control of
air flow through special ventilation systems and use of respirators.
Conditions/clinical presentations and specific etiologies requiring airborne precautions:
Conditions/clinical presentation Specific etiologies
Cough, fever, pulmonary infiltrate in Measles (rubeola)

person at risk for TB * Monkeypox
(pleuropulmonary or laryngeal TB) Tuberculosis (pleuropulmonary or laryngeal)
Rash, maculopapular with fever and ■ nonpulmonary lesions, during
one of coryza, conjunctivitis or procedures that may aerosolize tuberculi
cough bacilli
* Rash, vesicular with fever
* Smallpox
Varicella zoster virus
* ■ varicella (chicken pox)
* ■ zoster, disseminated
* ■ zoster in immunocompromised patient
*Use Airborne & Contact Precautions
Page 2
Aerosol-generating medical procedures (AGMPs) - are medical procedures that can generate
aerosols as a result of artificial manipulation of a patient’s airway. Examples include intubation,
manual ventilation, open endotracheal suctioning, CPR, bronchoscopy, sputum induction, nebulized
therapy, surgery, autopsy, and non-invasive positive pressure ventilation (CPAP, BiPAP)
Airborne Isolation Room – a single patient room that is equipped with special air handling (negative
pressure) and ventilation capacity.
Anteroom – is considered a clean area and is used to transition people in and out of the airborne
isolation room when it is under negative pressure. An anteroom is used as a transitional space
between the hallway and the airborne isolation room. This transition area is where the Healthcare
Worker puts on their PPE when entering the Airborne isolation room. The HCW also will store all
clean PPE in this area.
See Anteroom Protocol
Negative Pressure Room – also known as an Airborne Isolation Room; a negative pressure room
that is a single-occupancy patient-care room used to isolate persons with a suspected or confirmed
airborne infectious disease.
N95 Respirators – specific masks that filter particles one micron in size, have a 95% filter efficiency
and provide a tight facial seal with less than a 10% leak.
3.1. Maintain a high degree of suspicion for those patients who present with compatible symptoms of
an airborne infection, prompt implementation of airborne precautions and rapid diagnosis.
3.2. For the purpose of this guideline, the term Airborne Isolation Room will be used to
refer to a “negative pressure room”. An Airborne Isolation Room must have:
 Ventilation creating inward directional airflow from adjacent spaces to the room (‘negative
pressure’) that is regularly monitored.
 Direct exhaust of air from the room to the outside of the building or recirculation of air
through a HEPA filter before returning to circulation.
 Twelve (12) air changes per hour.
 The door into the room kept closed to maintain negative pressure, even if the patient is
not in the room.
 Windows closed at all times; opening the window may cause reversal of air flow, an
effect that can vary according to wind direction and indoor/outdoor temperature differentials.
All healthcare providers in high risk areas must be fit tested for an N95 respirator.
REFER TO AV 1900 RESPIRATORY PROTECTION PROGRAM POLICY (NOT AVAILABLE
TO NON IH FACILITIES)
3.3. Only immune healthcare providers should enter a room where airborne precautions are in place for
measles or varicella; an N95 respirator is not required.
3.4. An N95 respirator must be worn if non-immune health care providers are required to enter the room
of a patient with measles or varicella when there are no qualified immune health care providers
available and patient safety would be compromised if they did not provide care.
A point of care risk assessment for every patient interaction needs to be done to determine
additional precautions, room placement and PPE:
Page 3
Clinical Syndromes Requiring the Use of Controls (Including PPE) Pending Diagnosis
 Acute diarrhea and / or vomiting of suspected infectious etiology:

o GLOVES, SINGLE ROOM
o GOWN if skin or clothing will come into direct contact with the patient or the
patient’s environment and for paediatrics and incontinent/non-compliant adults
 Acute respiratory infection, undiagnosed:
o SINGLE ROOM/SPATIAL SEPARATION preferred, FACIAL PROTECTION,
GLOVES
patient’s environment
 Respiratory infection with risk factors and symptoms suggestive of Tuberculosis:
o FIT-TESTED N95 RESPIRATOR, NEGATIVE PRESSURE ROOM
 Suspected meningitis and/or sepsis with petechial rash:
o SINGLE ROOM, FACIAL PROTECTION
 Undiagnosed rash without fever:
o GLOVES
 Rash suggestive of varicella or measles:
o NEGATIVE PRESSURE ROOM -= only immune staff to enter
 Abscess or draining wound that cannot be contained:
o GLOVES
o GOWN if skin or clothing will come into direct contact with the patient
4.0 PROCEDURE
As well as Routine Practice, Airborne Precautions includes the following:
4.1 Source Control

a) A point of care risk assessment (PCRA) as per routine practices should be done to
determine if airborne precautions are required.
 Note that some diseases/conditions require two precaution categories;
airborne and contact – see table above
 Patients should be directed to put on a surgical/procedure mask, if tolerated
when not in an airborne isolation room.
 Place patients directly into an airborne isolation room with door closed.
 If a facility does not have an airborne isolation room, patient to
be placed into a single room; the patient should be instructed to keep the mask
on and the door should remain closed. Transfer as soon as possible to a facility
with an airborne isolation room.
 Signage placed at the entrance to patient room.
b) The following strategies should be applied to reduce the level of aerosol generation when
performing aerosol-generating medical procedures (AGMPs) for patients with
suspected airborne disease.
 AGMPs should be limited to those that are medically necessary.
 The number of personnel in the room should be limited to those required.
 Consider appropriate patient sedation.
 AGMPs should be performed in an airborne isolation room.
 Single rooms (with the door closed and away from high-risk patients), should be used
in settings where airborne isolation rooms are unavailable.
 N 95 respirators should be worn by all personnel in the room during the procedure.
 Closed endotracheal suction systems should be used wherever possible.
 In an emergency situation when an airborne isolation room is not available; at a
minimum pull the privacy curtains and all personnel to wear N95 respirator. Remove
visitors and other patients from the room/area.
Page 4
c) Intubated and ventilated patients

 An appropriate bacterial filter should be placed on the endotracheal tube to
prevent contamination of the ventilator and the ambient air.
 Endotracheal suctioning should be performed using a closed suction apparatus,
where possible.
4.2 Hand Hygiene

Perform hand hygiene as per hand hygiene guidelines IF0200.
4.3 Patient placement and accommodation:

 Place patient in airborne isolation room
 The airborne isolation room should have a toilet and sink for the patient, and a
designated hand washing sink for healthcare workers.
 Monitoring – ensure pressure differentials are correct and indicators/alarms are activated.
4.4 Patient flow/transport

 Communication is essential when a patient goes to another department for testing, to
another unit or to other healthcare settings/facilities. This communication must include
Emergency Medical Services (EMS) staff and other transport staff.
 Patients should be restricted to their room, unless medically necessary.
 Patient must wear surgical/procedure mask during transport.
 If the patient needs to be transported and cannot wear a mask, transport should be
planned to limit the exposure of other individuals (e.g. no waiting in the reception areas,
transport in empty elevator) and it should be communicated to receiving personnel so
that consistent precautions can be maintained. The transport personnel should wear an
N95 respirator during transport.

 Healthcare worker to wear appropriately fit-tested N95 respirator upon entering room and
when assisting or performing AGMPs.
Appropriate respirator use:
 Hand hygiene should be performed prior to putting on a respirator.
 A seal check should be performed.
 Respirators should be carefully removed by the straps to avoid self-
contamination.
 A respirator should not dangle around the neck when not in use.
 The respirator should be changed if it becomes wet or soiled (from the wearer’s
breathing or an external splash).
 The respirator should be discarded immediately after use, followed by hand
hygiene.
4.6 Management of patient care equipment

 As per routine practices. If contact precautions are also in use, then refer to Contact
Precautions Guideline 3.6.
4.7 Cleaning of patient environment

4.8 Education of patient, family and visitors

 Educate as per Airborne Precautions signage.
 Visitors should be limited.
 Visitors should be counseled about their risk and advised to wear an N95 respirator.
Page 5
4.9 Duration of precautions

 Airborne precautions should be discontinued after signs and symptoms of the infection
have resolved or as per Transmission Tables.
o REFER TO IH0100 TRANSMISSION TABLES
 Upon discharge or discontinuation of airborne precautions door must remain closed and
negative air flow maintained until all air in the room has been replaced. Requires 45
minutes.
4.10 Management of deceased bodies

 Airborne precautions should be used for handling deceased bodies and preparing bodies
for autopsy or transfer to mortuary services.
 Airborne precautions should be continued for the handling of a patient with infectious
respiratory tuberculosis, measles or varicella until appropriate time has elapsed to
remove airborne contaminants in the room - Requires 45 minutes.
4.11 Airborne precautions for Residential Care
In addition to routine practices:

 Resident to be placed into a single room; the resident should be instructed to keep a
mask on and the door should remain closed. Transfer as soon as possible to a facility
with an airborne isolation room.
4.12 Airborne precautions for Clients in a Home Environment

 The healthcare worker should wear a fit-tested N95 respirator.
5.0 REFERENCES
5.1 Routine Practices and Additional Precautions In all Healthcare Settings. Provincial Infectious
Diseases Advisory Committee (PIDAC), Ontario; November 2012.
5.3 Routine Practices and Additional Precautions Assessment and Educational Tools. Public
Health Agency of Canada; 2013.
Page 6
Page 7
Page 8
Point of Care Risk Assessment is on the backside of each Precautions Sign
Page 9
Airborne Precautions Sign - Form #807900
Page 10
Airborne & Contact Precautions Sign - Form #807901
Page 11
Airborne Communicable Disease Algorithm - Form #807907
Page 12
Page 13
Airborne Isolation Room – Anteroom Protocol EFFECTIVE DATE: February 2011
REVISED DATE:
1.0 PURPOSE
An anteroom is used as a transitional space between the hallway and the airborne isolation room.
This transition area is where the Health Care Worker puts on their PPE when entering the Airborne
isolation room. The HCW also will store all clean PPE in this area.
2.0 DEFINITIONS
Anteroom - anteroom is considered a clean area and is used to transition people in and out of the
airborne isolation room when it is under negative pressure.
3.1 During Airborne Precautions.
 The anteroom is to be used for anyone entering or exiting the patient room when the
room is used for airborne precautions.
 The laundry hamper shall be situated just inside the patient room when additional
precautions are in place.
 The only items that should be stored in this room include:
o PPE ( N95 respirators, procedure masks, gowns, eye protection, gloves).
o Garbage container.
o Alcohol based hand rub (ABHR) in a holder.
o Disinfectant wipes in a holder.
o Precaution signs.
o Hand soap in a holder.
o Paper towels in a holder.
 Posters could include – hand hygiene, donning and doffing, instructions for families.
3.2 No Additional Precautions in use.
o DO NOT USE the room for storage.

o May be used to go in and out of patient room.
o Use for hand hygiene prior to entering and on exit from room.
o May be used to don PPE as necessary for routine practices.
4.0 PROCEDURE
4.1 During Airborne Precautions:

1.0 Doors to and from the anteroom and the patient room shall remain closed when the
room is used for airborne precautions.
2.0 Perform hand hygiene in the anteroom on entrance and exit from room.
3.0 Put personal protective equipment (PPE) on before entering the patient room.
4.0 Remove the N95 respirator in the anteroom after you have closed the door to the
patient room.
For airborne/contact precautions remove the gown and gloves just inside the patient room, and then remove
the N95 respirator in the anteroom after you have closed the door to the patient room.
Section 04H – IH0300 (Droplet Precautions)
Page 1

IH0300: Droplet Precautions
REVISED DATE: April 2011, September 2014
February 2015, November 2016
REVIEWED DATE:
1.0 PURPOSE
Droplet Precautions refer to infection prevention and control interventions to be used in

addition to Routine Practices and are intended to prevent transmission of pathogens spread
through close respiratory or mucous membrane contact with respiratory secretions.
2.0 DEFINITIONS
Droplet Precautions – measures used for diseases that are spread by direct contact through
droplet transmission. Droplet transmission refers to large droplets, greater than 5 microns in
diameter, generated from the respiratory tract of the source patient during coughing or sneezing,
or during procedures such as suctioning or bronchoscopy. These droplets are propelled a short
distance of less than two metres (6 feet) through the air and deposited on the nasal, oral or
conjunctival mucosa of the new host or fall onto surfaces. Large droplets do not remain
suspended in the air. Special ventilation is not required since true aerosolization does not occur.
Droplet/Contact Precautions - microorganisms contained in these droplets can be deposited on

surfaces in the patient’s immediate environment and some microorganisms remain viable for
extended periods of time. Contact transmission can then occur by touching surfaces and objects
contaminated with respiratory droplets.
A point of care risk assessment for every patient interaction needs to be done to determine
additional precautions, room placement and PPE:

patient’s environment and for pediatrics and incontinent/non-compliant adults
GLOVES
o GLOVES
o GLOVES
Page 2
Conditions/clinical presentations and specific etiologies requiring droplet precautions:

Conditions/clinical presentations Specific etiologies
* Bronchiolitis * Adenovirus, respiratory strains
Cellulitis, in child <5 years old if * Bocavirus
Haemophilus influenzae type B possible * Coronavirus
* Cold Diphtheria, pharyngeal
* Cough, fever, acute respiratory tract H. influenzae, in children
* infection * Human metapneumolvirus
Croup * Influenza, seasonal, avian
* Epiglottis in child <5 years old Meningococcus
* Febrile respiratory illness Monkeypox – use airborne/contact
* Hemorrhagic fever in epidemiologic Mumps
* context Mycoplasma pneumoniae
Influenza-like illness * Parainfluenza virus
Meningitis Parvovirus B-19, aplastic crisis or chronic
Osteomyelitis, in children if H. influenzae infection in immunocompromised patient
* possible Pertussis
Paroxysmal cough, suspected pertussis Plague, pneumonic
Pharyngitis * Respiratory syncytial virus
Pneumonia, in children * Rhinovirus
Rash, macupapular with fever and one of * Rubella
* coryza, conjunctivitis or cough * Severe acute respiratory syndrome
Rash, petechial/purpuric with fever Smallpox – use airborne/contact
Rash, vesicular, pustular with Staphylococcus aureus in children with
epidemiologic pneumonia
* context or viral hemorrhagic fever Streptococcus, Group A
Septic arthritis, in children if H. influenzae ■ scarlet fever or pharyngitis in
possible children
Toxic shock syndrome, if Group A * ■ invasive disease
Streptococcus possible Viral hemorrhagic fevers (Crimean-Congo,
Ebola, Lassa, Marburg)
* Use Droplet & Contact Precautions
3.0 PROCEDURE
As well as Routine Practice, Droplet Precautions includes the following:
3.1 Source Control

 A point of care risk assessment (PCRA) as per routine practice should be done to
determine if droplet precautions are required.
 Note that some diseases/conditions require two precaution categories – see
table above.
 Signage placed at the entrance to the patient room, cubicle or designated bed space.
 Educate patients about respiratory hygiene. Once patient is in their room, the mask
can be removed.
 Droplet precautions in addition to routine practices are sufficient for aerosol-
generating medical procedures (AGMP) performed on patients on droplet precautions
who have no signs or symptoms of suspected or confirmed airborne illness.
Page 3
3.2 Hand Hygiene

 Perform hand hygiene as per IF0200 (Hand Hygiene Guidelines)
3.3 Patient placement and accommodation PRIVATE ROOM ALGORITHM

 Single room with toilet and hand washing sink preferred.
o Door may remain open.
o Signage placed at the entrance to the patient room, cubicle or designated
bed space.
o In Emergency rooms place signage on privacy curtain around cubicle.
 Cohort
o Cohort patients who are infected or colonized with the same microorganism
and are suitable roommates.
 Shared Room – when cohorting is not feasible:
o Maintain spatial separation of at least 2 metres between patients
o Privacy curtains between beds should be drawn to minimize opportunity for
droplet spread
o Roommates should be selected based on their ability to comply with
precautions.
o Roommates should not be at high risk for serious disease if transmission
occurs
o Droplet precautions should be applied in nursery settings.
3.4 Patient flow/transport:

another unit or to other healthcare settings/facilities. This communication must
include Emergency Medical Services (EMS) staff and other transport staff.
 The patient should wear a mask if tolerated and follow respiratory hygiene during
transport.
 If the patient cannot tolerate wearing a mask, transport staff should wear a
surgical/procedure mask and eye protection.
Remind patients to adhere to the 4 C’s when outside of their room.
 Patients should not use common areas of hospital such as lounge or go into other
patient rooms.

 PPE should be provided outside the patient room, cubicle or patient’s designated bed
space in shared room.
Page 4
 A surgical/procedure mask and eye protection should be worn

o When within two metres (6 feet) of the patient.
o Remove PPE and discard before leaving the room or bed space and do hand
hygiene.
 The same PPE should not be worn for more than one patient.
3.6 Cleaning and disinfection of non-critical patient care equipment


3.8 Waste, laundry, dishes and cutlery

 As per routine practices
3.9 Education of patient, families and visitors

 Educate as per droplet precautions signage.
 Recommend visit only one patient.
 Wear surgical/procedure mask and eye protection when within 2 metres of patient.
 For pediatrics, household contacts can choose not to wear PPE, as they will have
already been exposed in the household.
3.10 Duration of Precautions:

 Droplet precautions should be discontinued after signs and symptoms of the infection
have resolved or as per Transmission Tables
REFER TO IH0100 TRANSMISSION TABLES

 Routine practices, properly and consistently applied, should be used for handling
deceased bodies and preparing bodies for autopsy or transfer to mortuary services.
 Droplet precautions are not necessary
3.12 Droplet Precautions for Residential Care
In addition to Routine Practices:

 A point of care risk assessment should be done to determine if droplet precautions
are required – signage is available.
 Wear surgical/procedure mask and eye protection when within 2 metres of
symptomatic resident.
 More commonly used in combination with contact precautions.
 Restrict activities while resident is symptomatic.
3.13 Droplet Precautions for Emergency and Ambulatory Care Settings

 Triage – a point of care risk assessment must be done to determine if droplet
precautions are required.
 Contact between symptomatic patients and others should be avoided by minimizing
time spent in waiting rooms.
Page 5
 Patient should be separated from other patients by at least two metres.

 Symptomatic patients should be scheduled at a time when they are less likely to
encounter other patients.
3.14 Droplet Precautions for Clients in a Home Environment
In addition to Routine Practices:

 Healthcare workers should screen clients for respiratory illness by phone, prior to the
homecare visits, whenever possible.
 Ensure mask and eye protection are worn when within two metres of symptomatic
client.
Symptomatic clients in the home should be advised to:
 Stay home until symptoms resolved
 If medical appointment necessary – advise of symptoms
4.0 REFERENCES
4.1 Routine Practices and Additional Precautions In all Healthcare Settings. Provincial
Infectious Diseases Advisory Committee (PIDAC), Ontario; November 2012.
4.2 Routine Practices and Additional Precautions for Preventing the Transmission of
Infection in Health Care Settings; Public Health Agency of Canada; 2013.
4.3 Routine Practices and Additional Precautions Assessment and Educational Tools.
Public Health Agency of Canada; 2013.
Page 6
Point of Care Risk Assessment is on the backside of each Precautions sign
Page 7
Droplet Precautions Sign - Form #807903
Page 8
Droplet & Contact Precautions Sign - Form #807904
Section 04H – IH0400 (Contact Precautions)
Page 1

IH0400: Contact Precautions
REVISED DATE: June 2014,
September 2014, November 2016
REVIEWED DATE:
1.0 PURPOSE
Contact Precautions refer to infection prevention and control interventions to be used in

addition to Routine Practices and are intended to prevent transmission of infectious
agents, including epidemiologically important microorganisms, which are spread by direct or
indirect contact.
4.0 DEFINITIONS
Contact Precautions – measures used for diseases caused by epidemiologically important

micro organisms that may be transmitted easily by contact with the patient's intact skin or with
contaminated environmental surfaces (e.g. Clostridium difficile, MRSA, VRE, RSV). These
infections can be transmitted even if the organism has a low infective dose and there is
potential for widespread environmental contamination.
A point of care risk assessment for every patient interaction needs to be done to
determine additional precautions, room placement and PPE:

o GLOVES, SINGLE ROOM
patient’s environment and for paediatrics and incontinent/non-compliant adults
GLOVES
o GLOVES
o GLOVES
Page 1
Conditions/clinical presentations and specific etiologies requiring contact precautions:

Specific etiologies
* Acute viral respiratory infections * Adenovirus * Parainfluenza virus
* ■ bronchiolitis Adenovirus, conjunctivitis Poliomyelitis, acute infantile
* ■ cold Amebiasis, children * Respiratory syncytial virus
* ■ croup Antibiotic-resistant Rhinovirus
* ■ cough, fever, acute upper organisms * Rotavirus
respiratory infection Astrovirus, children * Rubella, congenital
* ■ febrile respiratory illness * Bocavirus Salmonella
* ■ fever without focus, acute, Brucellosis, major draining Scabies
children lesions Severe acute respiratory
* ■ influenza-like illness Burkholderia cepacia syndrome
* ■ pharyngitis Campylobacter * Shigella
Conjunctivitis Cholera, children Smallpox - use
Dermatitis Clostridium difficile airborne/contact
Desquamation, extensive * Coronavirus Staphylococcus aureus,
Diarrhea Cryptosporidiosis, children major draining wound
Draining wounds, major wound Diphtheria, cutaneous Streptococcus, Group A,
infection, abscess, infected Enteroviral infections, major draining wound
pressure ulcer or other skin infection children * invasive disease
if drainage cannot be contained by Enteroviral conjunctivitis or toxic shock syndrome
dressings Escherichia coli Vaccinia
Encephalitis, paediatric (enteropathogenic and Vancomycin resistant
Endometritis with signs of toxic shock enterohemorrhagic enterococci
Food poisoning strains) Vancomycin-resistant
Gastroenteritis Giardia Staphylococcus aureus
Gingivostomatitis, primary Hepatitis A, E, children Varicella-zoster virus
Hand, foot and mouth disease, Herpes simplex virus ■ varicella – use
children ■ encephalitis, children airborne/contact
Hemolytic uremic syndrome, contact neonatal ■ herpes zoster,
* Hemorrhagic fever ■ neonatal or disseminated or
Hepatitis of unknown origin, children mucocutaneous localized in
Herpangina, children * Human metapneumovirus immunocompromised
* Meningitis * Influenza seasonal, avian host, localized in normal
Necrotizing enterocolitis, children Monkeypox - use host if not contained
Pleurodynia, children airborne/contact Viral hemorrhagic fevers
Pseudomembranous colitis Norovirus – (Crimean-Congo, Ebola,
Rash, compatible with scabies droplet/contact in * Lassa,
* Rash, vesicular with fever outbreak Marburg)
* Rash, vesicular/pustular, with Yersinia enterocolitica
epidemiologic context of viral
hemorrhagic fever
*Use Droplet & Contact Precautions
Page 2
5.0 PROCEDURE
As well as Routine Practices, Contact Precautions include the following:
3.1 Source control

 A point of care risk assessment (PCRA) as per routine practice should be done to
determine if contact precautions are required.
 Note that some diseases/conditions require two precaution categories – see
table above
 Signage placed at the entrance to the patient room, cubicle or designated bed space
 Contact precautions in addition to routine practices are sufficient for aerosol-
generating medical procedures (AGMP) performed on patients on contact
precautions who have no signs or symptoms of suspected or confirmed airborne
illness
3.2 Hand Hygiene

 Perform hand hygiene as per IF0200 (Hand Hygiene Guidelines)
3.3 Patient placement and accommodation. PRIVATE ROOM ALGORITHM

 Single room with toilet, patient sink and hand washing sink preferred.
 Door may remain open.
 Signage placed at the entrance to the patient room, cubicle or designated bed
space
 In Emergency Rooms place signage on privacy curtain around cubicle.
 Cohort
o Cohort patients who are infected or colonized with the same microorganism and
are suitable roommates
 Shared Room – when cohorting is not feasible:
o Maintain spatial separation of at least 2 metres between patients.
o Roommates should be selected based on their ability to comply with precautions
o Roommates should not be at high risk for serious disease if transmission occurs.
o A patient with diarrhea should not share a toilet with another patient.
o Contact Precautions should be applied in nursery settings.
3.4 Patient Flow/Transport

another unit or to other healthcare settings/facilities. This communication must
include Emergency Medical Services (EMS) staff and other transport staff.
 Personal protective equipment should be removed and disposed of and hand
hygiene performed, prior to transporting patients.
 Health care provider to wear gloves and gown for direct contact with patient during
transport.
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 Patients do not need to wear gloves and isolation gown when outside the room
 Patients should not use common areas of hospital such as lounge or go into other patient
rooms.

 Personal protective equipment should be provided directly outside the patient room,
cubicle or patient’s designated bed space in shared rooms.
 Use gloves and gown when in direct contact with patient or patient environment.
 Remove gown and gloves and discard before leaving the room or bed space and
do hand hygiene.
 The same personal protective equipment should not be worn for more than one
patient.

 Dedicate patient care equipment (e.g. blood pressure cuff, commodes etc.).
 If equipment must be shared it must be cleaned and disinfected between patients.
 Do not take extra supplies into patient’s room.
3.7 Cleaning of the patient environment

 When precautions are discontinued or the patient is moved, do an additional
precautions discharge clean of the room/bed space and bathroom which includes
changing privacy curtains and cleaning and disinfecting or changing string/cloth call bells
or light cords.
 For Clostridium difficile Infections (CDI) please refer to the CDI cleaning poster
3.8 Waste, laundry, dishes and cutlery

 Use routine practices
3.9 Education of patients, families and visitors

 Educate as per contact precautions signage.
 Recommend visit only one patient.
 Visitors to wear gloves and gown if participating in direct patient care.
 Visitors to remove gloves and gown and perform hand hygiene prior to leaving room.
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3.10 Duration of precautions

 Contact precautions should be discontinued after signs and symptoms of the infection
have resolved or as per Transmission Tables.
REFER TO IH0100 TRANSMISSION TABLES
 Precautions should be discontinued only after the room/bed space and bathroom has
been isolation discharge cleaned.

 Contact precautions should be used for handling deceased bodies, preparing bodies for
autopsy or for transfer to mortuary services.
3.12 Contact Precautions for Residential Care
In addition to Routine Practice:

 A point of care risk assessment should be done to determine if contact precautions are
required – signage is available.
 Restrict activities if wound drainage or diarrhea cannot be contained.
 Follow the 4 C’s as in box above.
3.13 Contact Precautions for Emergency and Ambulatory Care Settings

 Triage - a point of care risk assessment must be done to determine if contact
precautions are required.
 Contact between symptomatic patients and others should be avoided by minimizing time
spent in waiting rooms.
 Placement in a separate room/area should be done as soon as possible.
 Symptomatic patients should be scheduled at a time when they are less likely to
 encounter other patients unless they can be placed directly into a separate room
 Additional precautions discharge clean required only for patients with uncontained
draining wounds, diarrhea or vomiting or uncontrolled respiratory secretions – need to
have good communication between patient care staff and housekeeping regarding
additional cleaning required.
3.14 Contact Precautions for Clients in a Home Environment

 Rest away from others, in a separate room, if available
 Use a designated bathroom, whenever possible
 Clean the bathroom frequently, especially frequently touched surfaces
 Not share towels or other personal items
 Stay home until symptoms resolved
 If medical appointment necessary – advise of symptoms
Page 5
6.0 REFERENCES
6.1 Routine Practices and Additional Precautions In all Healthcare Settings. Provincial
Infectious Diseases Advisory Committee (PIDAC), Ontario; November 2012.
Page 6
Point of Care Risk Assessment is on the backside of all Precautions signs
Page 7
Contact Precautions Sign - Form #807902
Page 8
Contact Plus Precautions – Form #807914

Used for Clostridium Difficile Infection (CDI) Only
Section 08S – IS0100 (Reportable Communicable Diseases)
Page 1

IS0100: Reportable Communicable Diseases
February 2015
REVIEWED DATE:
1.0 PURPOSE
To reduce the risk of transmission of communicable diseases within healthcare facilities and to programs.

2.1. The Infection Prevention and Control Practitioners will facilitate processes to ensure the
Reportable Communicable Diseases are reported to Public Health both from the clinical setting
and the laboratory setting, using the LIST OF COMMUNICABLE DISEASES IN BC JULY 2009.
2.2. THE Communicable Disease Regulation states in Section 1.2.1 that any person knowing or
suspecting that another person is suffering from a communicable disease shall without delay
make a report to the medical health officer.
3.0 PROCEDURE
Contact the Infection Control Practitioner (ICP) as soon as possible when a patient who is known or a
suspect case of a Reportable Communicable Disease included in SCHEDULE A is admitted to the
facility/program. The ICP will advise regarding reporting process.
 If the ICP is unavailable, contact the Communicable Disease (CD) Unit as soon as
possible at 1-866-778-7736.
The laboratory is responsible for reporting Schedule B diseases listed in the REPORTABLE
COMMUNICABLE DISEASES IN BC (JULY 2009) LIST.
 IH Immediately Notifiable Communicable Diseases
Note: In this document the term “patient” is inclusive of patient, resident or client.
Page 2
Effective Date: Sept.2006 Revised Date: July 2009
Section 08S – IS0200 (Clostridium difficile)
Page 1

IS0200: Clostridium difficile
December 2012, July 2015, November 2016
REVIEWED DATE:
1.0 PURPOSE
To prevent the transmission of Clostridium difficile infection (CDI) in healthcare facilities including
hospitals, residential care homes and community settings and to minimize the risk of complications
associated with CDI.
2.0 DEFINITIONS
Clostridium difficile (C. difficile) is a bacterium that causes mild to severe diarrhea and intestinal
conditions like pseudomembranous colitis (inflammation of the colon). C. difficile is the most frequent
cause of healthcare associated infectious diarrhea in hospitals and residential care facilities and is
becoming more prevalent in the community.
Most cases of C. difficile occur in persons who are taking certain antibiotics which can destroy the
person’s normal bacteria found in the gut, causing C. difficile bacteria to grow. When this occurs, the
C. difficile bacteria produce toxins which can damage the bowel and cause diarrhea. Some people
can have C. difficile bacteria present in their bowel and not show symptoms. There are many
different strains of C. difficile and one strain known as NAP1 (North American Pulsed Filed type 1)
can cause serious illness.
C. difficile bacteria are found in feces and produce spores that are resistant many common types of
environmental disinfectants. These spores can live in the environment for long periods of time,
contaminating toilet areas and commodes. People can get infected if they touch surfaces
contaminated with the spores, and then touch their mouth. Healthcare workers can spread the
bacteria to their patients if their hands are contaminated.
C. difficile poses a particular risk to the elderly, pediatric and oncology patients and pregnant women.
Additional risk factors include antibiotic usage, proton pump inhibitor usage, bowel disease and bowel
surgery, prolonged hospitalization, and immunosuppressive therapy post-transplant.
Symptoms include watery diarrhea, fever, loss of appetite, nausea and abdominal pain/tenderness.
Persons are infectious while diarrhea is present.
Additional Precautions Twice Daily Clean with a Sporicidal Disinfectant – the type of clean
housekeeping uses for cleaning and disinfecting rooms/cubicles where a patient is on additional
precautions for C. difficile. Cleaning occurs twice daily, the second cleaning and disinfection is 6-8
hours after the first cleaning and disinfection and focuses on the high touch areas in the patient
room/area/space and bathroom (IH Housekeeping for Healthcare manual pg.87).
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Additional Precautions Discharge Clean – refers to the cleaning and disinfection process of a
patient room when additional precautions is discontinued or the patient is discharged and includes
changing the privacy curtains (IH Housekeeping for Healthcare manual pg.109).
Best Practice Checklist for Management of CDI – is a tool used to monitor infection control
processes during usual CDI activity on a nursing unit and is NOT part of the patient chart. It can be
completed by either a nurse leader/educator or Infection Control Practitioners (ICPs).
Internal Alert – when the number of CDI cases in a unit or facility is above the pre-determined
threshold (trigger point) or there is suspected transmission. Internal alerts bring increased staff
awareness of CDI cases in the unit/facility so actions can be taken to prevent an outbreak. The
Infection Prevention and Control epidemiologist monitors the internal alert and informs the ICP when
the internal alert level is triggered at their site.
Outbreak Definition – CDI cases are classified as an outbreak when the number of new, time-
related, healthcare associated CDI cases in a unit or facility is above the expected threshold for that
unit or facility and where there is evidence of ongoing transmission despite appropriate interventions.
Declaring an outbreak must be done in conjunction with the facility Outbreak Management Team.
Outbreak Management Team – at a minimum, includes the site Infection Control Practitioner,
Infection Prevention and Control (IPAC) director, Medical Microbiologist and epidemiologist, site
administrator and medical director, nursing unit manager and housekeeping supervisor.
3.0 PROCEDURE
3.1 Additional Precautions

 Contact Precautions to be initiated at onset of diarrhea
3.2 Hand Hygiene

 Wash hands with soap and water (preferred)
 If no sink is in close proximity clean hands with alcohol-based hand rub (ABHR) and
wash with soap and water at first opportunity
 Do not perform hand hygiene at a patient sink, as this may cause contamination of the
healthcare provider’s. Use a dedicated staff hand washing sink
 Assist patients with cleaning their hands, especially after toileting and before meals

 Place patient in a single room with a dedicated toilet on Contact Precautions
 Door may remain open
 Brown Contact Precautions signage placed at the entrance to the patient room, cubicle
or designated bed space (i.e.) Emergency Department
 If patients with C. difficile must be cohorted, each patient must be assigned their own
commode and kept at the bedside; cohort according to the stage of illness (i.e.) do not
cohort new onset CDI with a patient who is recovering and has no diarrhea

 Transfers and/or bed moves should be avoided unless clinically necessary
 Communication of Contact Precautions is essential when a patient goes to another
department for testing, to another unit or to other healthcare settings/facilities including
communication with Emergency Medical Services (EMS) and other transport staff.
 PPE should be removed and hand hygiene performed, prior to transporting patients.
 If direct contact with patient is required during transport, then those staff must don PPE.
Page 3
3.5 Personal Protective Equipment

 PPE to be available directly outside the patient room, cubicle or designated bed space.
 Wear gloves and gown when in direct contact with patient or patient environment.
 Remove gown and gloves and discard before leaving the room or bed space and do
hand hygiene
3.6 Patient Care Equipment

 Dedicate equipment to a single patient
 Do not take extra supplies into patient’s room
 Promote “decluttering” initiatives to facilitate thorough cleaning of surfaces and
separation of clean and dirty items and equipment
 Do not take patient chart into the room.
 Clean and disinfect equipment used for transport after each use.
 Use the sporicidal wipes for cleaning and disinfecting equipment

 Use a sporicidal product (accelerated hydrogen peroxide 4.5%) for cleaning and
disinfection
 Clean occurs twice daily, the second cleaning and disinfection is 6-8 hours after the
first cleaning and disinfection and focuses on the high touch areas in the patient
room/area/space and bathroom (IH Housekeeping for Healthcare manual pg.87).
 The brown Contact Plus Precautions sign alerts Housekeeping staff of the need for twice
daily cleaning with a sporicidal disinfectant, Contact Plus Precautions Sign
The physical act of friction is necessary to remove C. difficile spores.
3.8 Education of Patients, Families and Visitors

 Educate as per Contact Precautions signage
 Advise families and visitors not to use patient bathroom
 Provide the Clostridium difficile pamphlet to the patient and family located in the
Infection Prevention & Control website. (Not available to non IH facilities).
3.9 Discontinuation of Contact Precautions

 Precautions may be discontinued when the patient has had no diarrhea for 72 hours;
nursing staff to use Bristol Stool chart - Form #809505 to monitor diarrhea
 It is not necessary to have a negative specimen prior to discontinuing isolation – no
retesting is done within 30 days of previous positive result
 Housekeeping will do an additional precautions discharge clean of patient room when
Contact Precautions are discontinued
 Patient to shower/bathe and put on clean clothes, then go into cleaned bed space
Page 4
3.10 Relapse of Symptoms

 Relapse refers to the recurrence of the symptoms of CDI within two months of the last
infection and symptom-free period – occurs in about 30% of cases
 If diarrhea recurs – place patient on Contact Precautions immediately
3.11 Treatment
 Use physician pre-printed orders for Clostridium difficile Treatment.
http://inet.interiorhealth.ca/infoResources/forms/Documents/829517.pdf
3.12 Surveillance
 Surveillance for healthcare associated CDI is carried out as per guidelines under 4.2 of ,
IV0200 DEFINITIONS FOR HEALTHCARE ASSOCIATED INFECTIONS (HAI)
 Best Practice Checklist for Management of CDI available to use when increasing
rates of CDI identified in specific units/facilities
3.13 Internal Alert

 When the number of CDI cases in a unit or facility is above the pre-determined threshold
(trigger point) or there is suspected transmission, then actions can be taken to prevent
an outbreak
 Internal alert levels are determined and monitored by the IPAC epidemiologist and team
 When an ‘internal alert’ has been reached, staff within the facility are alerted to the
situation and enhanced control measures implemented
 Facility administration should work with the unit staff and IPAC to put additional control
measures and resources in place
 An internal alert is for the operational purposes of that facility and a public
announcement is not required
3.14 Outbreak Management Team

 An Outbreak Management Team (OMT) is called together and works collaboratively in
the prevention, early detection and management of outbreaks
 Under the Public Health Act, consultation is required with the Medical Health Officer
(MHO) or designate for the management of outbreaks by IPAC and the facility
Administrator – Medical Microbiologist is point of contact for acute facilities
 Public notification of the outbreak is required and posted on the Interior Health public
website
 Implement control measures including outbreak signage, additional ABHR products with
instructions on hand hygiene for staff and patients, limit visitors, additional environmental
cleaning using a sporicidal disinfectant for all inpatient rooms and bathrooms on affected
units that continue to have a high incidence of CDI cases – continue this approach until
the incidence decreases
 The OMT advocates for enhanced resources required to implement control measures
 If new cases of CDI continue to be detected, the OMT may consider recommending the
closure of the affected units to admissions until the outbreak is controlled
 Outbreak declared over when the number of cases has returned to the endemic level
 Hold a debriefing session to identify lessons learned and how future outbreaks can be
prevented – the OMT to summarize outcome and lessons learned to share with
local/regional IPAC committees
Page 5
4.0 REFERENCES
4.1 ANNEX C Testing, Surveillance and Management to Clostridium difficile In All Health
Care Settings. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; 2013.
4.2 Best Practice for Environmental Cleaning for Prevention and Control of Infections in
nd
all Healthcare Settings. 2 Edition. Provincial Infectious Diseases Advisory Committee
4.3 Clostridium difficile Infection (CDI) Toolkit. Provincial Infection Control Network of BC;
2013.
4.4 Fact Sheet Clostridium difficile. Public Health Agency of Canada; 2014.
4.5 A Review of C. difficile Control Measures….. Dr. Michael Gardam, Director of Infection
Prevention & Control, University Health Network and Women’s College Hospital, Toronto,
Ontario; February 2012.
See the RESIDENTIAL CARE

PLAN – Resident with Clostridium See the ACUTE CARE PLAN –
difficile Associated Diarrhea Acute care plan for Clostridium
difficile Associated Diarrhea
Page 6
Contact Plus Precautions – Form #807914
Residential Care Plan for Clostridium difficile Infection
RESIDENT COMMENTS – Date &

GOAL INTERVENTION
CONCERN Signature
 C-difficile Control spread 1. In addition to Routine Practices, use Contact Plus Precautions: Add pertinent interventions
Infection of C-difficile  Dedicate toilet or commode at the onset of diarrhea (i.e.) decisions regarding a
 Empty contents of commode in Dirty Service Room in waste disposal unit designated toilet
Mobility: If the resident has uncontrolled diarrhea, keep them in their room until the
symptoms are resolved or can be easily contained with personal hygiene products.
2. Resident and Visitor Teaching:

 Assist residents with hand hygiene – to be done prior to leaving their room,
after using the toilet, prior to eating/handling food and when soiled.
 Remind visitors of hand hygiene and not to use resident’s bathroom
Contact Precautions can be discontinued when resident has no diarrhea for 72 hours.
Ensure Signage regarding C-difficile infection may be required. Contact Plus Precautions sign
Resident 1. Housekeeping needs to be informed to ensure twice daily cleaning is performed.
Confidentiality 2. Upon transfer, notify receiving sites that Contact Precautions are required.
 Environmental Reduce 1. Use a sporicidal product (accelerated hydrogen peroxide 4.5%) for cleaning and
Cleaning transmission of disinfection of resident room.
C-difficile
Clean occurs twice daily, the second cleaning and disinfection is 6-8 hours after the first
cleaning and disinfection and focuses on the high touch areas in the resident
room/area/space and bathroom.
Housekeeping will do additional precautions discharge clean of the room when Contact
Precautions are discontinued.
 Persistent or Prevent Clostridium difficile preprinted orders available for physician use.
recurrent recurring 1. Observe and report progression or recurrence of symptoms.
diarrhea infection 2. Use Bristol Stool chart - Form #809505 to monitor diarrhea.
Page 8
Acute Care Plan for Patients with Clostridium difficile Infection
Patient
GOAL INTERVENTION COMMENTS
CONCERN
 C-difficile Control spread 1. In addition to Routine Practice, use Contact Plus Precautions
associated of C-difficile o private room with dedicated toilet/commode
infection o empty contents of commode in Dirty Service Room in waste disposal
unit
2. Mobility: The patient should remain in his/her own room unless going to the operating
room, attending a medical treatment session, or requiring diagnostic tests.
3. Patient and Visitor Teaching:

 Assist patient with hand hygiene – to be done prior to leaving their room, after
using toilet, prior to eating/handling food & when soiled.
 Remind visitors of hand hygiene and not to use patient’s bathroom.
Contact Plus Precautions can be discontinued when patient has no diarrhea for 72 hours.
Ensure Patient 1. Post the Contact Plus Precautions sign on outside the patient’s door.
Confidentiality 2. When patient goes to another department, or is transferred to another facility, the
receiving department or facility MUST be notified of need for Contact Precautions.
Page 9
 Environmental Reduce Use a sporicidal product (accelerated hydrogen peroxide 4.5%) for cleaning and
Cleaning transmission of disinfection of resident room.
C-difficile
Clean occurs twice daily, the second cleaning and disinfection is 6-8 hours after the first
cleaning and disinfection and focuses on the high touch areas in the patient
room/area/space and bathroom.
Housekeeping will do additional precautions discharge clean of the room when Contact
 Persistent or Prevent 1. Clostridium difficile pre-printed orders available for physician use.
recurrent recurring 2. Observe and report progression or recurrence of symptoms.
diarrhea infection Use Bristol Stool chart - Form #809505 to monitor diarrhea.
Section 08S – IS0300 (Antibiotic Resistant Organisms)
Page 1

IS0300: Antibiotic Resistant Organisms
(ARO) REVISED DATE: November 2010
February 2015, July 2015, June 2016
REVIEWED DATE:
1. PURPOSE
To prevent transmission of Antibiotic Resistant Organisms (AROs) in healthcare facilities including

hospital, residential care homes and community settings.
2. DEFINITION
Antibiotic Resistant Organism (ARO) – microorganisms that have developed resistance to the
action of several antimicrobial agents and that is of special clinical or epidemiological significance.
This guideline will refer primarily to MRSA, VRE, ESBLs and CPOs.
Cohorting – the practice of grouping patients (infected or colonized) with the same ARO together, to
confine their care to one area.
Colonization – the presence of microorganisms in or on a host with growth and multiplication but
without tissue invasion or cellular injury. With most microorganisms, colonization is far more frequent
than clinical disease. The patient will be asymptomatic. MRSA colonization may occur in the nose,
perineum, decubitus ulcers, sputum, urine and at sites of invasive devices such as feeding tubes and
tracheostomies. VRE colonization occurs primarily in the feces.
Contact – an individual who is exposed to a person, colonized or infected, with an ARO in a manner
that allows potential transmission to occur, i.e. roommate.
CPO – Carbapenemase-Producing Organisms refers to bacteria such as Klebsiella, Escherichia coli

(E. coli), Acinetobacter, and Pseudomonas that are found in normal human intestines. In some parts
of the world these groups of bacteria have acquired genes that make them resistant to a broad
spectrum of antibiotics including those known as carbapenem antibiotics. Sometimes these bacteria
can spread outside the gut and cause serious infections, such as urinary tract infections, bloodstream
infections, wound infections, and pneumonia.
Decolonization – the use of topical and systemic antimicrobials to eradicate colonization of resistant
bacteria. Current evidence does not recommend MRSA decolonization therapy as this may promote
antibiotic resistance, long-term efficacy is poor and systematic therapy may lead to adverse events.
Enterococci – bacteria normally found in the gastrointestinal tract of 95% of healthy people.
Enterococci may contaminate open wounds and, occasionally, are capable of causing invasive
disease, particularly in severely immunocompromised people.
Page 2
ESBL – Extended Spectrum Beta Lactamase producing organisms – a group of Gram-negative

bacteria (predominantly bowel organisms) such as E.coli and Klebsiella, that produce enzymes that
break down antibiotics, rendering them useless. Significant infections include urinary tract infections
and surgical wound infections.
Infection – when sufficient cellular and tissue changes occur to produce overt signs and symptoms,
the individual has clinical disease. Depending on the microorganism and health status of the host,
this disease may range from mild to severe. Clinical manifestations of local or systemic infection can
include fever, increased white blood cell count, purulence, inflammation, redness, heat, swelling,
and/or pain.
MRSA - Methicillin Resistant Staphylococcus aureus – strains of Staphylococus aureus that are
resistant to oxacillin (cloxacillin). Most people with MRSA are colonized. High risk groups in the
community include injection drug users, homeless persons, chronically ill persons, individuals taking
frequent or prolonged courses of antibiotics and individuals who are in hospital for longer than 48
hours.
Outbreak Management Team – multidisciplinary team including Infection Prevention & Control,
Occupational Health, Administration, Nursing, Medical Staff, Support Services; may include Medical
Health Officer (MHO).
Point prevalence screening – the collection of specimens on all patients at a single point in time, to
determine the total number of cases and evidence of ongoing transmission of a particular
microorganism.
Screening – a process to identify patients at risk for being colonized with MRSA and/or CPO and
subsequently, obtaining appropriate specimens and ensuring Additional Precautions are
implemented.
Staphylococcus aureus (S. aureus) – a bacteria normally found in the nose and on the skin of 25 -
35% of healthy people. It can cause infections such as impetigo, boils, abscesses, wound infections
or invasive disease such as pneumonia.
VRE - Vancomycin Resistant Enterococcus – enterococci that have acquired resistance to

vancomycin. Most people with VRE are colonized. There is no evidence that infection with VRE is
associated with greater mortality than infection with vancomycin sensitive enterococci.
3. GUIDING PRINCIPLES
3.1 Due to the limited number of single rooms available in acute care use the Algorithm for
IPAC Private Room Allocation in Acute Care Facilities to determine priority for the single
room assignments. (NOT AVAILABLE TO NON IH FACILITIES)
3.2 How are AROs Spread?
Note
The single most common mode of transmission for AROs in a health care
setting is on the hands of health care workers who acquire it from contact with
colonized or infected patients, OR after handling contaminated surfaces or
equipment.
Page 3
3.3 An ARO Alert is entered into the patient’s electronic record by the Infection Control
Practitioner when required. Alerts must protect the confidentiality of the patient.
3.4 The ARO status of a patient should not affect the decision about accepting the individual in
transfer from another healthcare setting or department and a negative specimen is not
required to transfer a patient.
3.5 In high risk areas of acute care such as ICUs, burn units, transplantation units or
cardiothoracic units any patients potentially exposed to a known MRSA or CPO positive
patient should have screening cultures performed. However, in other situations screening of
contacts may not be practicable as there are limited possibilities to intervene based upon
results.
3.6 An outbreak of an ARO occurs when there is an increase in the rate of healthcare associated
cases (infected and colonized) over the baseline rate, or a clustering of healthcare
associated cases due to the transmission of a specific microbial strain(s) in a healthcare
setting. Infection Control would call together a multidisciplinary Outbreak Management Team
to review the situation and provide guidance and support in regards to appropriate control
measures to implement.
4.0 PROCEDURE
4.1 Acute Care Admission Screening for MRSA and CPO

 All patients being admitted to acute care for 24 hours or more require screening. Follow
procedure outlined on patient Admission History forms. Use the Acute Care Admission
Screening for MRSA and CPO tool for pre-surgical screening, for surgical patients with
an unplanned admission and for patient transfers between acute care facilities
Screening must be completed within 24 hours of admission
 All patients who have been hospitalized anywhere for more than 48 hours within the last
3 months require swabs for MRSA screening:
o Nose (1 swab both nares)
o Groin (1 swab both sides)
o One swab of any open wound
 All patients require a rectal swab for CPO screening if they answer ‘yes’ to any of the
following:
o Has the patient ever had a CPO?
o Has the patient had an overnight stay in a hospital or undergone a
medical/surgical procedure outside Canada within the past 12 months?
o Has the patient had dialysis outside Canada within the past 12 months?
o Has the patient had close contact with a known CPO patient within the past 12
months? (close contact defined as household member or roommate in hospital)
o Has the patient been transferred from a facility with known, active CPO
transmission?
o Any patient requiring CPO screening swabs must be placed on Contact
Precautions in a single room
o There are different types of CPOs, so patients who are known to be CPO
positive must be rescreened for each hospital admission
4.2 A PCRA (point of care risk assessment) for every patient interaction needs to be done to
help determine room placement and necessary personal protective equipment.
4.3 Hand Hygiene

 Perform hand hygiene as per IF0200 (Hand Hygiene Guideline)
Page 4
4.4 Patient Placement and accommodation – PRIVATE ROOM ALGORITHM

 All known ARO positive patients to be placed on Contact Precautions
 Single room with toilet, patient sink and hand washing sink preferred especially for ARO
patients with diarrhea or large uncontained draining wounds
o Door may remain open
o Contact Precautions signage placed at the entrance to the patient room, cubicle
or designated bed space including Emergency Department
 Cohort
o Cohort patients who are infected or colonized with the same microorganism and
are suitable roommates
o Contact your ICP regarding appropriateness of cohorting
 Shared Room
o Maintain spatial separation of at least 2 metres between patients
o Roommates should be selected based on their ability to comply with precautions
o Roommates should not be at high risk for serious disease if transmission occurs
o A patient with diarrhea should not share a toilet with another patient
4.5 Patient Flow / Transport

 Communication of Additional Precautions is essential when a patient goes to another
department for testing, to another unit or to other healthcare settings/facilities. This
communication must include Emergency Medical Services (EMS) staff and other
transport staff
 Personal protective equipment should be removed and disposed of and hand hygiene
performed, prior to transporting patients
 Health care provider to wear gloves and gown for direct contact with patient during
transport
4 C’s
 Clean Hands: do hand hygiene.
 Clean Clothes: wear a clean gown or clothes.
 Contained wounds/body fluids: wounds covered with clean
dressing. Urine/feces and other body fluids contained.
 Co-operative: able to follow instructions.
 Patients are not to wear gloves and/or an isolation gown when outside the room.
Patients should not use common areas of the hospital such as the
cafeteria or lounge and should not enter other patient rooms
4.6 Personal Protective Equipment

 Personal protective equipment should be available either directly outside the patient
room, cubicle or designated bed space
 Wear gloves and gown when in direct contact with patient or patient environment
 Remove gown and gloves and discard before leaving the room or bed space and
do hand hygiene
 The same personal protective equipment should not be worn for more than one
patient
Page 5

 Dedicate equipment to a single patient (e.g. blood pressure cuff, commodes etc.)
 If equipment must be shared it must be cleaned and disinfected between patients
 Do not take extra supplies into patient’s room
 Do not take patient chart into the room
 Clean and disinfect equipment used for transport after each use

 When precautions are discontinued or the patient is moved, do an additional
precautions discharge clean of the room/bed space and bathroom which includes
changing privacy curtains and cleaning and disinfecting or changing string/cloth call bells
or light cords
4.9 Waste, laundry and dishes

 Use Routine Practices
4.10 Education of patients, families and visitors

 Educate as per Contact Precautions signage
 Recommend to visit only one patient
 Visitors to wear gloves and gown if participating in direct patient care
 Visitors to remove gloves and gown and perform hand hygiene prior to leaving room
 Provide the appropriate ARO patient information pamphlet to the patient and family
available on the INFECTION PREVENTION & CONTROL WEBSITE. (NOT AVAILABLE TO NON IH
FACILITIES)
4.11 Surgical Settings (OR, PAR, DCS)

 REFER TO SURGICAL SERVICES PRACTICE M ANUAL. (NOT AVAILABLE TO NON IH FACILITIES)
 Pre-surgical screening is done as an outpatient and includes screening for AROs)
4.12 Emergency, Ambulatory Care and Outpatient Settings

 For all outpatients and diagnostic areas, additional ARO screening is not required
 Instruct patients to clean their hands upon entering and leaving the outpatient setting
 Clean and disinfect shared equipment between patients
 Use routine practice for cleaning environment
 If environment is visibly soiled, do an additional precautions discharge clean of the
room/bed space and bathroom which includes changing privacy curtains and cleaning
and disinfecting or changing string/cloth call bells or light cords
4.13 Maternity/Newborn Nursery

 All babies admitted to the Nursery from another hospital are screened for MRSA and
CPO and placed on Contact Precautions; if swab results are negative Contact
 ARO positive mom must be placed on Contact Precautions:
o Newborn must be placed on Contact Precautions in the Nursery if newborn is not
rooming in with their mother
o Newborn does not require screening unless admitted from another hospital.
4.14 Dialysis Settings

 Screening (including swabs taken) for MRSA and CPO should be done using the Acute
Care Admission Screening for MRSA & CPO screening tool, Form #807910:
o On initial admission to any hemodialysis facility (NOTE: If an in-patient, confirm
that screening swabs for MRSA and CPO were performed during their in-patient
stay)
Page 6
o Upon returning from an admission to an acute care hospital outside of Canada

or having had hemodialysis outside of Canada
o If requested (patients traveling to other health care centers outside of IH may
require screening swabs)
 Visiting dialysis patients to have screening swabs done by their home unit, prior to their
arrival to the visiting dialysis unit
 Admission to any hemodialysis unit should not be denied on the basis of ARO status
 Contact Precautions need to be implemented for ARO positive patients and can be done
at the bedside. However, a private room is preferred for patients with uncontained
draining wounds or uncontrolled diarrhea and for CPO positive patients
4.15 Mental Health – including inpatient Psychiatry

 Admission screening for AROs is not required
 A Point of Care Risk Assessment (PCRA) should be done to determine if Additional
Precautions are required
 Restrict activities if wound drainage or diarrhea cannot be contained
 Follow the 4 C’s as in box above
4.16 Residential Care

 A residential care facility is the resident’s “home” and infection control precautions must
be balanced with promoting an optimal, healthy lifestyle for the residents. Studies
indicate that residents who are colonized or infected with AROs do not endanger the
health of staff or other residents, particularly when healthcare providers consistently use
Routine Practices when providing ALL care in these settings
 Screening for AROs is not a recommended practice in Residential Care in BC
 A Point of Care Risk Assessment (PCRA) should be done to determine if Contact
Precautions are required – signage is available
 Restrict activities if wound drainage or diarrhea cannot be contained
 Follow the 4 C’s as in box above
 See the RESIDENTIAL ARO CARE PLAN
4.17 Community Care

 Home and Community Care Programs must balance infection control precautions with
promoting an optimal, healthy lifestyle for the client, particularly in view of the fact that
colonization or infection with an ARO may persist indefinitely. Experience to date does
not indicate that clients who are colonized or infected with these microorganisms pose a
health risk to healthcare providers, or to other household contacts, particularly when
healthcare providers consistently use Routine Practices when providing ALL care in
these settings
Hand hygiene and cleaning and disinfection of shared equipment are the most
important ways to reduce risk of transmission of any AROs
 ARO positive persons should not be denied admission to Community Care programs.
o Stay away from others, in a separate room, if available
o Use a designated bathroom, whenever possible
o Clean the bathroom frequently, especially frequently touched surfaces
o Not share towels or other personal items
o Stay home until symptoms resolved
o If medical appointment necessary – advise of symptoms
o See the COMMUNITY ARO CARE PLAN
Page 7
4.18 Outbreak Management

 Take surveillance specimens from all patients that are contacts (i.e. roommates) of the
source patient as well as others who were in close geographic proximity to the source
patient
 For MRSA, consider screening staff contacts if the outbreak is due to the same strain of
MRSA and new cases are identified despite precautions
 Specimens for detection of MRSA should include nasal swab, groin swab (perianal
preferred) and swab(s) from skin lesions, wounds, incisions, ulcers, exit sites of
indwelling devices; for newborn infants, a swab from the umbilicus should also be taken
 Consider conducting a prevalence screen/surveillance on the affected floor/unit if
additional cases are found after doing contact tracing, particularly if these cases have the
same strain as the source patient
 Continue prevalence screening on a regular basis (e.g. weekly) until at least two
consecutive screens are negative
5.0 REFERENCES
5.2 Best Practices for Infection Prevention and Control in Perinatology In All Health Care
Settings that Provide Obstetrical and Newborn Care; Provincial Infectious Diseases
Advisory Committee (PIDAC), Ontario; April, 2012.
5.3 Annex A: Screening, Testing and Surveillance for Antibiotic Resistant Organisms
(AROs) in All Health Care Settings. Provincial Infectious Diseases Advisory Committee
(PIDAC), Ontario; February, 2013.
5.4 Antibiotic Resistant Organisms Prevention and Control Guidelines For Healthcare
Facilities. Provincial Infection Control Network (PICNet) BC; March 2013.
ACUTE CARE PLAN FOR AROs (Antibiotic Resistant Organisms)
COMMENTS – Date
PATIENT CONCERN GOAL INTERVENTION
& Signature
Colonization: Control spread of 1. In addition to Routine Practice, initiate Contact Precautions
ARO 2. Always do a Point of Care Risk Assessment for every patient interaction to determine
any additional precautions that need to be taken
 MRSA 3. 4 C’s should be adhered to if patient is leaving room:
 ESBL  Clean Hands: Wash hands for at least 15 seconds with soap and water or alcohol
 Other based hand rub (ABHR).
 Clean Clothes: wear clean patient gown or clean clothes.
 Contain wounds/body fluids: wounds covered with clean, dry dressing. Urine/feces
and other body fluids contained.
4. Patient and Visitor Teaching: use ARO Information pamphlets
 Ensure compliance with proper hand hygiene.
 Teach visitors re: hand washing as above and use of appropriate PPE.
 Visitors are not required to wear PPE unless participating in direct patient care.
 Visitors and patients who leave the patient’s room are asked to not use the kitchen,
lounges or other facilities in the hospital.
5. Safety: Compliance with hand hygiene requires continuous reinforcement!
 Equipment that is not dedicated to resident use must be cleaned and disinfected
between uses.
6. Documentation: Each shift, check off on the patient record that the appropriate care
plan has been followed and Infection Control Recommendations remain in place.
Ensure Patient 1. Signage regarding Contact Precautions is required outside patient’s room.
Confidentiality 2. Information about the patient’s ARO status is to remain confidential among direct care
providers (i.e. housekeeping and dietary staff only need to know type of precautions,
not patient condition).
3. When patient goes to another department, or is transferred to another facility, the
receiving department or facility MUST be notified of ARO status.
ARO Infection Stabilize 1. Physician to coordinate antibiotic regime if required.

condition and 2. In addition to Contact Precautions, contact the ICP to determine necessary additional
eradicate activity restrictions and/or care interventions.
infection 3. Patients presenting with respiratory symptoms who have an ARO identified in their
sputum must be placed on Droplet/Contact Precautions.
Effective Date: September 2006 Revised Date: Feb 2011 / Feb 2015
RESIDENTIAL CARE PLAN FOR AROs (Antibiotic Resistant Organisms)
RESIDENT COMMENTS – Date &

GOAL INTERVENTION
CONCERN Signature
Infection: Control spread 1. In addition to Routine Practices, use Contact Precautions Add pertinent interventions (i.e.
of ARO  Always do a Point of Care Risk Assessment for every resident interaction to decisions regarding a
determine any additional precautions that need to be taken. designated toilet) and highlight
 MRSA  Room placement may need to be reviewed with ICP. areas under intervention that
 ESBL  WOUND: Cover open wounds with dressing or clothing when resident is in close apply to resident
 Other contact with other residents.
 SPUTUM: If possible, residents with symptoms of respiratory infection should be
Site: kept in their rooms until symptoms resolve.
 Wound 2. Mobility: The resident is not restricted from common living areas, dining facilities or
 Sputum recreational and socializing activities unless the resident has diarrhea, pneumonia or
copiously draining wounds. Any restrictions are only in place until the symptoms
resolve. The 4 C’s should be adhered:
 Clean Hands: Wash hands for 15 seconds with soap and water or use alcohol
based hand rub (ABHR).
 Clean Clothes: wear clean clothes every day.
 Contain wounds/body fluids: wounds covered with clean, dry dressing. Urine/feces
and other body fluids contained.
3. Resident and Visitor Teaching: use ARO Information pamphlets
 Assist with hand washing & appropriate use of ABHR – to be done prior to leaving
their room, after using the toilet, prior to eating/handling food and when soiled.
 Teach visitors re: hand hygiene as above.
Equipment that is not dedicated to resident use must be cleaned and disinfected
between uses.
1. Signage for Contact Precautions available if required.

Ensure 2. Information about the resident’s ARO status is to remain confidential among direct
Resident care providers.
Confidentiality 3. Upon transfer, notify receiving sites and transfer personnel of ARO status – teach
resident and visitors about additional precautions taken at acute care sites (Contact
Precautions, single room, etc.).
EFFECTIVE DATE: September 2006 REVISED DATE: Feb 2011 / Feb 2015
COMMUNITY CARE PLAN FOR AROs (Antibiotic Resistant Organisms)
CLIENT CONCERN GOAL INTERVENTION COMMENTS
Infection: Control spread of 1. In addition to Routine Practices, use Contact Precautions Add pertinent interventions to
ARO  Always do a Point of Care Risk Assessment for every client interaction to CHW care plan; i.e. decisions
determine any additional precautions that need to be taken. regarding a designated toilet
 MRSA  WOUND: Cover open wounds with dressing or clothing. and clothing over open wounds
 ESBL  URINE or STOOL: If possible, client should have separate toilet. Empty urinary will need to be included in the
 Other catheter contents in designated toilet. When separate toilet not available, the CHW care plan
shared toilet requires routine cleaning with a household disinfectant.
Site:  SPUTUM: If possible, clients with symptoms of respiratory infection should be
 Wound requested to stay at home until symptoms resolve.
 Stool 2. Mobility: The client is not restricted in home or public unless there is an uncontained
 Urine draining wound – public pools and contact sports or other skin to skin contact should
be avoided until the wound is healed. Client should notify any medical personnel of
 Sputum MRSA status prior to appointments. Teach client to follow the 4 C’s:
 Clean Hands: Wash hands for 15 s with soap and water or alcohol based hand rub
(ABHR) often while at home and in the community.
 Clean Clothes: wear clean clothes every day and practice good personal hygiene.
 Contain wounds/body fluids: wounds covered with clean, dry dressing or clothing;
urine/feces and other body fluids container.
3. Client & Family Teaching: use ARO Information pamphlets
1. Assist with hand washing with plain soap – to be done prior to leaving their home,
after using the toilet, prior to eating/handling food and when are visibly soiled.
 Remind visitors to practice good hand hygiene.
Ensure Client 1. Signage regarding ARO status is NOT required. To ensure client confidentiality,
Confidentiality 2. Information about the client’s ARO status is to remain confidential among direct care DO NOT write the ARO status
providers. on the CHW care plan.
3. Notify acute or residential site of ARO status upon transfers – teach client and visitors
regarding additional precautions taken at acute care sites (Contact Precautions, single
room, etc.).
EFFECTIVE DATE: September 2006 REVISED DATE: Nov 2010 / Feb 2015
Section 08S – IS0300S (Carbapenemase Producing Organisms (CPOs)
Page 11
Acute Care Admission Screening for

MRSA and CPO
Section 08S – IS0300A (Carbapenemase Producing Organisms (CPOs)
Page 1
EFFECTIVE DATE: July 2015

IS0300A Carbapenemase Producing
Organisms (CPOs) REVISED DATE:
REVIEWED DATE:
1.0 PURPOSE
To prevent transmission of CPOs (Carbapenemase Producing Organisms) in hospitals, residential

care homes and community settings.
2.0 DEFINITIONS
CPO – Carbapenemase-Producing Organism refers to bacteria that are resistant to carbapenems – a

class of antibiotic usually reserved to treat serious infections. These resistant bacteria produce an
enzyme (carbapenemase) that breaks down the structure of the carbapenem antibiotics, making
infections very difficult to treat. CPOs can arise through the acquisition of carbapenemase genes
from other bacteria. Some examples of these genes are the New-Delhi Metallo-β-lactamase (NDM)
and Klebsiella pneumonia carbapenemase (KPC).
Many people with a CPO harbor the bacteria without causing symptoms (colonization). Others may
have an infection in their bloodstream, urinary tract or surgical site, with very limited antibiotic
treatment options and poor clinical outcomes. In Canada, most CPO cases have been identified in
persons who have been hospitalized and/or had a medical procedure done in countries outside of
Canada.
CPOs are usually spread person-to-person through contact with infected or colonized people, or
contaminated surfaces or medical equipment. Good hand hygiene by healthcare workers, patients,
and visitors and careful cleaning and disinfection of rooms and equipment, can help prevent the
spread of CPOs.
Colonization – the presence of microorganisms in or on an individual with growth and multiplication

but without tissue invasion or cellular injury. With most microorganisms, colonization is far more
common than clinical disease.
Contact – an individual who is exposed to a person, colonized or infected, with a CPO in a manner
that allows potential transmission to occur (i.e.) roommate.
Infection – when sufficient cellular and tissue changes occur to produce overt signs and symptoms,
an individual has clinical disease. Depending on the microorganism and health status of the host this
disease may range from mild to severe. Clinical manifestations of local or systemic infection can
include fever, increased white blood cell count, purulence, inflammation, redness, heat, swelling,
and/or pain.
Page 2
Internal Alert – when the number of CPO cases in a unit or facility is above the pre-determined
threshold (trigger point) or there is suspected transmission. Internal alerts bring increased staff
awareness of CPO cases in the unit/facility so actions can be taken to prevent an outbreak.
Outbreak Definition – CPO cases are classified as an outbreak when the number of new, time-
related, healthcare associated CPO cases in a unit or facility is above the expected threshold for that
unit or facility and where there is evidence of ongoing transmission despite appropriate interventions.
Molecular confirmation of CPO genes in patient’s isolates is required to determine ongoing
transmission. Declaring an outbreak must be done in conjunction with the facility Outbreak
Management Team.
Outbreak Management Team – at a minimum, includes the site Infection Control Practitioner,
Infection Prevention and Control (IPAC) director, Medical Microbiologist, epidemiologist, site
administrator, site medical director, nursing unit manager and housekeeping supervisor.
Screening – a process to identify patients at risk for being colonized with CPO, obtaining specimens
for CPO identification and ensuring Additional Precautions are implemented.
3.1 Anyone being screened for CPO must be placed on Contact Precautions in a single room
while awaiting screening results. If the PCRA (point of care risk assessment) identifies
respiratory symptoms, use Droplet Contact Precautions.
3.2 How Are CPOs Spread?
Note
3.3 An ARO Alert is entered into the patient’s electronic record by the Infection Control
Practitioner.
3.4 Any patients potentially exposed to a known CPO positive patient should have a screening
test (rectal swab; stool if rectal swab not available) performed.
3.5 The CPO status of a patient should not prevent transfer of the individual within a facility or to
another facility.
4.0 PROCEDURE
4.1 Acute Care Admission Screening for CPO

All patients being admitted to acute care for 24 hours or more require screening. Follow
procedure outlined on patient Admission History forms. Use the Acute Care Admission
Page 3
Screening for MRSA and CPO tool for pre-surgical screening, for surgical patients with an
unplanned admission and for patient transfers between acute care facilities.
Patients require a rectal swab (stool if rectal swab not available) for CPO screening if they
answer ‘yes’ to any of the following:
 Has the patient ever had a CPO?
 Has the patient been outside of Canada and had an overnight stay in a hospital or
undergone a medical/surgical procedure within the past 12 months?
 Has the patient had dialysis outside Canada within the past 12 months?
 Has the patient had close contact with a known CPO patient within the past 12
months? (close contact defined as household member or roommate in hospital)
 Has the patient been transferred from a facility with known, active CPO
transmission?
 There are different types of CPOs, so patients who are known to be CPO positive
must be retested for each hospital admission.
Please Note: For negative screening results, there will be a comment on the lab
result that states ‘Continue Contact Precautions as patient has had a previous
positive CPO result’.
Any patient requiring CPO screening swabs must be placed on Contact Precautions in
a single room. Precautions may be discontinued if the screening swab is negative and the
patient was not previously CPO positive.
4.2 Patients who have a CPO identified in a clinical specimen must be placed on Contact
Precautions for the duration of their hospitalization. Use Droplet Contact Precautions if a
CPO is identified in a sputum culture.
4.3 Hand Hygiene

Perform hand hygiene as per IF0200 (Hand Hygiene Guidelines in IPAC Manual).

Place patient in a single room on Contact Precautions until discharge
 Door may remain open
 Additional precautions signage placed at the entrance to the patient room, cubicle or
designated bed space (i.e.) Emergency Department

 Transfers and/or bed moves should be avoided unless clinically necessary
 Communication of additional precautions is essential when a patient goes to another
department for testing, to another unit or to other healthcare settings/facilities including
Emergency Medical Services (EMS) and other transport staff.
 Healthcare provider to remove PPE and do hand hygiene prior to transporting patients.
 If direct contact with patient is required during transport, then those staff must don PPE.

 PPE to be available directly outside the patient room, cubicle or designated bed space.
 Wear gloves and gown when in direct contact with patient or patient environment.
 Remove gown and gloves and discard before leaving the room or bed space and do
hand hygiene
4.7 Patient Care Equipment

 Dedicate equipment to a single patient (e.g. blood pressure cuff, commodes etc.).
• If equipment must be shared it must be cleaned and disinfected between patients.
Page 4
• Do not take extra supplies into patient’s room.

• Do not take patient chart into the room.
• Clean and disinfect equipment used for transport after each use.

 Patient room to be cleaned daily and frequently touched surfaces to be cleaned twice
daily using regular hospital disinfectant – housekeeping to be notified by nursing staff
(Appendix 1: Enhanced Cleaning Checklist)
 Do an additional precautions discharge clean of the room/bed space and bathroom
which includes changing privacy curtains and cleaning and disinfecting or changing
string/cloth call bells or light cords (IH Housekeeping for Healthcare manual pg.109).
4.9 Waste, Laundry, Dishes and Cutlery

 Use routine practices
4.10 Education of Patients, Families and Visitors

 Educate as per additional precautions signage.
 Provide the Screening for CPOs patient information pamphlet to the patient and family
available on the Infection Prevention & Control website
4.11 Surveillance
 For patients confirmed to be positive for a CPO, Infection Prevention and Control (IPAC)
will collaborate with unit staff and the BC Public Health Microbiology & Reference
Laboratory (BCPHMRL) to collect data required for surveillance purposes
 For positive CPO isolates, BCPHMRL will assign a unique identifier which will be
included in the laboratory report and will notify the submitting laboratory
 The submitting laboratory will work with the site ICP to ensure completion of the
surveillance form for CPO https://www.picnet.ca/wp-content/uploads/CPO-Surveillance-
Form.pdf: Complete Appendix C for CPO colonization cases. Complete Appendix C and
Appendix D for CPO infected cases.
 Submit completed forms to the Provincial Infection Control Network (PICNet) and IPAC
epidemiologist
 The IPAC epidemiologist will submit denominator data to PICNet on a quarterly basis
including:
 Total number of hospital admissions per quarter
 Total number of inpatient days per quarter
 Total number of CPO cases per quarter
 PICNet and BCPHMRL will summarize the CPO data and report back to the health
authorities, the Ministry of Health and the BC Association of Medical Microbiologists
(BCAMM) quarterly.
4.12 Internal Alert

 When the number of CPO cases in a unit or facility is above the pre-determined threshold
(trigger point) or there is suspected transmission
 Triggering an internal alert does not require confirmed laboratory results and may include
patients that were known or found to be positive for a CPO on admission
 When an ‘internal alert’ has been reached, staff within the facility should be alerted to the
situation and enhanced control measures implemented
 Facility administration should work with the unit staff and IPAC to put additional control
measures and resources in place
 An internal alert is for the operational purposes of that facility and a public announcement
is not required
Page 5
4.13 Outbreak Management Team

 An Outbreak Management Team (OMT) works collaboratively in the early detection,
declaration and management of the outbreak
 Under the Public Health Act, consultation is required with the Medical Health Officer
(MHO) or designate for the management of outbreaks by IPAC and the facility
Administrator - Medical Microbiologist is point of contact for acute facilities
 The OMT to collaborate with the BCPHMRL to facilitate rapid testing of isolates to
determine CPO gene types
 The OMT facilitates communication of the outbreak situation to receiving hospitals of all
transferred patients and informs other health authorities and PICNet
 The OMT guides decisions to limit new admissions, close units or close an entire facility
if necessary
 Decisions around contact tracing to be done in consultation with the IPAC Medical
Director or designate, including the need for CPO screening swabs (i.e.) rectal swab,
ostomy site swab
 The OMT advocates for enhanced resources required to implement control measures
 The OMT to summarize outcome and lessons learned to share with local/regional IPAC
committees
5.0 REFERENCES
5.1 Toolkit for the Management of Carbapenemase Producing Organisms (CPO)

Provincial Infection Control Network (PICNet) BC; September 2014.
Page 6
Appendix 1
Section 08S – IS0400 (Scabies/Lice)
Page 1

IS0400: Scabies/Lice
REVISED DATE: November 2010
1.0 PURPOSE
To prevent transmission of scabies and lice to patients and staff.
2.0 DEFINITIONS
Scabies
 Scabies is a contagious parasitic infestation caused by a mite, Sarcoptes scabiei.
 Scabies infestations are identified by the following characteristics:
o Skin penetration is visible as papules or vesicles.
o Linear burrows formed by the mite under the skin.
o Severe pruritus.
These lesions commonly appear in interdigital spaces, anterior surfaces of wrists and ankles, axillae,
skin folds, genitalia, belt-line and abdomen. Itching may be intense, especially at night and lesions
may become secondarily infected due to scratching.
Crusted (Norwegian ) scabies presents as a crusty, scaly dermatitis usually on hands and feet,
including dystrophic nails. Some affected individuals may have a generalized erythematous eruption.
Norwegian scabies is highly infectious owing to the large numbers of mites present.
Definitive diagnosis of scabies infestation is by microscopic examination of mites extracted by a

needle or scalpel (skin scraping).
Lice
Lice (pediculosis) are called ectoparasites because they live outside the host’s body. There are three
types of human lice which are usually, but not always, confined to a certain part of the body. They
are named according to the region of the body that they infest or their general appearance: head
louse, body louse, and pubic or crab louse. These creatures cannot fly or jump, but head and body
lice move quickly, passing rapidly from host to host.
Head Lice
Head lice generally prefer the fine hairs of the head especially around the ears and the nape of the
neck or eyebrows and eyelashes. Adult larvae and nits are visible to the naked eye:
 Adult lice are reddish-brown.
 Unhatched eggs are pearly white.
 Hatched eggs are translucent.
Page 2
Infectious Period
 Scabies and lice can be transmitted up until the time they are eradicated by treatment with 5%
permethrin cream.
 The incubation period for primary infestation occurs as early as 10 days, but it is typically 4 – 6
weeks.
Transmission
 Scabies and lice are transmitted through direct or indirect contact.
 Although blood and body fluids are not affected by these infestations, the patient’s clothing, bed
linen, and mattress are contaminated by direct contact with the infected patient.
 Head lice are transmitted through contact with infested hair or with articles such as brushes,
combs, headgear, or clothing of the infested person.
 Transmission of pubic lice is usually by sexual contact.
3.0 PROCEDURE

 Patients with scabies or lice are placed on Contact Precautions
 REFER TO IH0400-CONTACT PRECAUTIONS GUIDELINE until 24 hours following treatment.
 In persons with crusted scabies, the length of additional precautions may be longer.
 Staff to wear a gown and gloves for all patient contact until the treatment has been
completed and Contact Precautions discontinued.
3.2 Treatment
 Ordered by the attending physician.
 5% permethrin cream applied as directed. Milder doses may be required for children and
pregnant or lactating women.
Itching may persist for days to weeks following treatment. This is not to be
mistaken for treatment failure.
 Carefully examine the patient for new burrows in seven days. If there is evidence of
continued infestation, treatment may be repeated if considered necessary - ordered by
the attending physician.
3.3 Staff
Contact Workplace Health and Safety if symptomatic.
3.4 Handling Patient’s Clothing, Linen And Laundry

 Place patient’s personal clothing in a plastic bag and securely close the bag. Send this
laundry home with the family to be laundered.
 Routine Practices are used for handling all laundry items – place soiled linen in
appropriate plastic laundry bag and send to Laundry for cleaning.
Page 3
3.5 Housekeeping
Perform routine cleaning.
REFER TO IF0100- ROUTINE PRACTICES FOR ALL CARE AREAS GUIDELINE
3.6 Management of Scabies Outbreaks

See B.C. Centre for Disease Control (BCCDC) for policy:
4.0 REFERENCES
4.1 APIC Text 2009.
4.2 BCCDC Communicable Disease Manual.
Section 08S – IS0500A (Tuberculosis)
Page 1

IS0500A: Tuberculosis
REVIEWED DATE:
1.0 PURPOSE
The goal of the Tuberculosis (TB) Management Program is to prevent transmission of TB to staff
and patients.
2.0 DEFINITIONS
The most common site of TB infection is in the upper regions of the lungs. Mycobacterium
tuberculosis is spread by the airborne route when patients expectorating viable tubercle bacilli
contaminate the surrounding airspace. Aerosolized tubercule bacilli can be inhaled by
susceptible patients and staff and can lead to primary tuberculosis infection. The incubation
period for TB is between two and twelve weeks.
Pulmonary and laryngeal TB are the only types of TB that are spread via the airborne route.
In Canada, TB occurs in well-defined populations including Aboriginal Canadians, the urban poor
or immigrants from high-incidence countries in Asia, Eastern Europe, Africa and Latin America.
Immunocompromised persons such as those with HIV and diabetes are also at an increased risk
of developing active TB. Other groups at risk include people who live or work in residential care
facilities (e.g. jail, nursing homes, drug treatment centers), alcoholics, indigent persons and IV
drug users. Persons who live in the same household with a high risk individual are also at risk.
Because healthcare providers have frequent contact with persons in these groups, the risk of
transmission of TB remains an important potential occupational hazard.
3.0 GUIDING PRINCPLES
A HIGH INDEX OF SUSPICION MUST BE MAINTAINED – EARLY DIAGNOSIS IS KEY IN PREVENTING

HEALTHCARE ASSOCIATED TRANSMISSION FROM INFECTIOUS CASES WHICH OFTEN OCCURS BEFORE
DIAGNOSIS.
3.1 Determinants of TB Transmission

 TB is spread by the inhalation of airborne organisms when a patient coughs,
sneezes or speaks – once infectious particles have been aerosolized, they are
spread throughout a room or building by air currents and can be inhaled by other
individuals.
 Procedures associated with increased risk of generation of infectious aerosolized
particles including bronchoscopy, laboratory and autopsy procedures, cough
inducing procedures (i.e. sputum induction), administration of aerosolized
therapies that induce coughing and irrigation of TB-infected wounds.
 Patients with respiratory secretions that are acid-fast bacilli (AFB) smear positive
are more infectious than those whose smear results are negative.
 Patients with laryngeal involvement are particularly contagious.
Page 2
 The risk of transmission increases with the increasing amount of time spent with
an infectious patient without wearing appropriate personal protective equipment
(PPE).
 In buildings with sealed windows and mechanical ventilation systems,
recirculation of air can contribute to transmission in healthcare facilities.
3.2 Risk classification: healthcare facilities

 Classification is based on the number of active inpatient beds and the number of TB
cases of all forms and sites.
Hospital with > 200 beds:
< 6 TB patients admitted annually = low risk.
> 6 TB patients admitted annually = medium risk.
Hospital with < 200 beds AND other facilities such as long-term care:
< 3 TB patients admitted annually = low risk.
> 3 TB patients admitted annually = medium risk.
 In Medium-risk hospitals a TB management committee is recommended, whose
members should include persons with day-to-day responsibility for infection
prevention and control and employee health, representation from senior
administration, laboratory, nursing, medicine, other health disciplines (e.g. respiratory
technology) and public health (additional members may be added from support
services such as pharmacy, housekeeping, physical plant).
3.3 Risk classification: healthcare workers

 High-risk activities including cough-inducing procedures (sputum induction,
pentamidine aerosol), autopsy, morbid anatomy and pathology examination,
bronchoscopy, designated mycobacteriology laboratory procedures, especially
handling cultures of M. tuberculosis.
 Intermediate-risk activities including regular direct patient contact (e.g. by nursing,
respiratory, social workers, physiotherapists, housekeeping) on units to which
patients with active TB may be admitted.
 Low-risk activities including minimal direct patient contact (medical records,
administration, maintenance) and those who work on units where TB patients are
unlikely to be admitted such as obstetrics or pediatrics.
 IH WH&S (Workplace Health & Safety) have developed a tool and will work
collaboratively with Infection Control Practitioners to establish risk classifications –
I.H FACILITY REFER TO THE FACILITY TUBERCULOSIS RISK

ASSESSMENT FORM
NON I.H. FACILITY REFER TO THE FACILITY TUBERCULOSIS RISK
ASSESSMENT FORM.
 Recommend that all facilities make available to their healthcare workers annual
summary information on the clinical, epidemiologic and microbiologic features of
patients whose TB is diagnosed within the hospital – will help to increase awareness
of TB in the patient population served by the hospital.
3.4 Early identification of patients with suspected TB

 Symptoms consistent with active TB include fever, cough for more than 3 weeks,
unexplained weight loss, hemoptysis, loss of appetite, and night sweats.
 Chest x-ray done in suspect cases.
 Sputum specimens tested for acid-fast bacilli (AFB) in suspect cases
Page 3
o Collect 3 sputum specimens 8 – 24 hours apart and at least one should be

collected in the early morning upon awakening.
o Do gastric aspirates in children too young to produce sputum.
4.0 PROCEDURE
There are 6 specific processes:

 Airborne Precautions
 Environmental Engineering Controls
 Respiratory Protection
 Personal Controls: Screening and follow-up
 Contact Investigation for Patient & Staff
 Discharge Planning
4.1 Airborne Precautions

(back to PROCEDURE)
Inform Infection Prevention and Control of all patients with confirmed TB and patients
who have a high suspicion of TB who are in the facility.
 Patient must be placed on Airborne Precautions in an appropriately ventilated
Airborne Isolation Room
 REFER TO IH0200 – AIRBORNE PRECAUTIONS
GUIDELINE
 If an Airborne Isolation Room is not available then arrange to have the patient
transferred to a facility with the necessary room requirements as quickly as possible.
 Staff entering the room must wear approved respiratory protection (will be referred to
as N95 respirators for remainder of document), ensuring the seal checks are done
when the N95 respirator is put on.
 REFER TO IH0200 – AIRBORNE PRECAUTIONS GUIDELINE
 Visitors entering the room should be offered an N95 respirator, staff to teach the seal
check and how to put the N95 respirator on. Visits by children should be discouraged
because of their increased susceptibility.
 Patient is to leave the room for essential procedures only and is to wear a
surgical/procedure mask when outside their isolation room.
 Exceptions due to extenuating circumstances must be reviewed and approved by the
attending physician & Infection Control – a written order is required.
 Notify receiving departments of Airborne Precautions requirements – staff will need to
wear an N95 respirator when the patient is unable to wear a surgical/procedure mask.
 If transport between facilities is required, patient should be transported in well-
ventilated vehicles (i.e. with the window open) and attendants should wear an
approved respirator mask – DO NOT use public transportation.
4.1.1 Special Situations:

 ICU
o Maintain Airborne Precautions.
o Place patient in an Airborne Isolation Room with door closed.
o Staff must wear N95 respirator.
o If intubation and mechanical ventilation is required, an appropriate bacterial
filter should be placed on the endotracheal tube to prevent contamination of
the ventilator and the ambient air.
o Use closed suction apparatus for endotracheal suctioning.
Page 4
 Surgery
o Surgery should be postponed or scheduled at the end of the day.
o If intubation and mechanical ventilation is required, an appropriate
bacterial filter should be placed on the endotracheal tube to prevent
contamination of the ventilator and the ambient air.
o Use Airborne Isolation Room (if available) for procedure.
o Staff must wear N95 respirator.
o Door to room patient is in must remain closed.
 Minor procedures that are not high risk for TB transmission

o Refers to urgent procedures needed for medical care that cannot be
postponed until the patient is deemed non-infectious such as blood work or
diagnostic imaging.
o Preference is to perform procedure in room with appropriately ventilated
negative pressure with staff wearing approved N95 respirator.
o If not possible, patient should be instructed to wear a surgical/procedure
mask during procedure, recovery and transport. Patient should be instructed
to keep the mask on and change the mask if it becomes wet.
4.1.2 Discontinuation of Airborne Precautions for Patients with suspect TB - on

approval only by the Infection Prevention & Control Practitioner, the
Respirologist, the Infectious Diseases Physician or the Medical Director for
 When three successive samples of sputum are negative on smear, unless
TB is still strongly suspected, cultures are pending and no other diagnosis has
been made.
 The sputum specimens should be collected 8-24 hours apart and at least one
should be an early morning specimen.
 When another definitive diagnosis is made and active TB is considered
unlikely.
Note:
A single negative AFB smear from bronchoalveolar lavage (BAL) does
NOT definitively exclude active TB and three induced sputum
specimens have superior yield for the diagnosis of active TB than a
single bronchoscopy.
 Patients with smear-positive TB – require three consecutive negative

sputum smears - the sputum specimens should be collected 8-24 hours apart
and at least one should be an early morning specimen AND there should be
clinical evidence of improvement AND evidence of adherence to at least 2
weeks of multidrug therapy based on the antibiotic sensitivity of the patient’s
organism.
 Patients with smear-negative, culture-positive TB – discontinue Airborne
Precautions after 2 weeks of appropriate multidrug therapy as long as there is
clinical evidence of improvement.
 In the event that a smear-positive, culture-negative condition develops during
treatment, Airborne Precautions may be discontinued provided three consecutive
sputum specimens are culture negative after 6 weeks of incubation.
 Patients with active Multidrug resistant (MDR-TB) – must remain in
Airborne Precautions for the duration of their hospital stay or until three
consecutive sputum cultures are negative after 6 weeks of incubation; if
discharge is being planned, refer to 7.0 DISCHARGE PLANNING.
Page 5
 Patients with pleural TB – if unable to collect sputum cultures, recommend

bronchoscopy to obtain specimens to rule out pulmonary TB – must ensure
samples are taken from various areas of effusion.
4.2 Environmental Engineering Controls

(back to PROCEDURE)
4.2.1 Ventilation
 Newly constructed Airborne Isolation Rooms should have 12 air changes per
hour; pre-existing rooms should have at least 6 air changes per hour or as
per current CSA Standards.
 The direction of air flow should be from the hall and into the room and then
exhausted outdoors.
 Direction of air flow should be tested with smoke tubes at all four corners of
the door daily when the room is occupied, unless the room is equipped with
automatic pressure monitoring.
 Windows and doors should be kept closed at all times.
 The air changes and direction of air flow should be verified at least every 6
months AND if any changes occur such as HVAC equipment failure or alarm
failure.
 Time needed to remove airborne contaminants after generation of infectious
droplet nuclei has ceased is 45 minutes.
4.2.2 Sputum Induction, Pentamidine Aerosol, Bronchoscopy Suites and

Autopsy Suites
 Airborne Isolation Room requires at least 12 air changes per hour or as per
current CSA Standards.
 Time needed to remove airborne contaminants after generation of infectious
droplet nuclei has ceased is 45 minutes.
4.3 Respiratory Protection Program

(back to PROCEDURE)
 Current recommendations call for particulate respirator masks that filter 95% of particles
of 1 micron or larger and have less than 10% leak to protect workers against airborne
TB.
 Most common product used are NIOSH-designated N95 respirators.
 Healthcare providers require education regarding the occupational risk of TB, the role of
respiratory protection to reduce that risk, the importance of wearing the N95 respirator
properly, doing a seal check each time the N95 respirator is put on so that there is a tight
facial seal and ensuring the N95 respirator is put on correctly before entering the
patient’s room.
 N95 respirators must be available for staff whenever a patient is identified who is
suspected of or confirmed to have active TB.
 N95 respirators should be worn by workers involved in the transport of patients
suspected of or confirmed as having active TB, e.g. ambulance workers, particularly
when patient cannot wear a surgical/procedure mask.
 N95 respirators should be available for caregivers, e.g. community healthcare workers
who may have to provide care while waiting for patient transfer to a facility with
appropriate environmental controls.
 TB patients can wear surgical/procedure mask when they leave their rooms as these
mask are effective in trapping the large infectious particles expelled by TB patients.
Page 6
 Visitors should be offered an N95 respirator, staff to teach the seal check and how to put
the mask on.
4.4 Personal Controls: Screening & Follow-up

(back to PROCEDURE)
4.4.1 Baseline Tuberculin Skin Testing (TST) For Healthcare Workers

 Appropriate baseline TST for all potentially exposed healthcare workers in all
healthcare settings is important (BCCDC TB Control does not recommend a
two step TST).
 Upon hire, all employees should have a TST unless they have documented
results of a prior positive test.
 Workers with reactions of less than 10 mm induration should be considered
TST negative for baseline screening purposes.
 Workers with a reaction of 10 mm induration or greater on the test should be
considered TST positive, be referred for chest radiography and medical
evaluation and consideration of prophylactic treatment of Latent TB Infection
(LTBI).
 Healthcare workers with history of a positive TST should not receive further
TSTs – performing annual chest radiography of asymptomatic TST-positive
staff is not recommended (Pg. 338 Canadian TB Standards 2007).
4.4.2 TST Following Unprotected Exposure

 Any healthcare worker who has unprotected exposure to a patient who is
confirmed to have active, contagious TB must be considered at risk of
infection.
 For TST-negative workers, a TST should be done as soon as possible and, if
negative, repeated after 8 to 12 weeks. If TST conversion occurs, the
worker should be referred for chest radiography and medical evaluation.
 For TST-positive workers, the worker should be educated regarding the
signs and symptoms of TB and if such symptoms develop, chest radiography
should be performed and three sputum specimens should be tested for AFB.
4.4.3 Periodic TST for Workers in Medium Risk Hospitals and Programs OR
Those Performing High Risk Activities in All Hospitals
 Annual TST is recommended for healthcare workers with negative baseline
TST who are involved in moderate-risk activities in medium-risk hospitals
AND for workers involved in high-risk activities in all hospitals.
4.5 Contact Investigation for Patients and Staff

(back to PROCEDURE)
(A person identified as having come in contact with a case of active disease. The degree of
contact is usually further defined on the basis of closeness. Contacts may be classified as
close, casual or community.)
 When a case of TB is identified and appropriate Airborne Precautions had not been
implemented, a large number of contacts who need to be assessed can result. This
includes patients, hospital staff, physicians, volunteers and visitors who were exposed to
the case during the infectious period.
 If the case arrived from the community or was transferred from another facility, contacts
outside the institution would also need to be considered.
Page 7
 ICP to work collaboratively with the Communicable Disease (CD) Unit, WH&S and
medical staff to ensure appropriate contact investigation and follow up is implemented
promptly.
 Patients are considered a contact if they have shared a room with another patient
confirmed with TB – they have had regular, prolonged contact with the source case and
share breathing space daily.
 Patient contacts are NOT infectious and DO NOT require Airborne Precautions, however,
they do require follow up evaluation by their family physician.
 ICP notifies CD Unit of positive active TB case and potential contacts in hospital – Public
Health will assist in follow up of discharged patients, visitors and volunteers.
 ICP notifies WH&S regarding the contact investigation of an active case of TB – WH&S
will carryout follow up for staff exposures (Section 5.2 above).
 ICP notifies the ‘contact’ patient’s attending physician regarding the potential exposure of
their patient to an active TB case and advises that follow up is necessary - if patient still
in hospital, a baseline TST can be done by the institution.
 ICP notifies the Patient Transport Office (PTO) of potential external contacts such as
ambulance personnel, first responders and other transport services and advises that
follow up is necessary – PTO will ensure contact is made with the necessary providers in
this regard.
4.6 Discharge Planning

(back to PROCEDURE)
 Initially smear-positive patients may be discharged home even if they are still smear
positive provided a smooth transition plan has been developed between the hospital and
community public health for follow–through provision of TB medications and ongoing
care.
 Some TB patients may be noncompliant, homeless or have circumstances where
community care is unlikely to succeed and may need hospitalized provision of treatment
medications until they become non-infectious (sputum is smear negative) – this process
may be voluntary by the patient OR under an Order by the Medical Health Officer under
the Health Act.
 Once all parties have been notified and a discharge date has been agreed upon
(minimum of 3 working days required to ensure services are in place), the discharge
can proceed.
 Public Health is responsible for evaluating conditions necessary for the discharge to
proceed including directly observed therapy (DOT) if indicated, evaluation of household
air recirculation in housing units such as apartment complexes, review of household
contacts including infants and children, patient counseling about precautions necessary
during infectious period of disease and to refrain from going into any other indoor
environment where TB transmission could take place AND if patient has to attend an
outpatient clinic, they must wear a mask until they are no longer infectious.
4.7 Process/Protocol
 As soon as possible after an in-patient is confirmed as having active pulmonary
tuberculosis, the CD Unit will coordinate a case teleconference – this is a collaborative
process for the purpose of information sharing, identification of case contacts, early
recognition of discharge planning needs and coordination of key stakeholders, including:
o CD Unit.
o Hospital Transition Nurse/Discharge Planner (specific to unit where patient is
located).
o Patient Care Coordinator [PCC] (specific to unit where patient is located).
o Hospital Infectious Disease Pharmacist [or designate].
o Urban Outreach Social Worker (if case in Kelowna).
o Urban Outreach Case Manager (if case in Kelowna).
Page 8
o Public Health Nurse (specific to geographic area).

o Hospital Social Worker (if patient not an Urban Outreach client).
o Home & Community Care Manager [or designate] (specific to geographic
area).
o Occupation Health Nurse Specialist.
o Hospital Infection Control Practitioner.
o WH&S Consultant (for fit-testing), Community Infection Control Practitioner
and others may join teleconference as needed.
 Needs to be a collaborative process between the hospital physician, MHO and
consultant TB physician from BCCDC TB Control division to determine
appropriateness of discharge.
 MHO will notify public health services to assure the out-patient prescription
medications are in place and that community protection protocols are established,
should the patient still be infectious.
 CD Unit will coordinate with local Public Health Nursing staff and the hospital
discharge planner, to ensure an adequate discharge plan is in place prior to patient
release.
 Notify family doctor for an appropriate follow-up appointment.
 Notify Home/Community Care Services to prepare for receiving and attending the
patient, giving sufficient time to allow for adequate fit-testing and education of staff, if
required.
 Notify transport services, if required.
 Once all parties have been notified and a discharge date has been agreed upon,
(minimum of 3 working [Mon-Fri] days required to ensure services are in place -
additional time may be required depending on the complexity of the case), the
discharge can proceed.
5.0 REFERENCES:
5.1 Canadian Tuberculosis Standards 6th Edition by The Public Health Agency of Canada
and The Lung Association, 2007; Chapter 16.
5.2 APIC Text of Infection Control and Epidemiology 3rd Edition 2009; Chapter 91.
5.3 Canadian Standards Association CAN/CSA-Z317.2-01 Special Requirements for

Heating, Ventilation, and Air Conditioning (HVAC) Systems in Health Care Facilities 2008.
5.4 WorksafeBC Occupational Health and Safety Regulations available:
Page 9
TUBERCULOSIS MANAGEMENT PROGRAM QUICK

REFERENCE
Goal is to prevent transmission of TB to staff and patients
Early diagnosis necessary
If TB suspected, implement Airborne Precautions immediately – place patient in Airborne Isolation

room and staff to wear N95 respirators
Place appropriate Airborne Precautions sign on door and ensure that the negative pressure is
turned on and working. Room pressure must be checked each shift.
Collect 3 sputum specimens 8 – 24 hours apart with at least one being an early morning specimen
Patient to wear surgical/procedure mask when outside of Airborne Isolation room
Visitors to be offered N95 respirator – teach re seal check
Children should not visit
Discontinue Airborne Precautions only on approval from ICP, Infectious Disease physician,
Respirologist, or Medical Director for IP&C
When Airborne Precautions are discontinued and room is cleaned, 45 minutes is required to
remove airborne contaminants
Discharge planning done collaboratively with Public Health and others – requires minimum of 3
working days to ensure necessary services are organized and available
Page 10
Page 11
Section 08S – IS0500B (Tuberculosis Risk Screening-Adult Residential
Care Facilities, Group Homes, Mental Health Care Facilities)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located
on IHNET at the Policies & Procedures Home Page
EFFECTIVE DATE: July 2007

IS0500B Tuberculosis Risk Screening –
Adult Residential Care Facilities, Group Homes, REVISED DATE: November 2010,
Mental Health Care Facilities June 2016
REVIEWED DATE:
1.0 PURPOSE
To ensure persons with active respiratory tuberculosis are excluded from admission to an Adult
Residential Care Facility (including Group Homes and Mental Health Care Facilities) until they have
been appropriately treated and are no longer infectious.
The Medical Health Officer may make alternative policy decisions based on local disease incidence
and prevalence.
2.0 DEFINITIONS
Risk factors for tuberculosis (TB) include:

 Contacts to active cases of TB disease
 Persons born in or travelled to high TB incidence countries
 Current or historical residence in a First Nations, Métis, or Inuit communities
 Homeless or under-housed (i.e. shelter users, those with no fixed address)
 Residents of congregate living settings (i.e. correctional facilities, long-term care facilities,
residential treatment programs)
 Immune compromised or illness affecting immunity ( i.e. persons with HIV)
Symptoms of Active Respiratory TB Disease:
Systemic Signs and Symptoms of Active TB Signs and Symptoms of Respiratory TB Disease
Disease
 Fever*  Cough (dry or productive) for two to three
 Night sweats* weeks or longer with or without fever or
 Loss of appetite (anorexia) phlegm
 Unexplained weight loss  Bloody sputum (hemoptysis)
 Fatigue  Chest pain
 Shortness of breath
 Abnormalities on chest x-ray**
* May be absent in the very young and elderly
** Radiographic presentation can be atypical in clients who are immune compromised
Immune compromised defined as persons with HIV infection; transplant recipient on immune
suppressing treatment; chronic renal failure and/or dialysis and/or other conditions per clinical
judgment/consultation with TB Services; taking (or about to begin) treatment with immune suppressing
therapies such as TNF alpha inhibitors, chemotherapy, or systemic corticosteroids (equivalent of ≥ 15
mg/day of prednisone for 2 weeks or longer)
Page 2
All persons being admitted to a licensed Adult Residential Care Facility need to be screened for signs
and symptoms associated with active TB disease. This process needs to be completed prior to the
person being admitted to the care facility, may occur while the person is still living at home or while
the person is in the hospital and can be done within one month prior to admission if not symptomatic.
This information will be recorded on the person’s chart.
As per the Medical Health Officer 2016, this excludes client stays of less than 30 days and
Community Hospice Bed admissions (palliative care clients).
If a client remains in convalescent or respite care for greater than 30 days, they do require TB
screening.
4.0 PROCEDURE
4.1 Prior to admission to an Adult Residential Care Facility, a risk assessment

must be performed using the IH Tuberculosis Risk Screening for Residential Care
Facilities, Group Homes and Mental Health Care Facilities (#811217) form:
 The Home Health Nurse performs for persons in community
 The Transition Liaison Nurse performs for patients in hospital
 Mental Health staff perform for persons entering Mental Health Care facilities
 Can be done within one month prior to admission if person not symptomatic
4.2 For all persons who are less than 60 years old:
 A tuberculin skin test (TST) must be done, unless contraindicated
o If client is in the community, refer client to Public Health Nursing for TST
o If client is admitted to hospital, nursing staff will perform the TST
 In addition, for those persons who have symptoms of respiratory TB disease a
chest x-ray is required – see 4.4 below
 If the person has a positive TST, a chest x-ray is required – see 4.4 below
 If the person has a TST contraindication, or is immune compromised, a chest x-
ray is required – see 4.4 below
 Contraindications for a TST include prior allergic response or severe reaction to a
TST, previous positive TST reaction, previous reactive IGRA (interferon gamma
release assay), previous active TB disease and burns or eczema at test site
4.3 For persons who are 60 years and over:

 With no symptoms of respiratory TB disease, no further action is required
 Who have symptoms of respiratory TB disease, a chest x-ray is required – see
4.4 below
4.4 Process for having chest x-ray done

 Person doing the client assessment completes all sections under Part 1 and 2 of the
BCCDC TB Screening Form – http://www.bccdc.ca/resource-
gallery/Documents/Guidelines%20and%20Forms/Forms/TB/CPS_TB_ScreeningFor
m939_20150722.pdf
 Ensure that the MRP’s (most responsible physician) name is listed on the form.
Page 3
 Ensure that the name of the person who needs to receive recommendations back is
listed in the “Additional Comments” section (i.e. ‘Please send recommendations to
Jane Smith, Home Health Nurse’; include mailing address)
 Send the last page of the BCCDC TB Screening Form with the client to the
radiology provider (this page automatically populates when information is entered
electronically into Part 1 and Part 2 of the form)
 Send the first page of the BCCDC TB Screening Form to BCCDC TB Services
 Recommendations from BCCDC TB Services are communicated back to providers
via the BCCDC TB Screening Form and/or physician narratives
 If a chest x-ray is required, refer person to MRP (most responsible physician) for
follow up; (MRP to order sputum for AFB/TB culture if person has productive cough)
 Person cannot be admitted to a residential care facility until assessment by MRP and
BCCDC TB Services has ruled out presence of active respiratory TB disease
4.5 Documentation
 Place the completed IH Tuberculosis Risk Screening form #811217 on the
person’s file
 When the person is admitted to an Adult Residential Care facility, Group Home or
Mental Health Care facility, send a copy of the completed IH Tuberculosis Risk
Screening form #811217 to the admitting facility; this meets the licensing
requirements by having the completed form on file
 If person was sent for chest x-ray and referral to BCCDC TB Services, include
recommendations from TB Services
5.0 REFERENCES
5.1 British Columbia Centre for Disease Control: Tuberculosis Manual. (November 2015)
Page 4
Tuberculosis Risk Screening for Residential Care EFFECTIVE DATE: July 2007
Facilities - Form #811217 REVISED DATE: June 2016
REVIEWED DATE: November 2010
Section 08S – IS0600 (Chickenpox (Varicella-Zoster) and Herpes Zoster (Shingles)
Page 1

IS0600: Chickenpox (Varicella-Zoster) and
Herpes Zoster (Shingles) REVISED DATE: November 2010,
December 2012
REVIEWED DATE:
1.0 PURPOSE
To prevent the spread of Varicella-zoster and herpes zoster to patients and staff.
2.0 DEFINITIONS
Varicella-zoster virus (VZV) – is the causative agent of two diseases:

 Varicella (chickenpox), the primary infection.
 Herpes zoster (shingles), a secondary infection due to a reactivation of latent varicella infection
in the dorsal root ganglia.
Chickenpox – typically infects children under the age of 10 years.

 Transmitted from person to person by direct contact, droplet or airborne spread of vesicle fluid or
sections of the respiratory tract and indirectly through articles freshly soiled by discharges from
vesicles or mucous membranes of infected people.
 Incubation period between 10-21 days.
 Is most contagious from 2 days before onset of rash until all lesions have crusted.
 Susceptible persons should be considered potentially infectious 7 to 21 days following exposure.
 Scabs from the lesions are not infective.
Shingles – lifetime risk of reactivation as zoster/shingles is about 15-20%.

 Can occur any time, most often in the elderly population
 Vesicles with an erythematous base appear in crops in irregular fashion along nerve pathways.
 Severe pain and paresthesia are common.
 Transmitted from person to person by direct contact, droplet or airborne spread of vesicle fluid
and indirectly through articles freshly soiled by discharges from vesicles or mucous membranes
of infected people.
 Scabs from the lesions are not infective.
Localized Shingles – localized lesions (< 2 dermatomes).
Disseminated Shingles – must be diagnosed by physician; very rare
Immunocompromised patients – those with cancer, especially leukemia and lymphoma; those with
HIV; those who have undergone bone marrow or solid organ transplantation; those who are taking
immunosuppressive medications, including steroids, chemotherapy, or transplant – related
immunosuppressive medications; patient status determined by the physician.
Healthcare Worker Exposure Contact – non immune staff that have had contact with a patient
with varicella who is not on Airborne/Contact Precautions.
Page 2
 Healthcare provider exposure: Contact WH&S 1-866-922-9464 or email

OHN@interiorhealth.ca.
 NOTE: Immune staff does NOT need to wear N95 respirator in patient room.
3.0 PROCEDURE
Precautions Infective Duration of Notify/ Comments

material Precautions
1. Chickenpox Airborne  Respiratory  Until all lesions  HCWs must be immune
(Varicella Zoster) Contact secretions + are crusted and  Non-immune HCW that
drainage from dry must enter room must
lesions wear N95 respirator
2. Shingles
(Herpes Zoster)
2a. Immunocompetent Routine Practice Drainage from
patient with: lesions
 Localized lesions
AND
 Lesions can be
covered with clothing
or dressing
2b. Immunocompetent Contact  Drainage from  Until all lesions

patient with:  All HCW must be immune
lesions are crusted and
 Localized lesions dry  HCW exposure: If non-
AND immune individuals are
 Lesions cannot be exposed to vesicular fluid
covered with a  Roommate should be
dressing immune to Chickenpox
2c. Immuno- Airborne  Drainage from  Until 72 hours of  HCWs must be immune
compromised Contact lesions and effective antiviral  Non-immune HCW that
patient with localized possibly treatment must enter room must
shingles respiratory OR wear N95 respirator
secretions  If untreated until
all lesions are
crusted & dry
Precautions Infective Duration of Notify/ Comments

material Precautions
Page 3
2d. Patient with Airborne  Drainage from Discontinue  HCWs must be immune
disseminated Contact lesions and precautions:  Non-immune HCW that
shingles possibly must enter room must
respiratory  72 hours after wear N95 respirator
secretions start of effective
antiviral therapy
AND
 No new lesions
appear
AND
 Existing lesions
are crusted and
dried
OR
 If untreated until
all lesions are
crusted and dry
4.0 Dermatomes – for a diagram of the levels of principal dermatomes
5.0 REFERENCES
4.1. B.C. Centre for Disease Control (BCCDC) Communicable Disease Manual – Varicella
Zoster; July 2004.
4.2. Alberta Health Services Infection Prevention and Control Manual 2012.
4.3. CDC Center for Disease Control and Prevention – Shingles (Herpes Zoster); 2012.
Section 08S – IS0700 (Invasive Group A Streptococcal Infections (IGAS)
Page 1

IS0700: Invasive Group A Streptococcal
Infections (IGAS) REVISED DATE: November 2010,
September 2014
REVIEWED DATE:
1.0 PURPOSE
To prevent transmission of Invasive Group A Streptococcal infections to patients and staff.

To provide guidance to staff on how to report a case of Invasive Group A Streptococcal Disease.
2.0 DEFINITION
Invasive Group A streptococcal (invasive GAS) disease is caused by Streptococcus pyogenes, a

gram-positive coccus. Certain strains of S. pyogenes are associated with severe invasive disease.
Clinical manifestation of severe invasive disease include: streptococcal toxic shock syndrome
(STSS), soft-tissue necrosis, including necrotizing fasciitis (NF), myositis or gangrene, meningitis,
pneumonia or death directly attributable to GAS infection. Case fatality rate overall is 15-20%.
Mortality is reduced by early diagnosis with surgical intervention for NF, antibiotic treatment and
supportive management.
Invasive GAS disease is confirmed through laboratory testing of specimens taken from normally
sterile sites.
2.1 Mode of transmission

 Primarily by large droplet contact of the oral or nasal mucous membranes with infectious
respiratory secretions or with exudates from wounds or skin lesions
 Or by direct or indirect contact with non-intact skin with exudates from skin or wound or
infectious respiratory secretions
 Transmission by contaminated equipment has rarely been reported
2.2 Incubation Period

 The incubation period for invasive GAS infection has not been determined
 The incubation period for non-invasive GAS infection is usually 1-3 days
2.3 Period of communicability

 In untreated cases 10 – 21 days
 Transmissibility generally ends within 24 hours of appropriate antibiotic therapy
 Evidence to date suggests the use of prophylaxis in close contacts may prevent severe
illness
2.4 Confirmed Case

 Laboratory confirmation of infection with or without clinical evidence of invasive disease
 Isolation of group A streptococcus (Streptococcus pyogenes) from a normally sterile site
(blood, cerebrospinal fluid (CSF), pleural fluid, pericardial fluid, peritoneal fluid, deep
tissue specimens taken during surgery [e.g. muscle collected during debridement of
necrotizing fasciitis], bone or joint fluid excluding the middle ear and superficial wound
aspirates [e.g. skin and soft tissue abscesses]).
Page 2
 When fetal demise occurs in association with a puerperal infection, isolation of group A
streptococcus from the placenta, amniotic fluid and/or endometrium is also considered
confirmatory for both the mother and the fetus.
2.5 Probable Case

 Streptococcal toxic shock syndrome (STSS) is characterized by hypotension (systolic
blood pressure of ≤ 90 mmHg in adults AND at least two of the following signs: renal
impairment, coagulopathy including disseminated intravascular coagulation, liver function
abnormality, adult respiratory distress syndrome (ARDS), or generalized erythematous
macular rash that may desquamate
 Necrotizing fasciitis (NF) is characterized by isolation of group A streptococci
(Streptococcus pyogenes) from a normally sterile body site or taken under sterile
conditions from deep tissue (aspirate) AND at least one of the following: histopathologic
diagnosis (tissue necrosis) or clinical diagnosis; gross fascial edema and necrosis
2.6 HCW Close Contact

 Exposure to the case during the period from 7 days prior to onset of symptoms in the
case to 24 hours after the case’s initiation of antibiotics
 HCWs who have had direct mucous membrane contact with the oral or nasal secretions
of a case (e.g. mouth-to-mouth resuscitation) or unprotected direct contact with an open
skin lesion of the case
 Chemoprophylaxis is indicated only for close contacts of cases presenting with clinical
evidence of severe invasive GAS disease
3.0 PROCEDURE

 Confirmed or suspected invasive cases must be placed on Droplet/Contact
Precautions.
3.2 Discontinuing Precautions

 Precautions may be discontinued after the patient has received 24 hours of appropriate
antimicrobial therapy.
3.3 Reporting
 Report case to Infection Control who will complete the Communicable Disease
Notification Tool (only available to Infection Control Practitioners)
 If Infection Control is not available then report case to the CD Unit (1-877-778-7736)
Monday to Friday 0830-1630 or the Medical Health Officer On-Call (1-866-457-5648)
after hours.
3.4 Management of Contacts

 Community contacts will be identified and followed up by the CD Unit – see BCCDC
guidelines.
 Chemoprophylaxis may be recommended for close contacts of severe invasive GAS
cases under the direction of the Medical Health Officer
 Healthcare workers may qualify for close contact chemoprophylaxis if Droplet/Contact
Precautions were not used during care of severe invasive GAS cases.
4.0 REFERENCE
Page 3
BC Centre for Disease Control Communicable Disease Control Manual. Invasive Group A
Streptococcal Disease. April 2014.
Section 08S – IS0800 (Meningococcal Infection)
Page 1
EFFECTIVE DATE: April 2009

IS0800: Meningococcal Infection
REVIEWED DATE:
1.0 PURPOSE
To prevent transmission of Meningococcal infection to patients and staff.
To provide guidance to staff on how to report a case of Meningococcal disease to Public Health.
2.0 DEFINITION
Meningococcal disease
Meningococcal disease is caused by the bacteria Neisseria meningitides (N. meningitides). The
bacteria can be found naturally in the throat or nose of 5-10% of the population, only rarely giving rise
to illness. However, when illness does occur, the infection can progress rapidly and is fatal in about 1
in 10 cases, striking young children and young adults most frequently.
The two most common presentations of invasive meningococcal disease are meningitis and
septicaemia.
The symptoms of meningococcal meningitis are identical to those of other forms of acute
bacterial meningitis. Signs of meningitis include sudden onset of fever, headache, and stiff neck.
Other symptoms frequently seen are nausea, vomiting, light sensitivity and altered mental status.
A petechial rash with pink macules may occasionally be observed.
Meningococcal septicaemia can occur with or without meningitis and may progress rapidly to
purpura fulminans (hypotension, fever and disseminated intravascular coagulation), shock and
death.
Less common presentations of meningococcal disease are purulent primary meningococcal

conjunctivitis and primary meningococcal pneumonia.
Infectious Period
 The incubation period is most commonly 3-4 days but can range from 2 to 10 days.
 Persons are communicable for 7 days prior to onset of symptoms until 24 hours after
initiation of appropriate antibiotic therapy.
Transmission
 Person to person spread occurs through direct contact with respiratory droplets from the
nose and throat of infected people.
Section 08S – IS0800 (Meningococcal Infection)
Page 2
3.0 PROCEDURE

 Confirmed or suspected cases must be placed on Droplet Precautions (Droplet/Contact
Precautions for pediatric patients).
 Gloves should be worn for contact with eye secretions of cases of primary meningococcal
conjunctivitis.

 Precautions may be discontinued after the patient has received 24 hours of appropriate
antimicrobial therapy.
3.3 Reporting
 Report case to Infection Control who will report case to Public Health.
 If Infection Control is not available then report case to Public Health via the CD Unit (1-866-
778-7736) Monday to Friday 0830-1630 or the Medical Health Officer On-Call (1-866-457-
5648) after hours.
 Contacts will be identified, notified of recommendations and provided direction regarding
medication distribution by Public Health.
 Chemoprophylaxis may be considered and is provided free of charge for close contacts of
invasive meningococcal disease and primary meningococcal conjunctivitis cases under
authorization of the Medical Health Officer.
 Chemoprophylaxis is only recommended for healthcare workers who have had intensive
unprotected contact (without wearing a mask or eye protection) with infected patients (i.e.
intubating, resuscitating, or closely examining the oropharynx) or unprotected contact with
the purulent discharge from the eye of a case of primary meningococcal conjunctivitis.
 Infection Control will ask Unit Managers to identify healthcare workers who meet the above
close contact definition with the patient since admission to 24 hours post treatment and
report these names to the Occupation Health Nurse Specialist for follow-up.
4.0 REFERENCES
4.1 Control of Communicable Disease Manual (19th edition). Heymann, D. (Ed). American
Public Health Association (2008).
4.2 Communicable Disease Control Manual. Meningococcal Disease. BC Centre for

Disease Control. February 2009.
Section 08S – IS0900 (Creutzfeldt-Jakob Disease)
Page 1

IS0900: Creutzfeldt-Jakob Disease
December 2012
REVIEWED DATE:
1.0 PURPOSE
To prevent the transmission of Creutzfeldt-Jakob Disease (CJD) to patients.
2.0 DEFINITION
Creutzfeldt-Jakob Disease (CJD) is an infection which causes progressive mental deterioration and
muscle weakness. It is often difficult to differentiate CJD from other forms of dementia. CJD is caused
by a small agent called a prion. Diagnosis is based on clinical signs, periodic EEG and brain material
histopathology. Confirmation of CJD does not usually occur until autopsy.
2.1. Infectious Period

 Incubation can be 6 months or as long as 30 years.
 There is no effective treatment.
 Patients are infectious throughout the symptomatic period.
2.2. Transmission
 CJD is not known to be spread person to person through routine direct or indirect contact.
Transmission has been documented via corneal transplantation, contaminated neurological
electrodes, dura mater grafts and injections of growth hormone or human pituitary gland
origin.
 Risk is higher in the Operating Room, Laboratory, CSSD and Autopsy Suite.
Infectious Materials Non-infectious Materials

CSF, brain, spinal cord and eye. Other Sweat, tears, saliva, stool and urine.
tissues that may be infectious and require Breast milk is also considered
cautious handling are lymph glands noninfectious.
kidney and lung.
3.0 PROCEDURE
3.1. When a patient is suspected of having CJD, notification shall be given to Infection Control
who will report case to Public Health. If Infection Control is not available then report case to
Public Health via the CD Unit (1-877-778-7736) Monday to Friday 0830-1630 or the Medical
Health Officer On-Call (1-866-457-5648) after hours.
3.2. Transfer of the patient to any other department requires notification of CJD status. This is
especially important for departments who will do invasive procedures - Imaging, O.R., morgue.
Section 08S – IS0900 (Creutzfeldt-Jakob Disease)
Page 2
3.3. As there is controversy about the effectiveness of sterilizing instruments used on CJD patients, a
minimum of reusable instruments should be used as they will need to be discarded following
use.
3.4. To control possible exposure:

 Restrict traffic and access to areas where a CJD patient is undergoing invasive procedures.
Use manual saws for craniotomies to decrease splatter and aerosolization.
 Double glove for surgery or autopsy. Hats, masks, eyewear, gowns and shoe covers should
also be used. Use disposable products and incinerate after using.
 No organs are to be procured for transplantation from patients with CJD. CJD patients may
not donate blood.
 All contaminated liquids, including rinse water and suctioned materials from surgery or
autopsy, must be retained and incinerated.
 Clearly label all specimens that are sent to the laboratory which are potentially infected with
CJD.
 Decontaminate all exposed surfaces with 1 Eq/L sodium hydroxide for 60 minutes. Rinse
thoroughly with water, then proceed with regular cleaning.
 All trash, needles and other disposables should be contained as biomedical waste.
4.0 REFERENCES
4.1. Creutzfeldt-Jakob Disease in Canada Quick Reference Guide 2007 - Public Health
Agency of Canada.
4.2. IH Surgical Services Practice Manual.
Section 08S – IS1000 (Respiratory Viruses)
Page 1
EFFECTIVE DATE: June 13, 2016

IS1000: Respiratory Viruses
(replaced RSV guideline) REVISED DATE:
REVIEWED DATE:
1.0 PURPOSE
To prevent transmission of respiratory viruses including Influenza, Parainfluenza, Respiratory

Syncytial Virus (RSV), Adenovirus, Human Metapneumovirus (hMPV), Coronavirus, Rhinovirus to
patients and staff.
2.0 DEFINITIONS
In general, respiratory viruses can cause acute upper respiratory tract infection in most people.
Lower respiratory tract infections are more common in children < 1 year old and in the elderly with
chronic pulmonary disease or functional disability.
Symptoms include:
 Acute onset of illness with a fever (>38C) and cough
 Sore throat
 Nasal congestion
 Malaise
 Chills
 Muscle/joint aches
 Headache
 Change in respiratory or mental status
**NOTE: In the elderly, fever may not be present

 Droplet transmission via direct contact with virus-containing secretions (i.e.) when
person coughs or sneezes
 Direct/indirect contact with virus-containing secretions on contaminated hands or
surfaces/equipment (viruses may persist on environmental surfaces for hours)
2.2 Incubation period

 Generally 1-3 days; varies depending on causative virus

 Generally 3-7 days from onset of symptoms
 Viral shedding may be longer in infants or immunocompromised persons
2.4 Diagnostic testing

 Nasal (or nasopharyngeal) swab or washings for respiratory virus
 Specimens should be collected from symptomatic persons within 48 to 72 hours of
onset of symptoms
Section 08S – IS1000 (Respiratory Viruses)
Page 2
3.1 Healthcare workers are rarely at risk for acquiring respiratory viruses when using Routine
Practices appropriately, including a point of care risk assessment (PCRA). When the PCRA
indicates a potential respiratory illness, then Droplet & Contact Precautions should be
implemented.
3.2 Watch carefully for other patients or healthcare workers with developing respiratory
symptoms. If unit transmission is suspected, notify the Infection Control Practitioner.
4.0 PROCEDURE

 Place on Droplet & Contact Precautions
 Staff to wear a surgical/procedure mask and eye protection when within 2 metres of
patient as well as gown and gloves for direct patient contact
4.2 Discontinuing Additional Precautions

 Based on the point of care risk assessment – if symptoms have resolved, Droplet
and Contact Precautions can be discontinued (up to 7 days from clinical onset in
young children and immunocompromised persons)
 For patients with Influenza who have been on antiviral treatment for 5 days, do a
point of care risk assessment – if symptoms have resolved, Droplet and Contact
Precautions can be discontinued
 Consult Infection Control Practitioner with questions or concerns
5.0 REFERENCES
5.1 Provincial Infection Control Network of British Columbia (PICNet BC). (February 2011).
Respiratory Infection Outbreak Guidelines for Healthcare Facilities.
https://www.picnet.ca/practice-guidelines
5.2 Centre for Disease Control and Prevention (July 2010) Interim guidance of Infection
Control Measures for H1N1 Influenza in Healthcare Settings, Including protection of
Healthcare Personnel http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm
5.3 Public Health Agency of Canada (2010) Respiratory Syncytial Virus http://www.phac-
aspc.gc.ca/lab-bio/res/psds-ftss/pneumovirus-eng.php
Section 08S – IS1100 (Rabies)
Page 1

IS1100: Rabies
REVIEWED DATE:
1.0 PURPOSE
To prevent transmission of Rabies to patients and staff.

To provide guidance to healthcare workers on how to report a case of rabies.
2.0 DEFINITION
Rabies is a preventable viral disease of mammals most often transmitted through the bite of a rabid
animal. The vast majority of rabies cases reported to the Centers for Disease Control and Prevention
(CDC) each year occur in wild animals like raccoons, skunks, bats, and foxes. Domestic animals
account for less than 10% of the reported rabies cases, with cats, cattle, and dogs most often
reported rabid.
Rabies virus infects the central nervous system, causing encephalopathy and ultimately death. Early
symptoms of rabies in humans are nonspecific, consisting of fever, headache, and general malaise.
As the disease progresses, neurological symptoms appear and may include insomnia, anxiety,
confusion, slight or partial paralysis, excitation, hallucinations, agitation, hypersalivation, difficulty
swallowing, and hydrophobia (fear of water). If vaccinations to prevent disease are not administered
before the onset of symptoms, death is almost certain.

 Depends on animal. Cats and dogs are infectious 3-7 days prior to symptoms.
2.2. Transmission
 Virus-laden saliva of rabid animal introduced through a scratch or bite. Person to Person
transmission is theoretically possible, but rare and not well documented. Organ transplants
of persons dying of undiagnosed CNS disease have lead to transmission of rabies.
3.0 PROCEDURE
3.1. Routine Practices only. No isolation required.
3.2. Reporting
 Contact Infection Control.
If Infection Control is not available then please contact Public Health.The Medical Health
Officer of Health must be notified as Rabies is a Reportable Communicable Disease.
REFER TO IS0100 – REPORTABLE COMMUNICABLE DISEASES
Section 08S – IS1100 (Rabies)
Page 2
3.3.Prophylaxis
 Please review the following BCCDC document.
4.0 REFERENCE
See B.C. Centre for Disease Control (BCCDC) for Rabies Protocol (July 2009):
Section 08S – IS1200 (Measles)
Page 1
EFFECTIVE DATE: February 2012

IS1200 Measles
REVISED DATE: December 2012
December 2014
REVIEWED DATE:
1.0 PURPOSE
To prevent transmission of measles to patients and staff.

To provide guidance to healthcare workers on how to report a case of measles.
2.0 DEFINITIONS
Measles (rubeola) is caused by a virus and is one of the most contagious of all infectious diseases,
with >90% attack rates among susceptible close contacts. Initial symptoms include 2-4 days of fever,
cough, runny nose and red inflamed eyes (prodromal period) followed by a maculopapular rash,
starting on the face and neck, spreading to the chest, arms and legs lasting at least 3 days. Koplik
spots may appear on the inside of the mouth.
Complications include ear infections, pneumonia and encephalitis (1 out of every 1000 cases) and
are most common in infants < 12 months of age. Measles during pregnancy results in a higher risk of
premature labor, spontaneous abortion and low birth weight infants.
In BC most clusters and outbreaks of measles occur in association with imported cases. BC has
experienced two larger outbreaks (2010 and 2014) in recent years, typically lasting not more than two
to three months.
Healthcare worker (HCW) contact identification – HCWs include students, physicians, facility
employees, emergency responders and others who were in a shared airspace with the case or for up
to 2 hours after the case left the room/space. All of these individuals should be assessed with
respect to their exposure.

 Airborne by aerosol and droplet spread, direct contact with nasal or throat secretions of
infected persons
 Less commonly spread by articles freshly soiled with nose and throat secretions

 Average is 8 – 12 days with a range of 7 – 18 days, rarely may be as long as 21 days

 From 1 – 2 days before the beginning of the prodromal period (usually about 4 days
before rash onset) to 4 days after rash appearance in a healthy person and for the
duration of measles illness in an immunocompromised person
2.4 Diagnostic testing - all specimens are sent to BCCDC for testing
 Virus detection in nasopharyngeal swab and urine
 Serology testing for measles specific IgM and IgG class antibodies
Page 2
3.1 Immune persons include the following:

 Birth date before January 1, 1970 (1957 for HCWs – these persons are assumed to have
acquired immunity to measles from natural infection. Those without a history of measles
disease should be considered susceptible and offered vaccine.
 Documented evidence of vaccination with 2 valid doses of live measles-containing
st
vaccine after their 1 birthday and given at least one month apart.
 Laboratory evidence of immunity
 Laboratory evidence of prior measles infection
3.2 A baseline assessment of all healthcare workers immunity and vaccination status against
measles needs to be done by WH&S.
3.3 Only immune healthcare workers should enter a room where airborne precautions are in
place for measles; an N95 respirator is not required.
3.4 An N95 respirator must be worn if non-immune health care providers are required to enter
the room of a patient with measles when there are no qualified immune healthcare providers
available and patient safety would be compromised if they did not provide care.
4.0 PROCEDURE

 Confirmed or suspect cases must be placed on Airborne Precautions – do not await
laboratory confirmation of the case

 Precautions may be discontinued 4 days after the onset of the rash in healthy individuals
 Precautions must remain in place for the duration of the illness in immunocompromised
patients
4.3 Reporting
 Investigate all clinically identified and laboratory reports of measles within 24 hours and
immediately notify the CD Unit (1-866-778-7736) Monday to Friday 0830-1630 or the
Medical Health Officer On-Call (1-866-457-5648) after hours
 Report case to Infection Control who will complete the Communicable Disease Notification
Tool (Available to Infection Prevention Control Practitioners only)
4.4 Management of Susceptible Exposed Patients

 Follow up exposed inpatients born after 1970 to ensure they have been immunized; all
other patients to be monitored for signs and symptoms of measles
 CD Unit to follow up with any patient contacts who have been discharged
4.5 Management of Susceptible Exposed Healthcare Worker

 Consider excluding HCW from any work in the health care setting from 5 days after the
first exposure to 21 days after the last exposure regardless of whether the HCW received
measles vaccine or immune globulin after the exposure
 Follow up provided by MHO and/or WH&S – See BCCDC guidelines
Page 3
4.6 Exclusion of Healthcare Worker Case of Measles

 Healthcare workers who are diagnosed with measles should be excluded from work for at
least four days after the onset of a rash
 Follow up provided by MHO and/or WH&S – See BCCDC guidelines
5.0 REFERENCE
5.1 BC Centre for Disease Control Communicable Disease Control Manual – Measles;
June 2014.
Section 08S – IS1300 (Mumps)
Page 1

IS1300 Mumps
REVISED DATE: December 2012
REVIEWED DATE:
1.0 PURPOSE
To provide guidance to staff on how to report a case of mumps to Public Health.
To prevent transmission of mumps to patients and staff.
2.0 DEFINITIONS
Mumps is a severe illness caused by the mumps virus. Mumps was previously a childhood disease
however, now it is more common in young adults. Symptoms include fever, aches and pains,
headaches and swelling of the salivary glands, especially in the parotid glands. Up to 1 in 5 people
do not have symptoms; however they can still spread the mumps virus to other people.
Complications of mumps includes painful swelling of the testicles in about 1:4 adult men and post-
pubertal boys and swelling of the ovaries in about 1:20 women – both of these conditions are
temporary and rarely result in permanent damage or sterility. Mumps can also cause temporary or
permanent deafness or serious illness such as encephalitis which can lead to convulsions or brain
damage. Mumps in early stages of pregnancy may increase the rate of miscarriage. Mumps do not
appear to cause birth defects.
Healthcare provider (staff) contact of a case of mumps – defined as individuals who have had
direct contact with oral/nasal secretions of an infectious case of mumps.
Prodomal period – the time during which the infectious process has begun but is not yet
clinically manifested by signs and symptoms.
WH&S - Workplace Health and Safety – provides the baseline assessment of all healthcare workers’
immunity and vaccination status and follow up in cases of an occupational exposure

 Usually 16-18 days to onset of prodromal signs and symptoms
 Symptoms can appear from 16-25 days after a person is infected with the mumps virus
 A person with mumps can spread the virus to others from 7 days before to 9 days after
symptoms develop.
2.2. Transmission
 Direct contact with saliva or respiratory droplets that are aerosolized from the nose or throat
 Spread through coughing, sneezing, sharing drinks, or kissing, or from contact with any surface
that has been contaminated with the mumps virus.
Page 2
2.3. Diagnostic testing

 Done by both serology and virus detection.
 Requires collection of both acute and convalescent serum specimens.
 If patient presents at ≤ 5 days after symptom onset, collect oral specimen.
 If patient presents at > 5 days after symptom onset, collect urine specimen.
 Buccal swab or saliva from the buccal cavity collected within the first 3 to 5 days of parotitis or
symptom onset is the preferred specimen.
 All specimens are sent to BCCDC for testing.
Mumps immunity is based on the following:

 Born prior to 1957 – considered immune.
 Born between 1957-1969 require only one dose of MMR.
 Born after 1970 – will receive two doses of MMR.
4.0 PROCEDURE

 Confirmed or suspect cases must be placed on Droplet Precautions – do not await
laboratory confirmation of the case.

o Precautions may be discontinued 9 days after the onset of parotid swelling.
4.3 Reporting
 Investigate all clinically identified and laboratory reported cases of mumps as soon as
possible and immediately notify the CD Unit (1-866-778-7736) Monday to Friday 0830-
1630 or the Medical Health Officer On-Call (1-866-457-5648) after hours
 Report case to Infection Control
 Infection Control will ask Unit Managers to identify staff who meet the contact definition
with the patient since admission and report these names to WH&S for follow-up
4.4 Management of Non-immune Healthcare Provider Contacts to a Case of Mumps

 Offer MMR vaccine to susceptible contacts who do not have a contraindication to the
vaccine.
 Although mumps immunization after exposure to mumps may not prevent the disease, it
is not harmful.
 Immune globulin is not recommended for mumps for post exposure prophylaxis
 Exclude the healthcare provider from the 10th day after the first exposure until the 26th
day (inclusive) after the last exposure to the case of mumps.
 Refer to WH&S for follow up and BCCDC guidelines
.
4.5 Management of Healthcare Provider (Staff) Cases of Mumps

 Healthcare providers who are diagnosed with mumps should be excluded from work
until at least five days after the onset of salivary gland swelling.
 This exclusion may be extended up to 9 days if the healthcare provider remains
symptomatic or if they work with vulnerable patients (e.g., immunocompromised).
 Staff working with immunocompromised or other vulnerable patients may be
reassigned to another area after day five, at the discretion of WH&S.
Page 3
 Prior to return to work the healthcare provider should contact WH&S to ensure they are not
longer contagious.
5.0 REFERENCE
5.1 Communicable Disease Control Manual - Mumps. BC Centre for Disease Control Interim
June 2011.
Section IS1400 – Bed Bugs
Page 1
IS1400 Bed Bugs EFFECTIVE DATE: December 2012
REVISED DATE:
REVIEWED DATE:
6.0 PURPOSE
To prevent transmission of bedbugs to patients and staff.
7.0 DEFINITIONS
Bed bug – is a small reddish brown oval shaped insect with a flattened
body. The size is 5-7mm long or the size of a lady bug. Bed bugs are
classified as blood-sucking parasites on warm-blooded hosts.
Bed bugs ARE NOT ASSOCIATED with the transmission of human disease.
8.1 Background Information:

 For the past fifty years, bed bugs were a relative rarity amongst pest control professionals. In
the last five years, bed bugs have been increasingly encountered in homes, apartments,
hotels, motels, dormitories, shelters and modes of transport. As such, they are occasionally
transported into hospital and other health care environments.
 Bed bugs have not been linked to the transmission of any disease and are not regarded as a
medical threat.
8.2 Biological Information:

 Hide in cracks and crevices during the day and come out at night to feed.
 Require blood meal for development.
 Typical life span between 6 to 12 months.
 Extreme heat (approx 45 degrees C) or cold is lethal – heat is more effective.
 Cannot fly but can crawl quickly over floors, walls and ceilings. They also hitch rides on
clothing, furniture, purses and luggage.
8.3 Signs of Infestation:

 If bed bugs are present there will be dark spotting and staining on sheets, mattresses, pillows
and carpets.
 With severe infestations there will be a sweet musty odour.
 Bed bugs usually bite people at night on any exposed skin – bite marks are typically raised
welts or localized swelling while others have no reaction at all.
 Lesions are often itchy and remain itchy for weeks.
 Main concern is the risk of secondary infection from scratching the lesions.
 It is important to recognize that not all bites or bite-like reactions are due to bed bugs.
Confirmation requires finding and identifying the bugs themselves.
Page 2
9.0 PROCEDURE
9.1 Acute Care – if a bed bug infestation is suspected:

 Obtain a specimen if possible.
 Place patient on Contact Precautions.

REFER TO IH0400 CONTACT PRECAUTIONS
 Contain patient possessions and

potentially infested items in sealed
plastic bags – label and ensure separation from clean items.
Patients should be instructed NOT to remove any belongings from sealed bags.
 Instruct family to wash and dry washable items using high temperature.
 Continue with routine cleaning and disinfection procedures. If any visible bedbugs noted in
the vicinity of the patient, wipe the area with a damp paper towel and discard in the garbage.
Seal the garbage bag and discard.
 For patients in the Emergency Department who have suspected bed bugs and require
transfer to a unit, place that patient in a private room if possible until the source of the bug is
confirmed and treatment is complete.
 Any decision to treat a room, evacuate a room or replace equipment will be made in
consultation with the unit staff involved, the unit leader, Housekeeping, Pest Control and
Infection Control as required and recommendations made on how to proceed will be
communicated with stakeholders.
 A physician assessment can determine whether antihistamines and corticosteroids may be
prescribed to reduce allergic reactions, and antiseptic or antibiotic ointments to prevent
infection.
 Infestations also may cause anxiety, embarrassment, and loss of sleep.
4.2. Residential Care

 Train healthcare providers to look for bites on residents and talk to family members.
 Train environmental and housekeeping staff on what to look for during routine
cleaning/maintenance.
 If a bed bug infestation is suspected follow Acute Care information above.
4.3 Client Homes

 Wearing light coloured clothing will assist in easier detection of bedbugs. Avoid pants with
cuffs.
 Limit work items being brought into a client’s home. Only bring in what is essential.
 Store work items in a pest proof bag or container that items will remain bug free in. If none
are available, consider hanging your items rather than placing on furnishings.
 Utilize Routine Practice Guidelines. If providing direct care, consider wearing a gown if there
is heavy infestation.
Page 3
 Equipment used on the client should be placed in a sealed bag and returned to the unit for
cleaning.
 Inspect clothing and equipment for bedbugs after visit and remove any stragglers.
4.4 Community Office

 Utilize Routine Practice Guidelines. If you suspect heavy infestation of bedbugs, wear gloves
and a gown to protect clothing.
 Place all personal belongings in a pest proof container during the visit. Backpacks and bags
are thought to be a means for transport of bedbugs. Clean the container with a moistened
paper towel and discard into the garbage. If any bedbugs are left in the container, shake into
the toilet and flush.
 Ideally the floor and chair should be a smooth surface and lightly coloured.
 Clean and disinfect equipment, stretcher, exam tables as per usual routine.
 If you see bedbugs crawling on the floor, vacuum up the bedbugs and immediately dispose
of the contents. If you use a dustpan and brush, transport the bedbugs to the toilet in a pest
proof container and dispose of in toilet. Store the brush in a pest proof container.
4.5 Staff
 Contact Workplace Health and Safety if symptomatic.
10.0 REFERENCES
10.1 Providence Health Care Nursing Care Standards. 2007; Bed Bugs Protocol.
10.2 Vancouver Costal Health (VCH) - BED BUGS - VCH STAFF INFORMATION SHEET.
10.3 Vancouver Island Health Authority (VIHA) Infection Prevention & Control Manual.
2009; Bed Bug Infestation pg 78 – 79.
Section IS1500 – Pertussis
Page 1
EFFECTIVE DATE: June 13, 2016

IS1500 Pertussis
REVISED DATE:
REVIEWED DATE:
1.0 PURPOSE
To prevent transmission of pertussis to patients and staff.

To provide guidance to healthcare workers on how to report a case of pertussis.
2.0 DEFINITIONS
Pertussis is an acute and prolonged infectious cough illness caused by Bordetella pertussis, a gram-
negative bacterium. The duration of pertussis illness is usually 6 to 10 weeks in children. The clinical
course of pertussis is divided into 3 stages:
 Catarrhal stage (lasts 1 – 2 weeks); symptoms indistinguishable from a respiratory tract
infection; intermittent cough becomes paroxysmal
 Paroxysmal stage (usually lasts 1 – 6 weeks but may persist for up to 10 weeks); individual
has repeated bursts or paroxysms of numerous, rapid coughs that follow each other without
inspiration and may end with an inspiratory “whoop” and may be followed with mucous
production and vomiting
 Convalescent stage (lasts 2 – 6 weeks or longer); recovery is gradual with a paroxysmal
cough subsiding and decreasing frequency of coughing bouts
The most common complication of pertussis is secondary bacterial pneumonia.
Pertussis is highly infectious – the secondary attack rate exceeds 80% among susceptible persons.
Neither vaccination nor natural disease confers complete or lifelong protective immunity against
pertussis or re-infection.
The highest incidence of pertussis generally occurs in infants < one year of age.
Pertussis demonstrates cyclical peaks every three to five years.
Chemoprophylaxis – Purpose is to prevent disease in susceptible high-risk individuals exposed to a

case of pertussis and to decrease transmission to high-risk individuals. Chemoprophylaxis with
appropriate antibiotics eliminates B. pertussis from the nasopharynx of infected individuals.
Chemoprophylactic treatment of all high-risk contacts (regardless of immunization status and whether
they have symptoms) is recommended because immunization provides only partial protection and
immunized people can still harbour and transmit B. pertussis.
Contact Identification – Identify contacts that had the following types of contact with the case during
the period of communicability:
 High risk contacts – that had the following types of contact with the case during the period
of communicability: face-to-face contact > 5 minutes; shared the same confined air space for
> 1 hour; or direct contact with respiratory secretions of the infected person:
o Infants < 1 year of age
rd
o Pregnant women in the 3 trimester
o All household or family daycare contacts IF there is an infant < 1 year of age or
rd
pregnant woman in 3 trimester in household or daycare
Page 2

 Transmitted from an infected person to susceptible persons, primarily through
aerosolized droplets of respiratory secretions or by direct contact with respiratory
secretions from the infected person

 Averages 7 – 10 days (range: 5 – 21 days)
 The infectious period is reduced to 5 days after the start of antibiotics

 Extends from the beginning of the catarrhal stage (one to two weeks before the onset of
paroxysmal coughing) to three weeks after the onset of the paroxysmal cough
2.4 Diagnostic testing

 Bacterial detection in nasopharyngeal swab
3.1 Follow BCCDC guidelines regarding chemoprophylaxis for contacts.
3.2 Chemoprophylaxis should be started as soon as possible - it may prevent contacts from
developing disease when it is given to contacts no later than 21 days after the contact's first
exposure to the case during the time the case was infectious.
3.3 Immunization following recent exposure is not effective against infection but will provide
protection if subsequent exposure occurs.
3.4 Exclusion of contacts from any setting is not indicated.
3.5 During community outbreaks, notification will be sent out to Infection Control Practitioners
(ICPs) by the CD Unit/MHO; ICPs will then notify hospital emergency rooms to heighten
awareness of potential pertussis cases.
4.0 PROCEDURE

 Confirmed or suspect cases must be placed on Droplet Precautions – do not await
laboratory confirmation of the case

 Until 5 days of appropriate antimicrobial therapy received
 3 weeks after onset of paroxysms if not treated
4.3 Reporting requirements for patients seen in hospital including Emergency

 Report high risk contacts, including infants < 1 year old and pregnant women in their 3
rd
trimester, of all lab-confirmed or probable pertussis cases to the CD Unit (1-866-778-

7736) Monday to Friday 0830-1630 or the Medical Health Office On-Call (1-866-457-
5648) after hours
 Notify ICP and Infection Prevention & Control (IPAC) Medical Director or designate; ICP
will complete Communicable Disease Notification Tool
Page 3
4.4 Management of Pertussis Case and Contacts

 CD Unit will notify ICP if they are aware of any high risk contacts (including infants < 1
year of age or pregnant women in the 3rd trimester) and/or if the pertussis case is
admitted to hospital
 Patient admitted to hospital including Emergency Department:
o Contact tracing for admitted patient contacts done by ICP using Insight Contact
Tracing Report and reviewed with the IPAC Medical Director or designate - MHO
consulted at the discretion of IPAC Medical Director or designate
o If necessary, ICP will utilize a multidisciplinary team to determine management
of patient case and contacts; team consists of Medical Health Officer (MHO),
IPAC Medical Director or designate, ICP, nursing unit manager and others as
required
o Follow up of community contacts provided by MHO/CD Unit
o Follow up of staff contacts provided by Workplace Health and Safety (WH&S)
o Follow up of the index patient (if still admitted) and patient contacts who
remain hospitalized will be done by the Most Responsible Physician under the
direction of the IPAC Medical Director and CD Unit as required
 Patient Discharged from Emergency Department when Pertussis result becomes
available:
o ICP will complete the Communicable Disease Notification Tool
o Follow up of index patient and community contacts provided by MHO/CD
Unit
o Follow up of staff contacts provided by WH&S
o Contact tracing for admitted patient contacts done by ICP using Insight Contact
Tracing Report and reviewed with the IPAC Medical Director or designate - MHO
consulted at the discretion of IPAC Medical Director or designate
o Follow up of patient contacts who remain hospitalized will be done by the
Most Responsible Physician under the direction of the IPAC Medical Director
5.0 REFERENCES
5.1 BC Centre for Disease Control Communicable Disease Control Manual – Pertussis;
June 2010.
http://www.bccdc.ca/NR/rdonlyres/FEC42ABA-A725-4AD4-AE08-
893234733BEA/0/EPI_Guideline_CDChapt1Pertussis_20100625.pdf
Section 09V - IV0100 (Surveillance for Healthcare Associated Infections)
Page 1

IV0100: Surveillance for Healthcare
Associated Infections REVISED DATE: November 2010
REVIEWED DATE:
1.0 PURPOSE
To reduce the occurrence of healthcare associated infections across the continuum of care (acute,
residential, community) and monitor the effectiveness of the infection prevention and control program.
2.0 DEFINITIONS
Community-Acquired Infections – infections present or incubating at the time of admission and with no
association to a recent hospitalization.
Denominator – the population at risk of acquiring a specific infection.
Device-associated Infection Rates – a rate of infection associated with exposure to a medical device,
such as a ventilator, central venous catheter or indwelling urinary catheter.
Epidemiology – the study of the frequency, distribution, cause and control of disease in populations that
forms the background for interventions to reduce transmission of infecting organisms, reduce the number
of HAIs and protect healthcare providers from infection.
Healthcare Associated Infections (HAIs) – infections that are not present or incubating at the time of
admission to the facility or program but are associated with admission to or a procedure performed in a
healthcare facility or program.
Surveillance – the comprehensive ongoing systematic collection, analysis and interpretation of outcome-
specific data for use in planning, implementing and evaluating healthcare practices closely integrated
with the timely dissemination of this data to those who need it
3.1 Surveillance activities identify risk factors for infection and other adverse events, implementation of
risk reduction strategies and monitor the effectiveness of the interventions.
3.2 HAIs are a major and continuing challenge in hospitals and residential care homes. It is estimated
that 220,000 infections are acquired in hospitals each year in Canada, resulting in 8,000 deaths.
3.3 It is estimated that between 30% and 50% of HAIs are preventable. Therefore, an infection
prevention and control program that is effective in preventing HAIs can substantially reduce
healthcare costs and, more importantly, the morbidity and mortality associated with HAIs. The
ultimate goal of surveillance is to have zero HAIs (while recognizing that not all HAIs are
preventable).
Section 09V - IV0100 (Surveillance for Healthcare Associated Infections)
Page 2
3.4 The use of surveillance data does not only measure clinical outcomes such as infections, but also
guides performance improvement activities and demonstrates improvements in both clinical
outcomes and healthcare practices.
3.5 HAIs are expressed as a rate, (e.g.) the number of persons at risk over a particular period of time.
Three elements are required to generate these HAI rates:
 the number of cases (i.e. persons developing a particular infection);
 the number of persons at risk (i.e. population at risk for development of that infection);
 the time period involved.
3.6 It is a recommended practice to adjust rates of HAIs for patient length of stay by using the number of
patient days as the denominator, rather than number of admissions or number of beds.
3.7 It is a recommended best practice to calculate rates of device associated infection that are adjusted
for duration of exposure to the device.
4.0 PROCEDURE
4.1 Surveillance for HAIs is an Interior Health wide program that is carried out by trained infection
prevention and control practitioners (ICP).
4.2 A computerized surveillance system is in place to track potential infection cases across the
continuum of care. In Acute Care settings, the system identifies potential infection cases based
on predetermined HAI case definitions.
REFER TO IV0200 – DEFINITIONS FOR HEALTHCARE ASSOCIATED INFECTIONS
4.3 In Residential and Community Care settings, ICPs collect data based on predetermined HAI case
definitions and enter the data into the computerized surveillance program.
REFER TO IV0200 – DEFINITIONS FOR HEALTHCARE ASSOCIATED INFECTIONS
4.4 Standardized electronic reports are generated on a regular basis and reviewed at site specific and
corporate Infection Control Committees. Analysis and interpretation of infection data may be
done with the facility’s Infection Prevention and Control Committee or other advisory body to the
Infection Control Team. Information is also disseminated to additional stakeholders with the
ability to change infection prevention and control practice.
5.0 REFERENCES
5.1 APIC Text 2009
5.2 Best Practices for Surveillance of Healthcare Associated Infections in Patient and
Resident Populations. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario;
October 2011.
5.3 CDC/NHSN surveillance definition of health care–associated infection and criteria for specific
types of infections in the acute care setting; American Journal of Infection Control; 2008.
Section 09V - IV0200 (Definitions for Healthcare Associated Infections)
Page 1

IV0200: Definitions for Healthcare REVISED DATE: November 2010
Associated Infections December 2012, July 2014
REVIEWED DATE:
1.0 PURPOSE
Using standardized case definitions for Healthcare Associated Infections (HAI) provides opportunity
for generating surveillance data that can be compared to or pooled with other similar facilities and
settings using the same case definitions with the intent to improve patient outcomes.
2.0 DEFINITION
Case definitions for Acute Care – standardized definitions for each HAI based on the CDC/NHSN
(National Healthcare Safety Network) definitions and the Provincial Infection Control Network
(PICNet) of British Columbia definitions and allows for comparability of findings and benchmarking
with other similar hospitals.
Catheter
Case definitions for Residential Care – standardized definitions for each HAI that have been
developed based on The McGeer Criteria in addition to consensus opinions from infectious disease
physicians, epidemiologists, infection prevention and control professionals, geriatricians and public
health officials and is specifically aimed at persons living in Residential Care facilities.
Device-associated Infection Rates – a rate of infection associated with exposure to a medical

device, such as a ventilator, central venous catheter or indwelling urinary catheter.
3.1 To establish priorities for an HAI surveillance system, consideration must be taken for the
types of patients/residents that it serves, the key medical interventions and procedures that
they undergo and the types of infections for which they are most at risk for.
3.2 When defining HAIs, consider the frequency of the infection, the impact of the infection
(including case fatality and excess costs associated with the infection) and the preventability
of the infection. The outcomes selected for surveillance should be re-evaluated at least
annually.
3.3 Syndromic surveillance of respiratory infections and gastrointestinal infections should be

undertaken in all hospitals and residential care facilities.
3.4 In Acute Care when a particular infection meets a case definition, it should only be
considered health care associated if:
 It was not present or incubating when the patient was admitted to the hospital;
 The infection does not represent a complication or extension of an infectious process that
was present at admission;
Page 2
 The infection occurred more than 48 to 72 hours after admission, and within 10 days
following discharge or longer if it is related to a surgical procedure, a Clostridium difficile
infection or an antibiotic resistant organism.
3.5 In Residential Care, in order for an infection to be considered healthcare associated

 There must be no evidence that the infection was present on admission to the facility or
readmission (following hospitalization or community visit);
 There must be no evidence that the infection resulted from a procedure performed at an
acute care hospital or in a physician’s office;
 Where residents regularly attend day programs or other activities in the community and
there is uncertainty about whether the infection occurred in community or the residential
care home, the case should be counted as an HAI.
4.0 PROCEDURE
4.1 Surgical Site Infections (SSIs) Definitions

An infection involving the surgical site within 30 days of the procedure, or within 90 days
(previously 365) if an implant is in place and the infection is related to the operative
procedure. There are 3 categories of SSIs:
4.1.1 Superficial Incisional Infection – occurs within 30 days of procedure and involves
only skin and subcutaneous tissue of incision.
Patient has at least 1 of the following:
1. Purulent drainage from superficial incision
2. Organisms isolated from aseptically-obtained culture of fluid or tissue from
superficial incision
3. Superficial incision that is deliberately opened by a surgeon and is culture-
positive or not cultured. (A culture negative finding does not meet criterion.)
AND Patient has at least 1 of the following S&S: - Pain or tenderness -
Localized swelling - redness – heat
4. Diagnosis of SSI by surgeon or attending MD
4.1.2 Deep Incisional Infection - occurs within 30 or 90 days of surgery and has implant if
after the 30 days and involves deep soft tissues of incision (i.e. fascial and muscle
layers)
1. Purulent drainage from deep incision
2. Deep incision that spontaneously dehisces or deliberately opened by
surgeon & is culture positive or not cultured. (A culture negative finding does
not meet criterion.) AND patient has at least 1 of the following S&S: - fever
(>38°C) - localized pain or tenderness
3. Abscess or other evidence of infection involving deep incision found on direct
exam, during invasive procedure, or by histopathologic exam or imaging test
4.1.3 Organ/Space Surgical Site Infection - occurs within 30 or 90 days of surgery

& has implant if after the 30 days & involves any part of the body excluding the skin
incision, fascia or muscle layers, that is opened or manipulated during the operative
procedure
1. Purulent drainage from drain that is placed into the organ/space
2. Organism isolated from an aseptically-obtained culture of fluid or tissue in the
organ/space
Page 3
3. Abscess or other evidence of infection involving organ/space found on direct

exam, during invasive procedure, or by histopathologic exam or imaging test
4.2 Clostridium difficile Infection (CDI) Definition

The presence of diarrhea or toxic megacolon AND positive CDI result OR diagnosis of
pseudo-membranous colitis OR histological/pathological diagnosis of CDI with or without
diarrhea And the following:
4.2.1 Criteria for New CDI Associated with YOUR Facility

1. Symptoms onset > 72 hours after admission OR
2. Symptoms onset in the community or occurring ≤ 72 hours after admission
AND - Pt was admitted for a period of at least overnight (≥24 hours) in the
past 4 weeks before hospitalization AND - Symptoms onset was less than 4
weeks after the last discharge from your facility
4.2.2 Criteria for New CDI associated with OTHER Healthcare Facility
1. Symptoms onset in community or occurring ≤ 72 hours after admission to
your facility AND
Pt was admitted to another healthcare facility (including acute/ LTC) for at
least overnight (or ≥24 hours) in past 4 weeks before current hospitalization
AND
Symptom onset was less than 4 weeks after discharge from that facility with
another facility
4.2.3 Relapse of CDI

 A CDI case (as defined above) with recurrence of diarrhea between 2 – 8
weeks after previous CDI case
 CDI identified less than 2 weeks after previous episode is considered to be a
continuation of previous CDI case
4.2.4 Community Associated

 A CDI case (as defined above) with symptom onset in the community or ≤ 72
hours after admission to a healthcare facility, provided the patient was not
admitted to any healthcare facility (including acute care and long-term care)
for ≥ 24 hours in the past 4 weeks before onset of CDI symptoms
4.3 Antibiotic Resistant Organisms (AROs) Definition

AROs include Methicillin Resistant Staphylococcus Aureus (MRSA), Vancomycin Resistant
Enterococcus (VRE), Extended Spectrum Beta-lactamase (ESBL)
4.3.1 Criteria for Healthcare associated with current admission to Your Facility
1. Not previously positive for ARO AND
Identified > 48 hours after patient admitted to your facility Or Newborn
4.3.2 Criteria for Healthcare associated with previous encounter with Your
Facility
Not previously positive for ARO AND identified ≥48 hours after admission and meets
one criteria:
1. Admitted to your facility at least over night (≥24 hours) within the last 12
months OR
2. Indwelling catheters or medical device at time of admission, which was
inserted by your facility OR
Page 4
3. Documented weekly visits to outpatient clinic (i.e. dialysis, oncology) in your

facility in the last 12 months
4.3.3 Criteria for Healthcare associated with Another Facility

Not previously positive for ARO AND identified ≤ 48 hours after admission and meets
one criteria:
1. Any contact with another healthcare facility as inpatient (acute/LTC) or as
outpatient (dialysis/oncology) within the last 12 months OR
2. Indwelling catheters or medical device at time of admission, which was
inserted by another facility
4.3.4 Community Associated

Any case without documented history of healthcare exposure including admission to
acute care, LTC or rehab, weekly visits to an outpatient clinic (dialysis, oncology, i.e.
use of indwelling catheter or other medical device)
Newborn: Less than 28 days considered case for Your Facility if the mother was not
known or suspected to be ARO positive on admission. In the case of a newborn
transferred from another facility and ARO identified ≤ 48 hours after admission the case
is classified as healthcare associated with Another Facility
Multiple Encounters: If a patient has multiple encounters with different healthcare

facilities in the last 12 months the classification of ARO will be based on the most recent
encounter
4.4 Ventilator Associated Pneumonia (VAP) – includes the classifications of both Possible and
Probable VAPs
 On a ventilator ≥ 3 days and > 14 days since last Ventilator Associated Condition (VAC)
(VAC - After a period of stability or improvement of 2 or more days, requires one of
the following: 1. Increase FIO2 of ≥ 20 points for ≥ 2 days
2. Increase in PEEP ≥ 3cm for ≥ 2 days)
 Within window period (2 days before + 2 days after VAC date – 5 days total) meets
BOTH Criteria:
1. Has a temp>38 ̊ C or <36 ͦ C OR white blood cell count ≥12.0 x 10⁹/l or 4.0 x 10⁹/l
AND
2. A new antimicrobial agent(s) is started and continued for ≥ 4 days
AND
 Within window period meets ONE of the following criteria:
1. Purulent respiratory secretions (1 or more specimens) defined as gram stain of
4+ WBC & 1 to 2+ epithelial cells
2. Positive culture of sputum endotracheal aspirate, BAL, lung tissue or protected
specimen brushing
AND
the organism is NOT excluded: “Normal respiratory flora,” “normal oral
flora,” mixed respiratory flora,” “mixed oral flora,” “altered oral flora” or
other commensal flora of the oral cavity or upper respiratory tract:
Candida species or yeast not otherwise specified; coagulase-negative
Staphylococcus species; and Enterococcus species, when isolated from
cultures of sputum, endotracheal aspirates, bronchoalveolar lavage, or
protected specimen brushings
OR
Page 5
Excluded organisms isolated from cultures of lung tissue or pleural fluid

including Candida species or yeast not otherwise specified, coagulase-
negative Staphylococcus species or Enterococcus species
OR
Test result meets one of the following criteria:
- Positive pleural fluid culture (from thoracentesis or initial placement of chest
tube)
- OR Positive lung histopathology
- OR Positive diagnostic test for legionella spp
- OR Positive diagnostic test for respiratory viruses
4.5 Central Line Associated Bloodstream Infection (CLABSI) Definition – surveillance

restricted to Intensive Care Unit (ICU) patients who:
 Have a central line in place > 2 calendar days OR central line has been discontinued
for < 3 calendar days AND
 There is a pathogen in 1 or more blood cultures AND infection is not suspected at
another site AND all elements of lab confirmed blood stream infection first present
together on or after the 3rd hospital day AND
 Patient has at least 1 of the following : -- Fever >38°C -- OR chills -- OR
hypotension (systolic <90) AND positive lab results that are not related to an infection
at another site AND common commensal is cultured from 2 or more blood cultures,
drawn on separate occasions AND criteria elements occurred within a timeframe that
does not exceed a gap of 1 calendar day AND all elements of lab confirmed blood
stream infection first present together on or after the 3rd hospital day
 Central line: An intravascular catheter that terminates at or close to the heart or in
one of the great vessels and is used for infusion, withdrawal of blood, or
hemodynamic monitoring.
 PICC line: a peripherally inserted central catheter is inserted in a peripheral vein and
then advanced through increasingly larger veins toward the heart until the tip rests in
the distal superior vena cava, is considered a central line.
 Non-lumened devices inserted into central blood vessels or the heart (i.e.
pacemaker) are not considered central lines if fluids are not infused, pushed or
withdrawn through the device.
4.6 Lower Respiratory Tract Infection (LRI) / Pneumonia Definition in Residential Care
Review chart to rule out other conditions that could account for symptoms (CHF, COPD)
For an LRI:
Are there TWO or more Signs & Symptoms:
 new or increased cough
 new or increased sputum production
 oxygen saturation < 94% or <3% from baseline
 abnormal lung exam new or changed
 pleuritic chest pain
 respiratory rate > 25 breaths/min
AND
 Is there 1 or more constitutional criteria: fever, leukocytosis, confusion or
functional decline?
For a Pneumonia:
Does the chest x-ray indicate pneumonia?
AND
Are there ONE or more Signs & Symptoms:
Page 6
 new or increased cough

 new or increased sputum production
 oxygen saturation < 94% or <3% from baseline
 abnormal lung exam new or changed
 pleuritic chest pain
 respiratory rate > 25 breaths/min
AND
Is there 1 or more constitutional criteria: fever, leukocytosis, confusion or functional
decline?
4.7 Skin & Soft Tissue Infection (SSTI) Definition in Residential Care
Criteria: Must have ONE of the following:
 Pus present at a wound, skin, or soft tissue site OR
 Are there FOUR or more signs and symptoms:
- serous drainage at site
- site swelling
- heat at site
- site tenderness or pain
- site redness
- one constitutional criteria : fever, leukocytosis, confusion, acute functional
decline?
 Was the wound secondary to an injury?
4.8 Catheter Associated Urinary Tract Infection (CAUTI) in Residential Care

Criteria: Resident must have indwelling urinary catheter and at least ONE of the following:
 Fevers, rigors OR new onset hypotension with NO alternate sign of infection
 Acute change in mental status OR functional decline with no alternate diagnosis
AND leukocytosis (WBC > 14,000)
 New onset suprapubic pain or costoverterbral angle pain or tenderness
 purulent discharge around catheter or acute pain, swelling of testes, epididymis or
prostate
AND
 Urine culture (> 10⁶ CFU/ml) correlates with symptoms
OR
 Positive blood culture & urine culture with same organism with no alternate site of
infection
 Fever (>38C) or chills, new flank or supra-pubic pain or tenderness, change in
character of infection
5.0 REFERENCES
5.1. CDI Surveillance Protocol – Provincial Infection Control Network (PICNet) BC, June 2014.
5.2. MRSA Surveillance Protocol – Provincial Infection Control Network (PICNet) BC, June
2014.
5.3. CDC/NHSN surveillance definition of healthcare associated infection and criteria for
specific types of infections in the acute care setting; 2013.
Page 7
5.4. Stone, Nimalie D. et. al. Surveillance Definitions of Infections in Long-Term Care
Facilities; Revisiting the McGeer Criteria. Infection Control and Hospital Epidemiology,
Vol. 33, No. 10 (October 2012), pp. 965-977.
Section 09V - IV0300 (Surgical Site Infections -SSIs)
Page 1

IV0300: Surgical Site Infections (SSIs)
REVISED DATE: November 2010, July 2014
June 2016
REVIEWED DATE:
1.0 PURPOSE
To identify the potential risks associated with surgical procedures and Surgical Site Infections (SSIs)
and include this information in the risk stratification and data analysis of SSIs with the intent to
improve patient outcomes.
2.0 DEFINITIONS
SSIs – Surgical Site Infections occur as a complex interaction between the microbial contamination
of the surgical site, the host response, and the local environment at the site of contamination. An SSI
is generally considered to be present when purulent drainage is identified at the surgical site. SSI
rates are the percentage of surgical operative sites that are infected and are usually stratified based
on the Surgical Wound Classification.
Surgical Wound Classification – a system of categorizing surgical procedures into risk groups
based on the likelihood of contamination of the surgical site at the time of the operative procedure.
Each operative wound is assessed and categorized as per the classes noted below
and is to be done upon completion of the surgery in consultation with the surgeon.
If a change in wound classification occurs, the reason must be documented on the OR Case Record
(i.e. gross break in technique, glove perforation, etc.).
The four classes of wounds include:
Clean Wounds (Class I) – uninfected operative wound in which no inflammation is encountered,

involve access only to the sterile body sites and carry the lowest risk (e.g. less than 5%) of surgical
site infection. Clean wounds are primarily closed and, if necessary, drained with closed drainage.
Operative incision wounds that follow non-penetrating (blunt) trauma should be included in this
category if they meet the criteria. There is no break in sterile technique
Clean-Contaminated Wounds (Class II) – an operative wound in which the respiratory, alimentary,
genital or urinary tracts are entered under controlled conditions and without unusual contamination.
A minor break in surgical sterile technique in an otherwise clean procedure would fit into this class.
Operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category,
provided no evidence of infection or major break in technique is encountered.
Contaminated Wounds (Class III) – carry a high risk (e.g. 10 to 15%) of infection often because
they involve unusual contamination from a non-sterile site. Examples include:
 Open, fresh, accidental wounds less than 8 hours old from a relatively clean source
 Gross spillage from the gastrointestinal tract
 Incisions in which acute, non-purulent inflammation is encountered
 Acute inflammation seen – without frank pus
Page 2
 The GU or biliary tracts are entered in the presence of infected bile or urine
 Operations with major breaks in sterile technique
 Examples of major breaks in sterile technique include: open cardiac massage, gross
spillage from the GI tract, use of unsterile instruments, drapes or supplies,
perspiration in the wound, unsterile foreign bodies in the wound, and insects in the
OR suite.
Dirty or Infected Wounds (Class IV) – Old traumatic wounds (over 12 hours) with retained
devitalized tissue or wounds where there is an existing clinical infection or perforated viscera or
fecal contamination.
Surgical Site Infection surveillance definitions include the following:
Superficial Incisional Infection – occurs within 30 days of procedure and involves only skin and
subcutaneous tissue of incision.
1. Purulent drainage from superficial incision
2. Organisms isolated from aseptically-obtained culture of fluid or tissue from superficial
incision
3. Superficial incision that is deliberately opened by a surgeon and is culture-positive or not
cultured. (A culture negative finding does not meet criterion.) AND Patient has at least 1
of the following S&S: - pain or tenderness - localized swelling - redness - heat
Deep Incisional Infection – [occurs within 30 or 90 days of surgery and has implant if after the 30
days] and involves deep soft tissues of incision (i.e. fascial and muscle layers)
1. Purulent drainage from deep incision
2. Deep incision that spontaneously dehisces or deliberately opened by surgeon & is culture
positive or not cultured. (A culture negative finding does not meet criterion.) AND Patient
has at least 1 of the following S&S: - fever (>38°C) - localized pain or tenderness
3. Abscess or other evidence of infection involving deep incision found on direct exam,
during invasive procedure, or by histopathologic exam or imaging test
Organ/Space Surgical Site Infection – [occurs within 30 or 90 days of surgery and has
implant if after the 30 days] & involves any part of the body excluding the skin incision, fascia
or muscle layers, that is opened or manipulated during the operative procedure
1. Purulent drainage from drain that is placed into the organ/space
2. Organism isolated from an aseptically-obtained culture of fluid or tissue in the
organ/space
3. Abscess or other evidence of infection involving organ/space found on direct exam,
during invasive procedure, or by histopathologic exam or imaging test
3.1 SSIs remain a substantial cause of morbidity and an associated mortality rate of 3% has
been attributed to them. Most SSIs are caused by the host’s own endogenous flora. The
Centres for Disease Control and Prevention (CDC) estimates that 2.7% of surgical
procedures are complicated by SSIs which translates into an extra hospital stay of
approximately 6.5 days for each SSI.
Page 3
3.2 Prevention of SSIs consists of:

 Minimizing access of bacteria to the surgical site through the use of antiseptic scrubs,
skin prep procedures, sterile barriers used during operative procedure, environmental
controls and prophylactic antibiotics.
 Enhancement of the Host during the operative procedure through administration of
supplemental oxygen and prevention of hypothermia and hyperglycemia.
 Delayed Primary/Secondary Closure is a viable option for massive disruptions of the
colon (e.g.) gunshot wound or pancreatic abscess.
4.0 PROCEDURE
Classification of Surgical Procedures is done by the Operating Room staff
Decision Tree – All procedures except C-sections
Decision Tree C-sections
5.0 REFERENCES
5.1 CDC/NHSN surveillance definition of healthcare associated infection and criteria for
specific types of infections in the acute care setting; 2013.
5.2 CDC/NHSN surgical site infection event; 2013.
Section 09V - IV0400 (Gastrointestinal Outbreak Guidelines)
Page 1

IV0400: Gastrointestinal Outbreak
Guidelines REVISED DATE: November 2010,
December 2014, October 2015
REVIEWED DATE:
1.0 PURPOSE
This guideline has been developed in collaboration with the Communicable Disease (CD) Unit and
provides guidance for healthcare facilities when a Gastrointestinal Outbreak is suspected.
To link to the Communicable Disease Gastrointestinal Infection Outbreak in Health Care Facilities
Toolkit
I.H. FACILITY GASTROINTESTINAL INFECTION OUTBREAK GUIDELINES
QUICK REFERENCE: GI OUTBREAK
GI OUTBREAK SURVEILLANCE TOOL
NON I.H. FACILITY GI OUTBREAK GUIDELINES
Section 09V - IV0500 (Respiratory Infection (RI) Outbreak Guidelines)
Page 1

IV0500: Respiratory Infection (RI) Outbreak
Guidelines REVISED DATE: November 2010
December 2012, September 2014, October
2015
REVIEWED DATE:
1.0 PURPOSE
This guideline has been developed in collaboration with the Communicable Disease (CD) Unit and
provides guidance for healthcare facilities when a Respiratory Infection Outbreak is suspected.
To link to the Communicable Disease Respiratory Outbreaks in Residential Care Settings Toolkit.
I.H. FACILITY RESPIRATORY INFECTION OUTBREAK GUIDELINES
QUICK REFERENCE: RI OUTBREAK
RI OUTBREAK SURVEILLANCE TOOL
NON I.H. FACILITY RI OUTBREAK GUIDELINES
Section 09V - IV0600 (Communicable Diseases in Employees)
Page 1

IV0600: Communicable Diseases in
Employees REVISED DATE: November 2010,
December 2012
REVIEWED DATE:
1.0 PURPOSE
To provide guidance in the prevention and management of healthcare provider exposures to and
infections with infectious diseases in the work place.
2.0 DEFINITIONS
Exposure – may occur when a healthcare provider is in direct or indirect contact with patient or co-
worker who has a known or suspected infection with a communicable disease. This contact may
occur through, but is not limited to, needle-stick, injuries, splashes, airborne droplets, contact with
nasal or throat secretions or close contact during examinations/treatment.
Healthcare Provider – includes Interior Health staff, physicians, students, volunteers, and all
persons who work within the Interior Health facilities.
Risk Assessment – healthcare providers are at risk of exposure to communicable diseases because
of their contact with patients or material from patients with infections both diagnosed and
undiagnosed. Use of immunization agents assists in protecting patients and healthcare providers
from becoming infected.
3.0 GUIDING PRINCIPLES – Refer to AV0900 – Prevention and Management of Occupational Exposure
to Communicable Diseases:
AV0900 – Prevention and Management of Occupational Exposure to Communicable Diseases
Page 2
PROCEDURE
4.19 EMPLOYEE WORK RESTRICTIONS WITH COMMUNICABLE DISEASES

Employees may not work in the healthcare environment during the known period of communicability
for:
Chickenpox (Varicella
Until all lesions are dried and crusted and no new lesions are forming.
zoster)
Diarrhea/Vomiting Until 48 hours after symptoms have resolved.
Restrict until 5 days after symptoms began or until symptoms have resolved
Influenza
whichever is longer.
Until 4 days after rash appears, or duration of illness in Immunodeficient
Measles (Rubeola)
individuals.
Mumps For 9 days after onset of swelling; less if swelling has subsided.
No restriction but pregnant workers are not to care for children with Parvovirus
Parvovirus B19 (fifth’s
and aplastic crisis or immunosuppressed patients with chronic Parvo infection
disease)
and anemia.
rd
Restrict until 3 week after onset of paroxysmal cough or 5 days of appropriate
Pertussis
treatment is completed.
Rubella (German
Until 5 days after rash appears.
measles)
Scabies or Pediculosis Until 24 hours after initiation of appropriate treatment.
Shingles (Herpes zoster) Patient contact is limited to immune patients and lesions are covered.
Until receiving appropriate therapy and clinical improvement. The employees

Tuberculosis
physician shall review the case prior to allowing the employee to return to work.
Employees may or may

not require work
restrictions due to
specific acute
infections or carrier
states.
Group A Streptococcus or
No restriction unless clearly associated with disease transmission.
Staphylococcus
Acute hepatitis B, or
Individual evaluation by Employee Health. Work restriction will depend upon the
HBsAg positive
employee's hygiene and preventing his/her blood and other body fluids from
Acute hepatitis C
contacting others.
HIV positive or AIDS
Neisseria meningitidis No restriction or treatment for carrier state required; for acute meningococcal
(meningococcus) disease, including meningitis, employees would be too ill to work.
Amebiasis, Salmonella,
Campylobacter, Shigella,
Food handlers are restricted. In other healthcare providers, evaluation by
Cholera,
Employee Health is necessary.
Worms/Parasites
Hepatitis A
Page 3
Employees must be evaluated by Employee Health or their private physician regarding their work area
if they have certain signs or symptoms of the following conditions:
Draining abscesses, boils
Exudative dermatitis
Herpes simplex (whitlow, stomatitis)
See Workplace Health & Safety
Uncontrolled respiratory symptoms/infections
Impetigo
Conjunctivitis
4.2 SUSCEPTIBLE EMPLOYEES
Exposure of susceptible employees to specific communicable diseases may require restriction from
work during the incubation period, for example:
Chickenpox, Varicella Incubation period is 10-21 days after exposure; restriction would be
from day 8 after first exposure thru day 21 after last exposure (up to
28 days if given VZIG varicella zoster immune globulin) or, if
disease develops, until the last crop of vesicles is dried and
crusted.
Measles, Rubeola Incubation period is 7-18 days; restriction would be, as per BCCDC
Communicable Disease Manual update March 2010, from day 5
after first exposure to day 21 after last exposure; if disease
develops, until 4 days after onset of rash. Live vaccine given to
susceptibles within 72 hours of exposure may prevent illness.
Mumps Incubation period is about 16 to 18 days: restriction would be from

12 until 25 days after exposure; if disease develops, for 9 days
after onset of parotid gland swelling, but less if swelling has
subsided. Immunization of susceptible persons following exposure
is of uncertain value.
Rubella Incubation period is 14-21 days; restriction would be from day 7

after exposure through day 23; if disease develops, until 4 days
after rash appears.
4.3 Occupational Exposure to a Communicable Disease
Infection Control Practitioner will complete the Communicable Disease Notification Tool
and forward it to the CD Unit and IH Occupational Health.
Page 4
5.0 REFERENCES
5.1 Prevention and Control of Occupational Infections in Healthcare. Public Health

Agency of Canada (PHAC); March 2002.
5.2 Guidelines for Infection Control in Healthcare Professionals. Bolyard EA,

Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deithman SD. AJIC (American
Journal of Infection Control), vol. 1998;26(3):289-354
5.3 Control of Communicable Diseases Manual. 19th Edition. David L. Heymann

(2008).Published American Public Health Association, WA DC
5.4 AV0900 - PREVENTION AND MANAGEMENT OF OCCUPATIONAL EXPOSURE TO

COMMUNICABLE DISEASES; IH Administrative Policy Manual – AV Workplace Health and
Safety; December 2009.
5.5 BCCDC Communicable Disease Manual.
Section 10X - IX0100 (Microbiology Specimen Collection)
Page 1

IX0100: Microbiology Specimen Collection
REVISED DATE: November 2010, June 2016
1.0 PURPOSE
This information is now available on the Microbiology website
Section 10X - IX0200 (Prevention & Control of Catheter Associated Urinary Tract
Infections -CAUTI)
Page 1

IX0200: Prevention & Control of Catheter
Associated Urinary Tract Infections (CAUTI) REVISED DATE: November 2010
February 2015, June 2016
REVIEWED DATE:
1.0 PURPOSE
This information is now available in the Urinary Catheters toolkit.
This information will not be available to anyone outside of Interior Health.
Section 10X – IX0300 (Pneumococcal Vaccine for Residential Care)
Page 1
EFFECTIVE DATE: June 2009

IX0300: Pneumococcal Vaccine for
Residential Care REVISED DATE: November 2010,
December 2012
REVIEWED DATE:
1.0 PURPOSE:
All persons being admitted to an Extended or Intermediate Care Facility are to be assessed for their
status of having received a pneumococcal vaccine in the past and this information will be recorded on
the resident’s chart. If they have not had a pneumococcal vaccine, they will be offered the vaccine
upon admission to the facility and this information will be recorded on the resident’s chart.
2.0 GUIDING PRINCIPLES:
2.1 Streptococcus pneumoniae (pneumococcus) can cause serious invasive disease including
bacteremia, meningitis and pneumonia in people with high-risk medical conditions and the
elderly. Pneumococcal infection is spread by droplet/contact from one person to another by
coughing, sneezing, close face-to-face contact and direct contact through saliva.
2.2 The pneumococcal polysaccharide vaccine is offered free to seniors 65 years and older and
to persons 2 years of age and older with certain medical conditions including those who have
no spleen or a spleen that is not functioning properly*, sickle-cell disease*, immune systems
weakened by disease or medical treatment*, chronic liver disease including cirrhosis*,
chronic hepatitis B or hepatitis C*, chronic kidney disease*, chronic heart or lung disease,
transplant patients, diabetes, cystic fibrosis, chronic cerebrospinal fluid leak, cochlear implant
candidate or recipient, alcohol dependency, homelessness and/or illicit drug use.* People in
these groups should receive a second dose of vaccine five years after the first dose and this
requires a physician order.
2.3 Residents of any age living in residential care are considered an at risk population for
suffering complications from pneumococcal disease and should receive the vaccine upon
admission to the facility if they have not already had the vaccine previously.
2.4 Contraindications for the vaccine include anaphylaxis reaction to the vaccine or component of
the vaccine in the past. Possible reactions to the vaccine may include soreness, redness and
swelling at the site of injection. Headache and mild fever may also occur. These reactions
are mild and generally last 1 to 2 days.
3.0 PROCEDURE
3.1 All Residential Care facilities should have pre-printed physician orders for “pneumococcal
vaccine on admission if resident has not been immunized in the past”. Upon admission, staff
is to seek out and document information about the resident’s pneumococcal immunization
Section 10X – IX0300 (Pneumococcal Vaccine for Residential Care)
Page 2
status by asking the resident and/or family, the resident’s physician (contact office) and/or the
Public Health office. Document information according to facility guidelines.
3.2 Residents who do not have a record of pneumococcal immunization with Public Health or
their family physician require immunization by the facility – this should be done within two
weeks of admission.
3.3 Do not delay immunization if proof of prior immunization is not available within this
two week time frame - when in doubt, with no documented proof: IMMUNIZE.
3.4 It is recommended that facilities carry out yearly audits to ensure the procedure for
administering and documenting pneumococcal vaccination in Residential Care Facilities is
being implemented appropriately with the target being at least a 90% vaccination coverage
compliance rate.
4.0 REFERENCE
4.1 Public Health Agency of Canada. Seventh Edition Canadian Immunization Guide 2006.
4.2 BC Centre for Disease Control. Communicable Disease Control Immunization Program,
Section VII – Biological Products, January 2010.
4.3 Required Organizational Practices 2012. Accreditation Canada; pg 52.
Section 10X - IX0400 (Pet Therapy and Visitation)
Page 1

IX0400: Pet Therapy and Visitation
1.0 PURPOSE
The purpose of a pet therapy & visitation program is to provide patients with the positive aspects of
stimulation, motivation and cooperation that human/animal interaction can offer in the hospital
environment. This form of therapy is used successfully with people in many healthcare settings and
literature supports the position that pet therapy increases cooperation with medical treatment and
feelings of well-being while decreasing the stress of illness and hospitalization. Our target audience
includes all eligible (as defined in this guideline) patients, with an emphasis on those patients who
experience long-term hospitalization, and/or demonstrate a need for unconditional love, positive
motivation and socialization while involved in their hospital experience.
To allow visitation of appropriately screened therapy dogs and their screened and trained handlers to
eligible patients. This guideline will cover residential pets, service, guide animals and patient owned
pets as well.
2.0 DEFINITIONS
Guide dog - this term shall refer to a dog which is in working harness and is certified to guide blind or
hearing impaired persons by an accredited canine school that is engaged in this specific type of
training.
Service dog - this shall mean a dog that is certified to assist disabled people by an accredited canine
school that is engaged in this specific type of training.
Therapy dog - this shall refer to animals that are brought by specially trained professionals, para-
professionals, and/or volunteers to provide opportunities for motivational, educational, recreational,
and/or therapeutic benefits to enhance quality of life.
Pet animal - this shall refer to any animal which belongs to a patient and whose presence in the
hospital is requested by the patient and his physician.
3.1 Visitation of any animals to critical care areas, rooms where Additional Precautions are being
implemented, medication or clean supply rooms, food storage or preparation areas, and
dining rooms is prohibited.
3.2 Service/guide animals care and health is the responsibility of their owners. They will be given
access to all areas in the facility except those noted in 3.1 above.
Page 2
3.3 Rodents, reptiles, and other exotic pets are prohibited without special permission of Infection
Control.
3.4 All pet therapy/residential animals will have an approved handler who will be responsible for
their health and well being as well as ensuring that they are in compliance with this guideline
3.5 Handlers will perform hand hygiene after all visitations. The handler will assist the patient in
performing hand hygiene prior to leaving the room.
3.6 Screened and trained pet therapy animal handlers must:

 Be individuals from agencies who will fully support these guidelines and any other
policies of IHA that may apply to or have bearing on pet therapy programs and the
general safety of our patients and families.
 Have submitted an application to and have the approval of the Volunteer Coordinator.
 Be a minimum of eighteen (18) years of age.
 Be a certified and approved member of an approved Therapy Dogs/ Pet Program.
3.7 Appropriately Screened Dogs for the pet therapy or residential program will:
 Be a minimum of one (1) year old.
 Complete the required dog history.
 Require that every animal receives a health evaluation by a licensed veterinarian at least
once per year and ensure that vaccinations are current, e.g.:
o Distemper.
o Hepatitis.
o Parainfluenza.
o Parvovirus.
o Rabies.
 Defer to the animal’s veterinarian regarding an appropriate flea, tick and enteric parasite
control program which should be designed to take into the account the risks of the animal
acquiring these parasites specific to its geographic location and living conditions.
 For the protection of both the animal and people, prevent the animal from entering the
Healthcare Facility from the onset of and until at least 1 week beyond the resolution of:
o Episodes of vomiting or diarrhea.
o Urinary or fecal incontinence.
o Episodes of sneezing or coughing of unknown or suspected infectious origin.
o Treatment with non-topical antimicrobials or with any immunosuppressive doses
of medications.
o Open wounds.
o Ear infections.
o Skin infections or ‘hot spots’ (i.e. acute moist dermatitis).
o Orthopedic or other conditions that, in the opinion of the animal’s veterinarian,
could result in pain or distress to the animal during handling and/or when
maneuvering within the facility
3.8 Dogs that do not meet screening requirements (regarding consequences for handlers not
following the above guidelines, policies or dogs that test positive for lab results):
 The documents supporting these actions will be kept on file with the hospital volunteer
coordinator and must be kept up to date. Those in non-compliance with the timely testing
of their dogs will be immediately suspended from the program.
 Dogs who test positive in the throat and/or fecal cultures will be immediately suspended
from the program.
 One positive Salmonella culture will permanently retire a dog from the program.
 A total of three positive cultures over any period of time, for any of the above stated
pathogens or parasites, will permanently retire a dog from the program.
Page 3
 If a dog has been removed from scheduling due to a positive test that dog will not be
scheduled again until the following criteria have been met and documented:
o For treated parasite or pathogen, a first retest will be performed no sooner than
seven (7) days following completion of the prescribed treatment. After two
consecutive negative retests (30 days apart), the dog will be able to resume
visits.
 Appropriately Screened Cats/Birds for the pet therapy or residential program will:
o Be full grown animals and not juveniles.
o Complete the required history.
o Receive a yearly exam and certificate of good health with all appropriate
vaccinations.
o Have passed a standard temperament test.
o Be groomed (bathed, nails trimmed) within 24 hours prior to visitation.
o Not be in estrus (heat) when participating in therapy work.
3.9 Personal Pets

 Pet visitation will be restricted to special situations where the patient care team, doctor,
nurses and/or social workers believe such visitation will benefit the patient.
 Pets are limited to cats and dogs and must:
o Be visiting a specific patient.
o Be clean and well groomed prior to entering the facility.
o Have a veterinarian exam and certificate of health, within the past year
documenting current immunizations and being free of disease and parasites and
in good health.
o Not be aggressive, hyperactive or difficult to control.
o Be supervised and contained with leash/cage, by the designated pet handler at
all times. This supervision includes any necessary care and cleanup.
4.0 PROCEDURE
4.1 Arranging a visit:

 All visits will be approved by the attending physician.
 The supervising nurse and/or charge nurse will be notified that the animal visit is to
occur.
4.2 Appropriate patients for visits:

 Before a patient will be considered eligible for any visitation, the following requirements
must be met:
o Physician consent (by verbal or written order).
 The following patients will not be eligible for dog visitation:
o Patients on Additional Precautions due to infection.
o Patients with known immunodeficiency disorders.
o Patients with known animal allergies.
o Patients whose physician requests that their patient not receive a visit.
o Any patient or parent who expresses any concern regarding a visit will not be
included in the visit.
4.3 Animal Waste

 If animal waste occurs at anytime during the visit, the dog handler will be responsible for
immediately cleaning the area with the approved provided clean-up kit. The handler will
be provided with the following materials:
o Disposable gloves.
o Plastic bags.
o A container of a germicidal cleaning agent
Page 4
(All used materials will be put in the plastic bag which will be disposed of in
an appropriate waste container.)
 If an animal should develop symptoms of any illness following a hospital visit, the handler
will immediately notify the Infection Control Department.
5.0 REFERENCE
5.1 Sandra L. Lefebvre, et al. Guidelines for animals – assisted interventions in health care
facilities. AJIC American Journal of Infection Control 2008; 36:2 pp 78-85.
Health Care Settings; Public Health Agency of Canada; 2013, P.32.
Section 10X – I X0500 (Soiled Utility Rooms)
Page 1
EFFECTIVE DATE: March 2008

IX0500: Soiled Utility Rooms
1.0 PURPOSE
To minimize the risk of infection transmission in clinical areas that generate soiled equipment, soiled
linen and waste.
2.1. Requirements for Soiled Utility Rooms include:

 Work counter with sink, gooseneck faucet and wrist blades.
 Separate wall-hung hand sink for hand washing with soap and towel dispensers.
 Space for waste receptacles and soiled linen receptacles; provision for storing and
transporting soiled linen in covered leak proof containers.
 Hospital approved equipment and products for cleaning and sanitizing bedpans, urinals,
and basins.
 Closed cupboards or covered bins for containing clean supplies such as bedpans,
urinals, basins, incontinence supplies, and lab supplies such as urine dipsticks, specimen
containers.
 *If closed cupboards are not available, ensure open shelves are located away from
“splash risks” around sinks, and bedpan sanitizers.
2.2. Items that can be housed in Soiled Utility Room include:

 Cleaning supplies and products readily available for non-housekeeping staff.
 Soiled equipment, soiled laundry.
 Personal Protective Equipment to wear while cleaning items including eye protection,
surgical/procedure masks, fluid resistant apron, household gloves.
 Items to be cleaned after each use, such a commode, once cleaned, they need to be
stored elsewhere.
 General and Biohazardous waste containers.
 Specimen fridge for holding laboratory specimens.
2.3. Items that should not be kept in a Soiled Utility room include:
 Kleenex boxes.
 Skin antiseptics/cleansers.
 Personal hygiene supplies (soaps, mouth care products, lotions).
 Sterile items such as wound dressings.
3.0 REFERENCES
3.1. Best Practice for Environmental Cleaning for Prevention and Control of Infections in All
Healthcare Settings; Provincial Infectious Disease Advisory Committee (PIDAC), Ontario,
May 2012.
Section 10X - IX0600 (Equipment Cleaning)
Page 1

IX0600: Equipment Cleaning
December 2012, March 2013
REVIEWED DATE:
1.0 PURPOSE:
To prevent the transmission of microorganisms from soiled equipment to patients.

Cleaning is a shared responsibility between multiple departments and healthcare providers.
2.0 DEFINITION
See the glossary in Appendix A for definitions
3.0 GENERAL PRINCIPLES
3.1 Dedicate equipment for a single patient.
3.2 Shared equipment must be cleaned and disinfected between patient uses.
3.3 Clean soiled equipment immediately – must be cleaned prior to disinfection.
3.4 Disinfectant wipes should be used for point of care cleaning and disinfection of patient
equipment; wipes must be kept wet and discarded if they become dry.
3.5 Never reuse single use equipment that is not appropriate to dedicate to single patient use
(i.e. critical equipment) – discard immediately after use.
3.6 Do NOT use tape that leaves a residue on patient equipment.
3.7 Report damaged equipment to manager for replacement.
3.8 Do NOT stockpile supplies and equipment in patient room – clutter increases the risk of cross
contamination in patient care areas (including hallways).
3.9 Personal care items (i.e. lotions, skin cleansers, razors) are single patient use and not to be
shared between patients.
3.10 Assign responsibility for routine cleaning of equipment.
3.11 Foot care equipment must be sterilized between patient use – if the equipment is assigned as
single patient use, it can be low level disinfected between use on that same patient.
Section 10X - 1X0600 (Equipment Cleaning)
Page 2
4.0 PROCEDURE
4.1 Wear appropriate personal protective equipment (PPE) for the task.
4.2 Clean and disinfect reusable equipment in a designated area.

 Clean small items in patient rooms prior to use on another patient.
 Transport large items to the soiled utility room for cleaning.
 Avoid performing equipment cleaning in high traffic areas like hallways or where
contact with clean items may occur (clean hallway carts).
4.3 Wipe equipment thoroughly – if cloth/wipe comes away dirty, repeat until it comes away
clean.
4.4 Allow equipment to air dry.

 Some items may require rinsing off prior to use – ensure disinfectant has adequate
contact time with the equipment/device before rinsing.
4.5 Designate a location for clean equipment (ideally, clean storage rooms or clean service
rooms) where they are transported after cleaning.
 Implement a process where the item is identified as clean, disinfected and ready for
use on another patient.
4.6 Cardboard/paper items

 Wipe laminated cardboard/paper with cloth or wipe – if not laminated, discard after
use.
4.7 Fabric items

 All fabric items used in patient care areas must be washable.
 Washing can take one of 3 forms:
o Coated Fabric (i.e. vinyl) – wiped using procedure above.
o Non coated cloth – launder.
o Non-washable fabrics not recommended
4.8 Electronic items

 Wipe equipment thoroughly including all cables, avoiding any electrical or electronic
connectors to prevent malfunction.
 Use approved screen cleaners
 Allow to air dry.
4.9 Toys
REFER TO IX0700 TOY M ANAGEMENT
4.10 Macerators (Vernacare)

 Dispose of cardboard items immediately after use into macerator and run cycle.
 Do not allow items to accumulate in macerator to avoid plugging the machine.
4.11 Washer/Disinfector (Deko)

 Place “blue ware” items used for elimination (i.e. bedpans, urinals) immediately in
machine after use.
 Once items are cleaned and disinfected, ensure clean items are stored to facilitate
complete drying.
 Items can be used for any patient after completing this process.
Page 3
 Establish a schedule for regular cleaning of “blue ware” (i.e. wash basins, denture
cups).
4.12 Appendix B – Equipment Cleaning Table
4.13 Appendix C – information on hydrotherapy tubs and use of public pools for therapeutic
interventions.
5.0 REFERENCES
5.1 Best Practices for Cleaning, Disinfection and Sterilization in all Health Care Settings.
Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario; February, 2010.
5.2 Hand Washing, Cleaning, Disinfection and Sterilization in Health Care. Health Canada -
Canada Communicable Disease Report. 1998; 24 Supplement 8: i-xi, 1-55.
5.3 Infection Control Guideline for the Prevention of Healthcare Associated Pneumonia.
5.4 Infection Prevention and Control Manual. Capital Health. Cleaning and disinfection of
non-critical patient care equipment. Policy IC 08-001; July 2012.
5.5 Montana State Hospital. Policy and Procedure Manual. Cleaning of non-critical, reusable
patient care equipment. Policy IC-19; March 2010.
5.6 Saskatoon Health Region. Infection Prevention and Control Manual. Non-critical Patient
Care Equipment – Cleaning and Disinfection. Policy 20-80; October 2006.
5.7 Seven Oaks General Hospital. Policy and Procedure Manual. Cleaning of non-critical,
reusable patient care equipment. Policy Code: 7311-07-01; December 2007.
Page 4
APPENDIX A
Antiseptic
An antimicrobial chemical designed for use on the skin or mucous membranes that inhibits the growth
and reproduction of microorganisms (i.e.) alcohol based hand rub (ABHR) for hand hygiene.
Bioburden
The number and types of viable microorganisms that contaminate the equipment/device.
Cleaning
The physical removal of dirt, dust or foreign material. Cleaning usually involves soap and water,
detergents or enzymatic cleaners. Thorough cleaning is required before disinfection or sterilization
may take place.
Disinfectant
A product that is used on medical equipment/devices, which results in disinfection of the
equipment/device. Disinfectants are applied only to inanimate objects. Some products combine a
cleaner with a disinfectant.
High Level Disinfection

The process of using a chemical to kill all vegetative “live” bacteria, fungi, mycobacterium, and
viruses. This does not necessarily kill bacterial spores.
Intermediate Level Disinfection:

Inactivates M. tuberculosis, vegetative bacteria, most viruses, and most fungi, but does not
necessarily kill bacterial spores.
Low Level Disinfection

Using a chemical to kill most vegetative “live” bacteria and some fungi as well as enveloped viruses.
This does not kill mycobacterium or bacterial spores.
Noncritical Medical Equipment/Device

Equipment/device that either touches only intact skin (but not mucous membranes) or does not
directly touch the patient. Reprocessing of noncritical equipment/devices involves cleaning and may
also require low-level disinfection.
Personal Protective Equipment

Barriers placed between the infectious source and ones own mucous membranes, airways, skin, and
clothing to prevent exposure to blood and body fluids.
Reprocessing
The steps performed to prepare used medical equipment/devices for re-use (e.g., cleaning,
disinfection, and sterilization).
Sterilization
The complete elimination or destruction of all forms of microbial life. Accomplished by either physical
or chemical processes.
Page 5
APPENDIX B
Recommended Minimum Cleaning and Disinfection Level and Frequency for Non-
critical Client/Patient/Resident Care Equipment and Environmental Items
The following chart relates to non-critical patient care equipment only, i.e.,
equipment that comes into contact with intact skin.
This chart also includes environmental surfaces and items that do not come
into contact with skin.
CL = Physical removal of visible soil dust or foreign material (may use soap and
water, detergent or hospital grade disinfectant with detergent properties)
LLD = Soak item in or wipe surfaces with hospital grade disinfectant (wipe or
cloth dampened with disinfectant), allow disinfectant to dry prior to reuse to
allow item “contact time” for disinfection to occur
Item Minimum Cleaning Minimum Frequency Remarks

and Disinfection
Level:
CL = Clean only
HLD = Clean + High-
level Disinfection
LLD = Clean + Low-
level Disinfection
Airflow sensors LLD  between patients  clean with detergent and

water before disinfection
(Sleep Lab)
Apnoea Monitor LLD  between patients

 when soiled
Monitor/ Sensor Pad
Arrest Cart See Resuscitation Cart
Basin CL  after each use  dedicated to patient

 between patients  dry completely before use
 between patients  automated process

LLD recommended
Page 6

and Disinfection
Level:
CL = Clean only
HLD = Clean + High-
level Disinfection
LLD = Clean + Low-
level Disinfection
Bassinette LLD  weekly

 when soiled
 between newborns
Bath Seat/ Raised Toilet

Seat
Single patient use LLD ▪ when soiled ▪ ideally dedicated to each
patient
Multiple patient use LLD ▪ between patients
Bed
Bedrail and extender LLD ▪ daily
Mattress LLD ▪ clean between

patients and when
soiled
Halo bed LLD ▪ after each patient and

when soiled
Visitor cot LLD ▪ change linen and

clean between uses
Bedpan and Urinal

Disposable ▪ dispose immediately
Multiple patient use LLD ▪ between patients ▪ washer/disinfector

recommended for
reusable items after each
use
▪ remove gross soil and
fluids before automated
disinfection unless
machine equipped with
“flush” cycle
Bladder Scanner LLD ▪ between patients
Page 7

and Disinfection
Level:
CL = Clean only
HLD = Clean + High-
level Disinfection
LLD = Clean + Low-
level Disinfection
 between patients
Blood Pressure Cuff LLD  ideally stays with patient
 when soiled until discharge
Breast Pump (Hospital

Grade)
 between uses  dedicated to patient
Pump Kits
Disposable:CL  when soiled  discard when damaged or
heavily soiled
 dry completely before
reuse
 store with patient/baby to
avoid contact with other
kits
 between uses  dedicated to patient –

HLD(min) washed and completely
between different
patients dried after each use
 stored with patient/baby
 HLD/sterilized according
to Manufacturer’s
instructions before use
with another patient
Pump Motor
LLD  between uses
 when soiled
Call Bell LLD ▪ daily and between

patients
Cardiac Monitor LLD ▪ daily and between

patients
Cast cutting
Blades CL or ▪ when soiled ▪ send for sterilization if
contact with blood or body
disposable
fluids
Saws CL ▪ when soiled
Page 8

and Disinfection
Level:
CL = Clean only
HLD = Clean + High-
level Disinfection
LLD = Clean + Low-
level Disinfection
Chair LLD ▪ daily and when soiled

Includes recliners, patient
chairs and shower
chairs
Chart Cover LLD  when soiled  charts and clipboards

should not go into rooms
Binder and/ or clipboard
on Additional Precautions
 replace worn binders
Clippers (handle)
Surgical LLD ▪ between patients ▪ disposable heads
Commode Chairs
patient
▪ patients with VRE or
C.difficile must have
dedicated commode
▪ for C.difficile, consider
cleaning with a sporicidal
agent
fluids before cleaning and
disinfection
Multiple patient use LLD ▪ when soiled ▪ remove gross soil and
▪ between patients
disinfection
Cord Clamp  must be single-use,

disposable and discarded
after use
Cyclers LLD ▪ between patients

(Peritoneal Dialysis)
Defibrillator See Resuscitation Cart
Page 9

and Disinfection
Level:
CL = Clean only
HLD = Clean + High-
level Disinfection
LLD = Clean + Low-
level Disinfection
Diagnostic Imaging LLD ▪ when soiled and on

leaving Contact
Portable - Machine
Precautions room
Portable - portable grid/ LLD ▪ between patients if not ▪ ideally should be covered
covered (e.g., pillowcase)
film cassette
Mammography - paddles LLD ▪ between patients
Dopplers  wipe immediately after

 after each use use to remove residual
Transducers LLD
ultrasound gel before
cleaning
Probes LLD  after each use
 probes that contact
mucous membranes or
non-intact skin require
high-level disinfection
ECG
Machine and Cables LLD
Electric Razor
Razor body and Handle LLD ▪ as required ▪ must be single patient use
Electronic Devices
patient
(e.g. Bedside monitors) ▪ between patients
▪ patients with VRE or
C.difficile should have
device cleaned daily
regardless of soilage
▪ for C.difficile, consider
cleaning with a sporicidal
agent
disinfection
▪ consult manufacturers
instructions for screen
cleaning
Page 10

and Disinfection
Level:
CL = Clean only
HLD = Clean + High-
level Disinfection
LLD = Clean + Low-
level Disinfection
▪ cleanable covers are
highly recommended for
difficult to clean
components
Multiple patient use/ LLD ▪ when soiled ▪ remove gross soil and
Personal Devices used in ▪ between patients
disinfection
patient areas (i.e.
Tablets) ▪ consult manufacturers
instructions for screen
cleaning
▪ cleanable covers are
highly recommended for
difficult to clean
components
Glucometer LLD ▪ after each use
Halo Bed See Bed
Hydraulic Lift
Machine LLD ▪ as required
Sling Launder ▪ between patients and ▪ dedicated to patient if
when soiled possible
▪ launder if visibly soiled
Hydrocollator ▪ drain and thoroughly clean
Interior LLD ▪ every week ▪ allow 10 mins contact time
with disinfectant for
interior surfaces then
rinse well prior to refilling
with water
▪ allow fresh water to reach
appropriate temp prior to
re-immersing packs
▪ regular temperature
monitoring required as per
manufacturers
recommendations
Exterior LLD ▪ every week
Page 11

and Disinfection
Level:
CL = Clean only
HLD = Clean + High-
level Disinfection
LLD = Clean + Low-
level Disinfection
Ice Machine
Interior LLD ▪ every 6 months ▪ drain and thoroughly clean
with a de-limer
Exterior LLD ▪ every 3 days
 between patients ▪ do not use without a cover

Ice Packs LLD
▪ discard if damaged
Intravenous (IV) LLD
 when soiled
Pumps, Poles, Warmers
 weekly
Isolette LLD
 when soiled
Laryngoscope
Handle LLD  between patients
Mattress See Bed
Measuring Container
(urine)
CL ▪ after each use
Single patient use
Multiple patient use LLD ▪ after each use ▪ one container per patient,
labelled with name
Ophthalmoscope LLD  between patients
Orthopedic Equipment LLD ▪ between patients

Crutches, traction etc.
Otoscope
Handle LLD  between patients
Page 12

and Disinfection
Level:
CL = Clean only
HLD = Clean + High-
level Disinfection
LLD = Clean + Low-
level Disinfection
Ear speculum Disposable or HLD
Otoacoustic Emission Disposable or HLD
(OAE) screening tips
Oxygen Delivery
Systems  dedicated to patient
Disposable:CL
Masks  daily
 discard when damaged or
 when soiled
heavily soiled
 rinse all disinfectants from
surface before reuse with
same patient
reuse with same patient
 dedicated to patient
 daily
Disposable:CL  discard when damaged or
NP/tubing  when soiled heavily soiled
(externally only)
 handle condensate
carefully – remove from
tubing, do not drain back
towards patient
Nebulizers  after use  dedicated to patient
Disposable:CL
 discard when damaged or
heavily soiled
 rinse after cleaning using
sterile water
reuse with same patient
Oximeter Probes LLD ▪ between patients  if single-use, discard after

use
▪ refer to manufacturer’s
instructions for cleaning
▪ discard if damaged
Physio/OT Equipment LLD ▪ between patients and
when soiled ▪ educate users to clean
after use if appropriate
Page 13

and Disinfection
Level:
CL = Clean only
HLD = Clean + High-
level Disinfection
LLD = Clean + Low-
level Disinfection
▪ clean personal splints prior
to immersion
▪ drain and thoroughly clean
Splint Baths LLD ▪ weekly ▪ allow 10 mins contact time
with disinfectant for
interior surfaces then
rinse well prior to refilling
with water
▪ allow fresh water to reach
appropriate temperature
before reuse
Sheepskin Launder ▪ between patients

▪ when soiled
OT assessment Areas CL
(e.g. kitchen/bathroom) ▪ after use
▪ pour wax into disposable

Wax Bath (wax) plastic bag or washable
container for individual
patient use
▪ do not reuse wax
▪ discard if cracked
Pillow LLD ▪ between patients and
when soiled
Reflex Hammer LLD
 between patients and

Restraints CL  launder
when soiled
 weekly and after use
Resuscitation LLD  avoid taking cart into
Cart/Arrest Cart Contact Precautions
room, have a designated
clean person to pass
supplies as required
 after each use
Defibrillator LLD
Page 14

and Disinfection
Level:
CL = Clean only
HLD = Clean + High-
level Disinfection
LLD = Clean + Low-
level Disinfection
 after each use
Trays LLD  all items taken into
Contact Precautions room
must be discarded and
not returned to the cart,
even if unopened
Scales
 daily and when soiled
Adult LLD
 after each use
Diaper LLD
 after each use

Newborn LLD  do not use phenolics
 after each use

Speculum Light LLD
 after each use

Stretcher LLD
 after each use

Stethoscope LLD  ideally use own
stethoscope
 if shared, disinfect ear
pieces
Suction Machines LLD
 when soiled
Table
 when soiled
Bedside LLD
Over bed  daily
Telephone
 daily
Bedside/Nursing Station LLD
 when soiled
 daily
 when soiled
Portable LLD
Telemetry Equipment
Monitor and Cables LLD  between patients
Page 15

and Disinfection
Level:
CL = Clean only
HLD = Clean + High-
level Disinfection
LLD = Clean + Low-
level Disinfection
 when soiled
Thermometer LLD  when soiled

(electronic)  daily
Tourniquet LLD  between patients or  preferably dedicate to
disposable patient
 discard when soiled/
cracked
Transfer Belts CL  once weekly  use transfer belts on top

 when soiled of clean patient
clothing/gown
Transfer Boards LLD  between patients
 when soiled
Transport Equipment
Walker LLD  after each use
Wheelchair
Tub  Iodine and chlorine

Bath board/Jets/Surfaces LLD  after each use products may damage tub
surfaces
Ultrasound Transducers  use high-level disinfection
Handle and Cable LLD  between patients for transducer probes if
they touch mucous
External
membranes or non-intact
skin
Urinal See Bedpan
Urine Measuring See Measuring Container

Container
Vacutainer Holder LLD  between patients  Single patient use
preferred
 discard if visibly soiled
Ventilator
Machine CL  daily
 when soiled
Page 16

and Disinfection
Level:
CL = Clean only
HLD = Clean + High-
level Disinfection
LLD = Clean + Low-
level Disinfection
Ventilator Circuit LLD  between patients  ventilation circuits used on
an individual patient
 disposable or should not be routinely
sterilized between changed based on
patients duration of use – only
when visibly soiled or
mechanically defective
 disposable or
In-line monitoring devices sterilized between
(i.e.temp. probes) patients
Walker See Transport Equipment
Wall-mounted Oxygen LLD  between patients

and Suction Fixtures  when soiled
Warming Cupboard
Exterior CL  weekly
Interior CL  every 6 months

Water Jug CL  daily  clean in dishwasher
 if disposable, change daily
Wheelchair See Transport Equipment
This document /excerpt was adapted with permission from the Ontario Agency for Health Protection
and Promotion (Public Health Ontario)/Provincial Infectious Diseases Advisory Committee (PIDAC).
PIDAC documents contain information that requires knowledgeable interpretation and is intended
primarily for use by health care workers and facilities/organizations providing health care including
pharmacies, hospitals, long-term care facilities, community-based health care service providers and
pre-hospital emergency services in non-pandemic settings. Public Health Ontario assumes no
responsibility for the content of any publication resulting from changes /adaptation of PIDAC
documents by third parties.
Page 17
APPENDIX C
Part 1: Infection Control Recommendations for Hydrotherapy
Recommendations for Hydrotherapy are required to prevent infections to pool participants and staff, as
well as to prevent contamination of the pool.
1. Contraindications: According to the BC Swimming Pool, Spray Pool and Wading Pools
Regulations, it is contraindicated for residents, staff, community clients or their attendants to
enter the pool with the following:
 Open areas of the skin (unless covered by a waterproof bandage).
 Fungal infections (i.e. Athlete’s foot, fungal infections of the groin).
 Unmanaged fecal incontinence.
 Fever, diarrhea or vomiting.
 Any other identified infections may be a contraindication. Appropriateness of swim
session for these cases will be at the discretion of the nurse, physiotherapist, doctor,
health care assistant, in consultation with the lifeguard.
2. Hand Hygiene: Hand hygiene is the single most effective measure available to prevent
infections. Hand hygiene should be done:
 Before and after direct care with a client.
 Before and after working with gloved hands.
 Before and after working with open areas/dressings, urinary equipment, ostomy
equipment or body fluids.
 Between working with different clients.
3. Urinary Incontinence:
 The bladder must be emptied before entering the pool.
4. Fecal Incontinence:
 Swimmers with fecal incontinence are requested to arrange their pool time around
their bowel habits.
 Swimmers are requested to have a bowel movement prior to bathing.
 Swimmers should wear properly fitting waterproof pants/incontinence product.
5. Ostomy Appliances:
 Must be firmly secured and able to withstand pool related activities (temperature,
moisture, body movements and exercises).
 It is the responsibility of the client, or the client’s attendant, to ensure that the bag is
secured to the body and free from seepage.
 Ostomy bags must be clean before entering the pool.
6. Skin lesions and Rashes:

 It is the responsibility of the client, or nurse, to check the skin for any wounds before
the pool session.
 If open wounds are present prior to swimming, the session should be cancelled.
 If the wound is small and can be completely covered and sealed by one waterproof
dressing, then the session can continue once the bandage had been properly
applied.
 Waterproof dressings can include various brands of waterproof bandages. Water
resistant bandages will allow water to move through the bandage therefore allowing
organisms to be carried to and away from the wound.
Page 18
 Non waterproof bandages, tape, dressings, etc… must be removed before entering
the pool. Rationale: These items, if dislodged, become trapped in the pool filter
system resulting in mechanical breakdown. Also, if an open area is covered by an
inadequate dressing, the pool will potentially be contaminated.
Page 19
Part 2: Infection Control Practices for Pool Usage
Pool users are required to adhere to the following practices when using the pool:
1. All pool users are required to wash their hands upon arrival and before leaving the pool facility.
An antiseptic hand sanitizer solution is an option, if the hands are not visibly soiled.
2. All pool users are required to place a clean towel or other adequate barrier on the change bench
to sit on as well as place their clothing on while changing.
3. All clothing and personal belongings are to be stored neatly away in either the lockers or
underneath the benches after changing and while using the pool.
4. All pool users are required to take a cleansing shower using warm water and soap before
entering the pool.
5. No person shall enter the pool whom:
 Is obviously ill.
 Has an open wound that has not been appropriately covered.
 Has sore or infected eyes.
 Has a discharge from the ears or nose.
6. Disinfecting wipes should be supplied in each change room and should be used to wipe benches
between each use. Clients and staff are encouraged to use these wipes before and after using
the benches. The wiped surface is left to air dry for effective disinfecting.
7. Disinfecting wipes are also used to wipe the grab bars and lifts after each use.
8. Disinfecting wipes are used to wipe the sling back and lift after each use. Lift slings should be
washed after each use.
9. Change rooms should be cleaned and sanitized thoroughly once daily, or more often, as needed.
10. The pool deck should be cleaned and sanitized thoroughly once daily, or more often, as needed.
11. Wheelchairs that have been contaminated with body fluids are cleaned in the following manner:
excess contaminant is absorbed with paper towel. The chair is then rinsed under a shower with a
continuous flow of clean water. Disinfectant is then sprayed on the item and left for a minimum of
10 minutes (or per manufacturer instructions). The chair is then rinsed under clean water again,
before storing it its regular location.
12. Head floats that have been contaminated with feces or blood will be thrown out. Other body
fluids contaminating the head floats can be either wiped with a hospital approved disinfectant or
washed in the washer.
13. Body fluid spills, (outside the pool basin) are first soaked up using paper towel. Dispose of the
paper towel in the garbage. A hospital approved disinfectant is then used to wipe the area, which
is left to air dry. A mop can be used for large spills after the paper towels have absorbed as
much of the spill as possible. Mop head must be washed and disinfected before reuse on
another surface.
14. Vomit in the pool may create a higher risk for infection.
Page 20
Part 3: Infection Control Guidelines for Staff
1. Staff are expected to follow the same infection control guidelines set out for community clients.
These include washing hands upon arriving at work, protecting open wound with waterproof
dressings, putting a towel down on any bench you use to change on, ensuring your belongings are
tucked away while working and having a cleansing shower before and after using the pool.
2. Staff are also expected to ensure a clean environment by doing the following:
 Remind community clients to wash their hands upon arrival.
 Remind community clients to take a cleansing shower before entering the pool.
 Remind community clients to place their towel down upon the bench to sit on while changing.
 Wipe the benches in the change room with a hospital approved disinfectant as often as time
permits, preferably between each client.
3. Staff are expected to wear appropriate footwear around the pool following the footwear guidelines for
pool staff.
4. Staff should encourage clients to wear appropriate footwear around the pool facility.
5. Do not allow any open wounds that are not appropriately covered in the pool.
Part 4: Responding to Fecal Accidents in Rehabilitation Swimming Pools
Information from the Center for Disease Control (Atlanta, Georgia) addresses fecal accidents in pools. In
recent times, there have been increasing concerns about the transmission of Cryptosporidium parvum in
swimming pools. While this parasite can cause self-limited diarrhea in healthy people, the diarrhea can be
much more significant in those with severe immunosuppresion. The infecting dose of Cryptosporidia is quite
small, and even a small visible fecal spill of liquid can contaminate an entire pool. Most bacteria are very
susceptible to low concentration of free chlorine, however, Cryptosporidia are not. Chlorine (2ppm) kills
Escherichia coli in less than 1 minute, while Cryptosporidia may require as long as 8 hours.
Although Cryptosporidia may be found in the stool of people who have persistent diarrhea and nausea,
investigators from the CDC have demonstrated Cryptosporidia are not carried as normal human enteric flora,
and is not found in formed stool.
In order to address the potential hazards of Cryptosporidia parvum, pool protocols have been designed to
combat this organism. This has lead to the recommendation of raising chlorine concentrations for up to 8
hours, and to maintain the pool unused for 3-4 filtration cycles for 24 hours.
The consequences of these policies have been significant on pools used for rehabilitation patients. Many
individuals may have incompetent sphincter control, resulting in minor incontinence without diarrhea or being
unwell. Small accidents, which have been totally contained within the bathing suit, are a relatively common
occurrence. Unfortunately, these occurrences have been sufficient to trigger pool-closure responses, which
last 24 hours. The consequence is that pools may be closed as often as they are open. This results in
severe restrictions, inconvenience, and loss of valuable therapeutic pool time for many individuals.
To address pools potential contaminated with feces or vomit, please refer to the “Fouled Pool Remedial
Procedure”.
Page 21
REFERENCES
BC Health Act, “SWIMMING POOL, SPRAY POOL AND WADING POOL REGULATIONS”, B.C. Reg.
289/72,O.C. 4190/72 Responding to fecal accidents in disinfected swimming venues. CDC MMWR weekly.
May 25, 2001. 50(20); 416-417.
Vancouver Coastal Health. Guidelines for the Stan Stronge Pool.
Provincial Infection Control Network of British Columbia. Appendix 7: Pools. PICNet Antibiotic Resistant
Organism Provincial Guidelines. Draft Two. April 18, 2008.
Interior Health Fouled Pool Remedial Procedures
Section 10X - IX0700 (Toy Management)
Page 1

IX0700: Toy Management
REVIEWED DATE:
1.0 PURPOSE:
To prevent transmission of infections by contact routes, toys used in any department, inpatient unit or
practice for therapeutic, diagnostic or entertainment purposes will be cleaned/disinfected on a routine
basis and when visibly soiled .Recognizing the importance of play and education to a hospitalized
child and realizing the potential of spread of infection with shared toys, hands and person-to-person
contact, the following guidelines are recommended.
2.0 GENERAL PRINCIPLES
2.1. Only toys that can be easily cleaned (plastic or non-porous) are provided.
2.2. Stuffed toys are not permitted. If a child must have a stuffed toy, it must be labeled with the
child’s name, used only by that child and sent home or discarded at discharge.
2.3. Mobiles that contain stuffed toys are not allowed.
2.4. No special precautions are needed for magazines or books, unless visibly soiled. Items that
cannot be cleaned with hospital-approved disinfectant or soap and water should be
discarded.
2.5. Rooms with children on Additional Precautions will remain there throughout hospitalization.
When the patient is discharged, toys should be disinfected with hospital-approved
disinfectant before return to a central storage area.
2.6. Stuffed toys in common areas such as halls, waiting rooms, family rooms that are used to
enhance the décor are not permitted.
2.7. Communal toys including large wheel toys are cleaned weekly and when visibly soiled.
2.8. Toys used for testing will be cleaned after each use.
3.0 PROCEDURE
3.1. Use regular soap and water for cleaning visible dirt/soil.
 Wash toys with soap using friction.
 Rinse with water and dry.
3.2. Hospital approved disinfectant for cleaning toys that are mouthed or contaminated and those
used with children on Additional Precautions.
 Wipe toys with disinfectant.
 Allow 10 minutes contact time.
 Rinse with water and dry.
Section 10X - IX0700 (Toy Management)
Page 2
4.0 REFERENCES:
4.1. Guidelines for Isolation Precautions in Hospitals, Hospital Infections Program, Center for
Infectious Diseases, Center for Disease Control, U.S. Department of Health and Human
Services, Atlanta, Georgia, 1996.
4.2. APIC Text 2009; Chapter 39 Pediatrics, Basic Principles
Section 10X – IX0800 (Personal Care Supplies Best Practice Guidelines)
Page 1
A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on
IHNET at the Policies & Procedures Home Page
EFFECTIVE DATE: June 2009

IX0800: Personal Care Supplies
Best Practice Guidelines REVISED DATE: November 2010
1.0 PURPOSE:
To ensure that personal care supplies are not shared and are kept clean and prevent transmission of
microorganisms to other patients and healthcare providers.
2.0 DEFINITION
Personal care supplies include items used for bathing, skin care, nail care, oral hygiene, denture
care, dressing care and incontinence care.
Included are the following items:

 Skin cleansers.
 Lotions.
 Creams.
 Soaps.
 Razors.
 Toothbrush.
 Toothpaste.
 Denture box.
 Comb and hairbrush.
 Nail file and clippers.
 Dressing supplies.
 Any other articles needed for personal hygiene.
3.0 GENERAL PRINCIPLES:
Personal care supplies should not be shared between patients.
3.1 Acute Care, Rehabilitation units, and Psychiatry units

 Each patient should bring in his/her own personal care items.
 Electric razors should not be shared between patients.
 Personal disposable razors can be used and must be disposed of in designated waste
receptacle.
 Nail/foot care equipment must be sterilized between patients.
 Lotions, soaps and creams - Use a ‘tongue’ depressor or separate cup to dispense to
avoid contamination of the bottle and contents.
 Unused products kept at the bedside should not be restocked unless they can first be
appropriately cleaned and disinfected. Single-use items must not be reprocessed and
must be discarded.
Section 10X – IX0800 (Personal Care Best Practice Guidelines)
Page 2
3.2 Residential Care

 Each resident must have his/her own personal care items.
 Personal care items should be cleaned regularly.
3.3 Foot care clinics or contractors coming into Interior Health facilities
 Shared foot care equipment must be sterilized between residents/clients. This includes
clippers, files, and scissors.
4.0 PROCEDURE
4.1 Labeling
 Each patient’s personal supplies should be identified with his/her name and kept at
his/her bedside in a clean container (e.g. in a washable cosmetic bag or plastic
container). Toothbrush and oral hygiene products should be kept in a separate bag or
container at the bedside.
 Patient’s personal care items must be sent with the patient when discharged.
4.2 Cleaning and Storage

Lotions:
 Preferably, use lotions in a bottle with a pump and labeled with patients name.
Soaps:
 Bar soap must be kept in a clean, dry soap dish that allows the bar to drain between
uses.
 Personal liquid body soap is preferred because it is more easily stored between uses.
Wound/Skin Cleansers:
 Wound and skin cleansers must not be shared. Each patient should have a personal
cleanser labeled with the patient name.
 Each resident should have a personal incontinence care cleanser labeled with their
name.
Creams:
 Use a tongue depressor to dispense cream from jar to avoid contaminating the cream.
Toothbrush:
 Change every three months and after an illness. Keep in a plastic toothbrush container.
Ensure it is stored protected from toilet aerosols.
Denture box:
 Label with patient name. Rinse and dry daily.
Comb and Hairbrush:

 Label with patient name. Clean at the same time as hair is washed. Clean in hot soapy
water, rinse and allow to air dry.
Hair Rollers:
 Wash in hot soapy water between residents.
Nail file and clipper:

 Label with patient name. Clean and dry after each use.
Section 10X – IX0800 (Personal Care Best Practice Guidelines)
Page 3
Razors:
 Clean electric razors after each use with a personal razor brush. Don’t share.
 Personal disposable razors can be used and must be disposed of in designated waste
receptacles.
Bedpans:
 Clean and disinfect after each use. Never place on the floor.
 Disposable bedpans are acceptable.
Bowls for washing:

 Clean with soap and water and dry after each use.
5.0 REFERENCE:
5.1 Infection Prevention and Control Best Practices For Long Term Care and Community Care
Including Health Care Offices and Ambulatory Clinics. June 2007 Sponsored by Canadian
Committee on Antibiotic Resistance.
Section 10X – IX0900 (Construction Projects)
Page 1

IX0900: Construction Projects
REVISED DATE: September 2012
December 2012, December 2014
REVIEWED DATE:
1.0 PURPOSE
Construction projects, in particular renovation projects, pose potential health risks for patients,
staff, visitors and construction personnel that may lead to healthcare associated infections.
These risks most commonly develop when dust particles contaminated with bacteria and/or fungi
are dispersed into adjacent patient care areas. The primary fungus associated with these
infections is Aspergillus while the main bacterium is Legionella.
Note
 CSA Z317.13-12 Dec 2012 shall be used to determine population risk group,
construction activity type, and preventative measures.
 Prevention Measures will be outlined in the construction documentation prior to
the construction project starting and prior to the project going to tender.
 Class of Preventative Measure Level I and II will be determined by the Plant
Services staff in the facilities. If Plant Services staff has questions pertaining to
the stratification of the risk groups, the Infection Prevention and Control
Practitioner will be contacted.
 Infection Prevention and Control Practitioners will be involved in all discussions
involving the Class of Preventative Measure Level III and IV and the ICP will sign
off the Infection Control Construction permit.

The Infection Control Practitioner must be given a minimum of 48 hours
.
notice by anyone requesting a permit before the scope of work can be
assessed and a permit issued.
The IX1000 Construction and Renovation Guidelines are the specifications that are provided
to the consultants in the tender package. This document will be included in the Request for
Proposal as well as the “front end” document that Facilities Management provides to the
consultants when preparing tenders.
All new projects or renovations shall ensure that appropriate infrastructure is in place to support
the IH hand hygiene program and will follow the CSA Z8000-11 standards.
Section 10X – IX0900 (Construction Projects)
Page 2
2.0 References
2.1 CSA Standard: Canadian health care facilities. CSA Z8000-11 September 2011.
2.2 CSA Standard: Infection Control during Construction or Renovation of Health

Care Facilities. CSA Z317.13 – 12 Dec 2012
Section 10X – IX1000 (Construction & Renovation Guidelines)
Page 1

IX1000: Construction & Renovation Guidelines
REVISED DATE: September 2012
December 2012, February 2013, March 2013
May 2014
1.0 PURPOSE REVIEWED DATE:
To prevent construction or renovation related infections in staff, clients and visitors.
To provide guidelines to be followed during construction or renovation of health care facilities.
2.0 GUIDELINE
2.1. Pre-Approval Assessment
A well-managed multidisciplinary team with appropriate expertise will be established early

in the planning stage of construction and renovation projects. The multidisciplinary team
shall include:
 Infection prevention and control.
 Administration.
 Project management.
 Environmental services.
 Health care (e.g. medical and nursing staff).
 Design (e.g. architects, engineers).
 Operations and maintenance.
 Construction/renovation personnel.
Assessment of the risks to occupants of the health care facility is necessary before
construction or renovations begin. The Planning Department and Engineering or
operations and maintenance will keep the Infection Control Service informed regarding
the location of all areas of renovation and construction as soon as possible, during the
planning stages.
Page 2
2.2. Approval
The Infection Control /Construction Form will be used by the Infection Control
Practitioner, or designated person, when assessing projects. All construction and
renovation shall utilize CSA Z317.13-12 to determine risk group, construction activity
type, and preventative measures( Appendix 1-3).
The Infection Control Service must review all planned projects falling under the category
of Class of Preventative Measure Level III and IV. All construction workers must follow
the infection control procedures described in this guideline.
Engineering or operations and maintenance and/or the Planning Department in
collaboration with the Infection Control Service will determine the Class of Construction
Activity for each project.
Page 3
Infection Prevention and Control Measures for New Projects
For preventative measures III and IV (includes new construction projects, construction on
vacant land, facility additions, and space redevelopment) the following shall apply:
 Prior to construction the constructor shall present an infection control plan to the
multidisciplinary team including selection, design, application, specification, and
assembly of construction materials to be used in the project.
 Constructor proposed infection prevention and control measures must encompass
the duration of the project and ongoing maintenance and operations.
 The multidisciplinary team shall communicate its policies and procedures to the
constructor before construction begins.
 The constructor should designate an individual responsible for infection control to
liaise with the multidisciplinary team and monitor and coordinate the infection
control procedures. The multidisciplinary team should designate a representative to
communicate with the constructor and attend construction meetings as necessary.
 On approval of the infection control plan by the multidisciplinary team, the
constructor should coordinate infection control education sessions for all suppliers
and subcontractors participating in the project. A copy of the infection control plan
shall be provided to all subcontractors and compliance will be imposed in all
subcontracts.
 Infection Prevention and Control Practitioners will be involved in all discussions
involving the Class of Preventative Measure Level III and IV and the ICP will
sign off the Infection Control Construction permit.
 The Infection Control Practitioner must be given a minimum of 48 hours notice

by anyone requesting a permit before the scope of work can be assessed and a
permit issued.
 Infection prevention and control measures shall be constantly monitored and shall
be reviewed at every construction and project management meeting.
 If, during construction, events that can present infection risks occur, intervention
procedures shall be implemented immediately to resolve the problems.
 Plumbing and HVAC systems shall be supplied, installed, and commissioned in
accordance with CAN/CSA-Z317.1, CAN/CSA-Z317.2, and CAN/CSA Z318.0.
Page 4
2.3. Project Monitoring
An ICP shall
ensure that the appropriate preventative measures are initiated and adhered to.
As a member of the multidisciplinary team, the ICP shall have the authority to stop
construction if there is a significant failure to adhere to the required preventative
measures. The multidisciplinary team shall have a procedure in place for notifying
relevant HCF and construction management personnel in the event of a construction
stop.
2.4. Infrastructure
All projects, both new construction and renovation, shall utilize CSA Z8000-11 standards
to ensure that appropriate infrastructure is in place within IH healthcare
facilities(Appendix 4.)
3.0 REFERENCES
3.1. Canada Communicable Disease Report: Construction-related nosocomial infections in

patients in health care facilities. July 2001
3.2. CSA Standard: Infection Control during Construction or Renovation of Health Care
Facilities. CSA Z317.13 – 12 Dec 2012
3.3. CSA Standard: Canadian health care facilities. CSA Z8000-11 September 2011.
Page 5
APPENDIX 1
Infection Control Construction Permit / Sign Off Form
Location of Construction:___________________ Supervisor:____________________
Project Coordinator: ____________________ Project Start Date: ___________________
Contractor Performing Work:___________________ Estimated Duration: __________________
Supervisor:___________________ Telephone:____________________
YES NO CONSTRUCTION LEVEL YES NO Population RISK GROUP
TYPE A: Inspection, non-invasive activity GROUP 1: Least Risk

TYPE B: Small scale, short duration, moderate
to high levels GROUP 2: Medium Risk
TYPE C: Activity generates moderate to high
levels of dust, requires greater 1 work shift for GROUP 3: Medium/High
completion Risk
TYPE D: Major duration and construction
activities requiring consecutive work shifts GROUP 4: Highest Risk
Area Free of Hazardous Materials: Yes No (if No, attach description and abatement requirements).
Visual Checklist for work within existing building to check for Mold Presence completed.
 Mold Presence not detected

 Mold Detected
 Abatement Complete
Type of Construction or Renovation: Circle A B C D (Risk Assessment for Types of Construction

Activity Table, Schedule 1)
Population Risk Group: Circle 1 2 3 4
CLASS OF PREVENTATIVE MEASURE

Construction Level (Type A,B,C,D)
Type A Type B Type C Type D
Group 1 I II II III/IV
Group 2 I II III IV
Group 3 I III III/IV IV
Group 4 I - III Contact IC III/IV III/IV IV
Class of Preventative Measure Required: Level I II III IV
Has the multidisciplinary team been involved; Yes No
Date: ___________________________ Date: ___________________________
________________________________ ________________________________
Interior Health – Infection Control Professional Construction Representative
Additional Requirements: Attach copy
Date: ___________________________ Signature: ___________________________
Date: ___________________________ Signature: ___________________________
Infection Control Measures in Place. Work Authorized to Proceed:
Date: ___________________________ Date: ___________________________
________________________________ ________________________________
Interior Health – Infection Control Professional Construction Representative
Page 6
Original: Infection Control Practitioner

Copy: Project Manager or Plant Manager
APPENDIX 2
Schedule 1
Type of Construction Activity for Risk Assessment: (Table 3: taken from CSA Guideline Z317.13-12
Dec 2012)
Construction Level Type A: a)activities that require removal of not more than one ceiling tile
or require wall or ceiling panels to be opened;
Inspection, non-invasive activities
b)painting (but not sanding) and wall covering;
c)electrical trim work;
d)minor plumbing work that disrupts the water supply to a
localized patient care area (i.e. one room) for less than 15 min.;
and
e)other maintenance activities that do not generate dust or
require cutting of walls or access to ceiling other than for visual
inspection.
Construction Level Type B: a) activities that require access to chase spaces;
Small scale, short duration activities b) where dust migration can be controlled, cutting of walls or
that create minimal dust. These ceilings for installing or repairing minor electrical work,
include, but are not limited to, ventilation components, telephone wires, or computer cables;
c) sanding or repair of a small area of a wall; and
d) plumbing work that disrupts the water supply of more than
one patient care area (i.e. two or more rooms) for less than
thirty min.
Construction Level Type C: a) activities that require sanding of a wall in preparation for
painting or wall covering;
Activities that generate a moderate to
high level of dust, require demolition, b) removal of floor coverings, ceiling tiles, and case work;
require removal of affixed facility
c) new wall construction;
component (e.g. sink) or assembly
(e.g. countertop or cupboard), or d) minor duct work;
cannot be completed in a single work
shift. These include, but are not e)electrical work above ceilings;
limited to, f) major cabling activities; and
g) plumbing work that disrupts the water supply of more than
one patient care area (i.e. two or more rooms) for more than 30
min but less than 1 h.
Construction Level Type D: a) activities that involve heavy demolition or removal of a
complete cabling system;
Activities that generate high levels of
dust, and major demolition and b) new construction that requires consecutive work shifts to
construction activities requiring complete; and
consecutive work shifts to complete.
These include, but are not limited to, c) plumbing work that disrupts the water supply of more than
one patient care area (i.e. two or more rooms) for 1 h or more.
Page 7
Border Risk Groups Assessment (Table 2: taken from CSA Guideline Z317.13-12 Dec 2012)
Group 1  Office areas

Lowest Risk  Unoccupied wards
 Public areas
 Laundry and Soiled Linen cleaning areas
 Physical Plant Workshops and housekeeping areas
Group 2  Patient care areas unless listed in Group 3 or 4
Medium Risk  Outpatient clinics (except for oncology & surgery)
 Admission and discharge units
 Waiting rooms
 Autopsy and morgue
 Occupational therapy areas remote from patient care areas
 Physical therapy areas remote from patient care areas
Group 3  Emergency (except trauma rooms)
Medium to High Risk  Diagnostic Imaging
 Labor & birthing rooms (non-operating)
 Nurseries for healthy newborns
 Nuclear medicine
 Hydrotherapy
 Echocardiography
 Laboratories
 General Medical and surgical floors
 Pediatrics
 Geriatrics
 Long Term care
 Food preparation serving and dining areas
 Respiratory therapy
 Clean linen handling and storage areas
 Intensive care units (ICU’s)
Group 4  Operating rooms (including prep, induction, post-anesthetic care unit
Page 8
Highest Risk (PACU), and scrub areas

 Anesthesia storage areas and work rooms
 Oncology units and outpatient clinics for cancer patients
 Transplant units and outpatient clinics for transplant patients
 Wards and outpatient clinics for patients with AID’s or other
immunodeficiency diseases
 Dialysis units
 critical care nurseries (NICU)
 Labor and delivery operating rooms
 Cardiac catheterization and angiography areas
 Cardiovascular and cardiology patient areas
 Endoscopy
 Pharmacy admixture rooms
 Sterile processing rooms
 Sterile supply areas
 Burn care units
 Animal rooms
 Trauma rooms
 Protective environment isolation rooms
 Tissue culture laboratories
 Bronchoscopy
 Cystoscopy
 Pacemaker insertion rooms
 Dental procedure rooms
 Central processing department
Construction activity and Risk Group Matrix

 The Infection Control Service must be involved with the multidisciplinary team at the planning stage
for all Class of Preventative Measure Level III and IV activities. An Infection Control Practitioner will
be assigned to each project and will regularly visit the construction area.
 Please notify the Infection Control Service when work is being done on hallways adjacent to patient
care areas that fall into a Population Risk Group of 3 or 4.
 Circumstances may necessitate changing the Class of Preventative Measure Level at any time during
the project. Any changes to the scope of work, the Infection Control Practitioner assigned to the
project, must review to determine if there is a further impact on infection control.
Page 9
CLASS OF PREVENTATIVE MEASURE

Construction Construction Construction Construction
Level Type A Level Type B Level Type C Level Type D
Populations I II II III/IV
Risk Group 1
Population I II III IV
Risk Group 2
Population I III III/IV IV

Risk Group 3
Population I – III III/IV III/IV IV

Risk Group 4 *Contact infection
control to ensure
appropriate
classification
 See Table 3 for Construction Activity and Table 2 for Population Risk Group.
 Shaded activity areas indicate increased risks to population and implementation of stringent Infection
Control precautions. Infection Control Construction Permit/Sign Off Form required for all Construction
Activity.
 When the Class of Preventive Measure is Level III/IV, a multidisciplinary team shall determine the
appropriate prevention measures required, either Level III or Level IV.
Guidelines for Dust Containment during Construction

Engineering and operations or maintenance staff and/or the Planning Department in collaboration with the
Infection Control Service will determine the Class of Construction Activity for each project. Please refer to
the guidelines below for dust control measures for the Activity Class of the project. If the level of
construction activity changes during the course of the project, please notify Engineering and operations or
maintenance, and/or the Planning Department and/or the Infection Control Service before proceeding.
Page 10
APPPENDIX 3
CLASS OF
PREVENTATIVE MEASURE
Level I Engineering or Operations and Maintenance Staff or Constructors
 Minimize dust during construction operations.
 Clean the work area with a HEPA vacuum cleaner if necessary.
 Wipe work surfaces with a hospital approved disinfectant after the project is completed.
 Immediately replace any ceiling tile or access panel displaced for visual inspection.
Plumbing Activities
 Schedule water interruptions during low activity.
 Flush water lines for a minimum of 10 minutes prior to reuse - check for discolored water.
 Ensure that gaskets and items made of materials that support the growth of Legionella are not
being used.
 Ensure faucet aerators are not installed or used.
 Maintain as dry an environment as possible and report any leaks that occur to walls and
substructures.
Environmental Services
 Report discolored water and water leaks to Maintenance and Infection Control.
Medical/Nursing Staff
 Minimize patients' exposure to construction/renovation area.
 Ensure that patient care equipment and supplies are protected from dust exposure.
After construction
 The multidisciplinary team shall review the preventive measures that were undertaken and
assess their effectiveness.
Level II Note: In addition to following preventative measure I the following measures shall be met.
Engineering or Operations and Maintenance Staff or Constructors

 Seal windows and unused doors.
 Seal plumbing penetrations, electrical outlets, and any other sources of potential air leaks in the
construction area.
 Seal air vents in the construction area and if possible disable until construction completed
 Use drop sheets to control dust.
 Place walk off mat outside of entrance of construction area to trap dust from the equipment and
shoes of personnel leaving the area.
 Wet mop and /or vacuum (with HEPA filtered vacuum) at end of day as well as when the mat is
visibly soiled.
 Walk off mats shall be of sufficient size to ensure that constructors have to place both feet on the
mat at least once on exiting the construction area.
 Water mist work surfaces to control dust while cutting (note: caution should be exercised when
such techniques are used on cellulose or fibre based materials that are intended to stay in place
Page 11
following construction work).
 Contain debris in covered containers or cover with a moistened sheet before transporting it for
disposal.
 Place supplies and equipment in covered containers during transportation through the healthcare
facility to prevent contamination in other areas.
 Remove debris in the evening when patients are in their rooms and visitors have left. If this is not
possible debris should be removed at the end of the work day.
 Wipe work surfaces with a hospital approved disinfectant at end of project
Plumbing Activities
 Avoid collection tanks and long pipes that allow water to stagnate.
 Hyper chlorinate (to a minimum of 50 parts per million) or superheat (to a minimum of 70 degrees
Celsius) stagnant domestic water (especially if Legionella is already present in the domestic water
supply). The water lines in the construction area and adjacent patient care areas shall be flushed
for a minimum of ten minutes before reuse; and note: Preventative technologies (e.g. silver-copper
ion treatments) may be considered in lieu of the techniques specified above.
 Be aware of the impact of techniques to remove bacterial growth and choose the approach that
minimizes the risks associated with such work
Medical/Nursing Staff/Administration
 Identify high-risk patients who may need to be temporarily moved away from the construction
zone.
After Construction
 The multidisciplinary team shall
a. Review the preventive measures that were undertaken and assess their effectiveness;
and
b. Conduct a final inspection to ensure that the ventilation system is functioning properly
in the construction area and adjacent areas.
 Infection prevention and control personnel shall ensure that the construction area has been
thoroughly cleaned before building occupants are readmitted to the completed construction
area.
 Environmental services and healthcare staff shall
a. Ensure that the construction area has been cleaned with a HEPA filter-equipped
vacuum cleaner, a wet mop, or both, as necessary, and that horizontal work surfaces
have been wiped with a disinfectant; and
b. Report discolored water and water leaks to the maintenance and infection prevention
and control departments.
Level III Note: In addition to following preventative measures I and II the following measures shall be
met.
Minimization of dust generation and dispersal
 Erect an impermeable dust barrier, from the floor to the underside of the deck (including the
areas above false ceilings) consisting of two layers of 0.15mm (6 ml) fire-retardant polyethylene
(or an equivalent barrier) and gypsum wall board protection approved by the multidisciplinary
team. The dust barrier shall remain in place until the project is complete and the area has been
cleaned thoroughly and inspected. After construction has been completed, the dust barrier shall
Page 12
be removed to prevent the spread of dust and other debris particles adhering to the barrier;
 Use impermeable vessels constructed to contain contaminants. Such vessels shall have a
monolithic (one-piece) exterior shell constructed of a minimum of 0.20 mm (8 ml) fibre-
reinforced, fire-retardant polyethylene. The construction of the vessel shall allow for
containment of contaminants within the vessel and have ports through which HEPA-filtered
vacuum cleaners or portable construction HEPA-filtered air units can be easily attached to draw
the unit under negative pressure;
 Vacuum mechanical and electrical systems and spaces above drop or false ceilings, if
necessary; and
 Remove protective clothing before entering patient care areas.
Ventilation Systems
 Disable the ventilation system and seal duct openings in the construction area until the project
is completed;
 Maintain a negative pressure of 7.5pa (0.03 in wc) within the construction area using portable
HEPA filter-equipped air filtration units that include pressure gauges and an alarm. Filters shall
be monitored and replace if clogged or functioning below the manufacturers specifications;
 Ensure that the air is exhausted directly outside and away from intake vents and filtered
through an HEPA filter. In conditions that prohibit exhausting exhaust outside, air may be
recirculated in accordance with Clauses 6.6 and 7.2.3.6 (CSAZ317.13-12); and
 Ensure that the ventilation system is functioning properly and cleaned if contaminated by soil or
dust after the construction project is complete.
Portable construction HEPA-filtered air units
 Construction area exhaust shall be HEPA filtered. Filters shall be visually inspected by the
constructor at least daily, condition documented, and replaced when loaded.
 HEPA filtered air units shall be certified at the beginning of any preventative level III or IV
construction activity. Units shall be recertified at least every 12 months and the recertification
shall be documented.
 Construction, maintenance, and repair area exhaust air shall not be discharged to areas
occupied by Population risk group 3 or 4. Measures related to recirculated air shall require
approval from the multidisciplinary team.
 The relative space pressures between areas occupied by Population risk group 3 or 4 shall be
continuously monitored.
Impact on the facility HVAC system
 Portable air filtration units may affect a facility’s HVAC system; therefore,
 The main facility system shall be verified for operation in accordance with design during
construction work.
 The healthcare facility and constructor shall verify the pressure relationships for critical areas
near the construction area.
Construction air handling
 Permanent air handling systems should not be used for exhausting air from construction or
renovation work areas. Temporary duct work may be installed for such purposes. However, it
Page 13
shall not connect to the facility’s HVAC system.

 In cases where air cannot be directly exhausted outside(not tying into another system), exhaust
air may be piped to the building exhaust system if an engineering analysis has been performed
by qualified personnel to ensure that the exhaust air will not be re entrained into the occupied
building and the multidisciplinary team approves piping to the exhaust system.
 Where air cannot be directly exhausted outside or piped through the building exhaust system, it
may be recirculated into areas of the building occupied by Risk Group 1 or 2 if multidisciplinary
team approval is granted. Construction exhaust air shall not be recirculated into building areas
occupied by Risk Group 3 or 4.
Cleaning and Maintenance
 Engineering or operations and maintenance staff in the construction area shall clean outside
the work area with a HEPA filter-equipped vacuum cleaner every day or more frequently if
necessary.
 Environmental services staff shall

a. Increase the frequency of cleaning adjacent to the construction area.
b. Wet mop and vacuum the area with a HEPA filter-equipped vacuum cleaner as
necessary and when the work is complete; and
c. Wipe exposed surfaces with a hospital grade disinfectant.
Role of infection prevention and control personnel
 To collaborate with the environmental services staff to ensure the construction area is
thoroughly cleaned when work is complete;
 Inspect the integrity of dust barriers; and
 In collaboration with the facility program manager, designating a traffic pattern for constructors
that avoids patient care areas and a traffic pattern for clean or sterile supplies and equipment
that avoids the construction area.
Role of healthcare staff
Healthcare staff shall
 Ensure that patient care equipment and supplies are protected from dust exposure;
 Ensure that patients do not go near the construction area;
 Ensure that staff do not visit the construction area; and
 Report discolored water and water leaks to maintenance and infection prevention and control
personnel.
After Construction
 The multidisciplinary team shall
c. Review the preventive measures that were under taken and assess their effectiveness;
and
d. Conduct a final inspection to ensure that the ventilation system is functioning properly
in the construction area and adjacent areas.
 Infection prevention and control personnel shall ensure that the construction area has been
thoroughly cleaned before building occupants are readmitted to the completed construction
area.
 Environmental services and healthcare staff shall
Page 14
c. Ensure that the construction area has been cleaned with a HEPA filter-equipped
vacuum cleaner, a wet mop, or both, as necessary, and that horizontal work surfaces
have been wiped with a disinfectant; and
d. Report discolored water and water leaks to the maintenance and infection prevention
and control departments.
Level IV Note: In addition to following preventative measures I, II, and III the following measures shall be
met.
 Ensure that all access shall be from outside the occupied areas of the healthcare facility, or
construct anterooms at access points to the construction area if access is from within the
healthcare facility;
 Place a walk-off mat outside and inside the anteroom to trap dust from equipment, debris, and
the shoes of personnel leaving the construction area. Walk off mats shall be of sufficient size to
ensure that constructors have to place both feet on the mat at least once on exiting the
construction area;
 Ensure that the constructors
a. Leave the construction area through the anteroom so that they can be vacuumed with
a HEPA filter-equipped vacuum cleaner before leaving; or
b. Wear protective clothing that is to be removed each time they leave the construction
area and before going into patient care areas;
c. Repair holes in walls within 8 hours or seal them temporarily;
d. Ensure that ventilation systems are working properly in adjacent areas; and
e. Carefully remove barrier walls and use short term protection to minimize environmental
contamination during removal.
 Environmental services staff shall ensure that the construction area is thoroughly cleaned when
work is complete.
 Infection prevention and control personnel shall regularly visit the construction area to ensure
that preventative measures are followed. The frequency of their visits shall be determined by
the multidisciplinary team
 Infection prevention and control measures shall be constantly monitored and shall be reviewed
at every construction and project management meeting
 If, during construction, events that can present infection risks occur, intervention procedures
shall be implemented immediately to resolve the problems
 Plumbing and HVAC systems shall be supplied, installed, and commissioned in accordance
with CAN/CSA-Z317.1, CAN/CSA-Z317.2, and CAN/CSA Z318.0
 Before substantial completion and occupancy, the constructor shall have satisfied all infection
control measures. Detailed inspections shall be performed by the multidisciplinary team
After construction
 In addition to preventative measures II and IIl before the completed construction area is
occupied any portions of the infection control plan still in effect shall be reviewed by the
multidisciplinary team.
 If necessary such portions shall be incorporated into the healthcare facilities ongoing operating
Page 15
policies and procedures.
Page 16
APPENDIX 4
Quick Reference Guide for CSA Z8000-11 Guidelines
Infection Prevention and Control & Facility Infrastructure Requirements
Infection Prevention & Control shall be involved from the design phase through to commissioning
in both new construction and renovations of existing facilities.
Canadian Standards Association (CSA) Standards shall be incorporated into all

construction/renovation projects. With renovations every effort shall be taken to follow the latest
CSA standards.
This includes:
1. CSA Z317.2 – 10: Special requirements for heating, ventilation, and air conditioning (HVAC)
systems in health care facilities, 2010.
2. CSA Z8000 – 11: Canadian health care facilities, 2011.
The need for facility renovations shall be identified by the mandatory use of the biennial audit tool Best
Practices for Hand Hygiene in all Healthcare Settings: Supplementary checklist for facilities and
infrastructure needed to support healthcare providers; Provincial Hand Hygiene Working Group –
Facilities/Infrastructure Team (2012)
Quick Reference Guide for CSA Z8000-11 Guidelines
Item Explanation Page

Airborne isolation rooms Each acute care facility shall have a minimum of one AIR Page 94 (also
(AIR) per inpatient unit unless a risk assessment demonstrates see page 26-27
otherwise of CSA Z317.2-
10)
Allied Health Services For complete information see pages > Page 244-247
Ambulatory Care For complete information see pages > Page 174-183
Ceilings For complete information see pages > Page 354, Page
361-362
Clause 11 Table of common requirements Page 327-353
Clean supply/utility room Clean and soiled utility rooms shall be separate Page 329
Supplies shall be stored in mobile shelving that is
cleanable, smooth, non porous, and tolerant of
hospital disinfectants; or automated dispensers
 Equipment and supplies shall not be exposed to
direct HVAC air flow, or stored by windows
 See section on floors/walls/ceilings
Dialysis For complete information see pages > Page 184-191
Dining Room For complete information see pages > Page 333
Electrodiagnostic For complete information see pages > Page 267-273
Page 17
Services
Emergency For complete information see pages > Page 209-223
Examination/procedure/tr  A wall mounted hand hygiene sink shall be Page 333-335

eatment room located adjacent to the door along with a hand
hygiene station
 Soiled linen hamper and soiled garbage
container shall be provided
 Storage of supplies should be provided in closed
cupboards
Floors For complete information see pages > Page 359-361
Hand hygiene sinks Dedicated hand hygiene sinks shall be provided Page 96-97
A hand hygiene sink is required:
 In each inpatient bedroom
 Where treatments/exams/assessments are
provided
 Locations designed for one patient: one sink
 Locations designed for three or more patients:
one sink per three patients, with 6 m. or less
between any patient and sink
 Inside(if plastic pipes used), or adjacent to each
diagnostic MRI room
 Stainless steel hand hygiene sinks shall be used
in areas handling radioactive materials
 In each soiled utility/soiled holding room
 In any food prep area
 Inside or within 6 m. of each nursing station
 Inside or within 6 m. of each staff lounge
 In medication preparation areas
 Within 6 m. of each laboratory work station and
within each work room
 Where soiled linen is handled
 Any area where hands are likely to be
contaminated
 In each airborne isolation room and each
anteroom
 For complete information on materials, size,
construction, location, controls, backsplash, Page 337-339
dispensers and hand dryers see pages >
 Sinks must have water supply & drainage
separate from hemodialysis piping Page 186
Housekeeping closet For complete information see pages > Page 339
Infection Control general For complete information see pages > Page 21-24, 91-
information 94
Inpatient room  Shall be single bedded rooms, unless the Page 22, 340-
functional program, with supporting 342
documentation, demonstrates the necessity of a
two-bed arrangement
 Shall have one washroom per patient
Page 18
Inpatient isolation rooms For complete information see pages > Page 343-344
Inpatient washrooms For complete information see pages > Page 342-343
Laboratory For complete information see pages > Page 248-266
Laundry for Rehab and For complete information see pages > Page 344
LTC
Maternal and Newborn For complete information see pages > Page 128-135
MDR  Stainless steel is preferred for surface materials Page 311-325

 Open hoppers shall be located away from staff
work areas and traffic areas
 Ceilings shall be resistant to humidity, non
porous, non shedding, and shall be constructed
without fissures, open joints or crevices
 Solid walls shall have a hard, smooth finish and
may be sealed in epoxy or spray painted
 Flooring shall have integral coved base
 Shelving shall be non porous, non shedding, and
easily cleanable
 The top and bottom of storage carts shall be
solid
Medical Imaging For complete information see pages > Page 278-284
Medication Room For complete information see pages > Page 345
Oncology For complete information see pages > Page 192-208
Operating Rooms and For complete information see pages > Page 224-243
Procedure Rooms
Pharmacy The mixing of parenteral therapy solutions requires Page 285-290
special work stations and air handling
 Chemo prep requires negative pressure
 Sterile medication prep requires positive
pressure
 Anterooms are recommended
 Satellite pharmacy Page 348
Respiratory Cough inducing procedures require special room Page 274-277,

requirements and air handling 347
Scrub sinks Shall be provided where operative procedures are Page 97

performed including ORs, delivery rooms, endoscopy
suites, interventional radiology, and cardiac
catheterization suites
Soiled utility room  Shall be separate from clean utility room Page 348-349
 Separate hand hygiene sink shall be provided
 No storage of clean equipment
 May store patient waste disposal equipment and
stool/urine/vomit specimen supplies
 Shall have human waste management system
Page 19
Splash protection shall be provided on walls near

water supply, sinks, or human waste
management system
 PPE should be available
 Shall provide storage for soiled linen, garbage,
and biohazard carts
Surfaces – ceilings, Shall be smooth, non porous, seamless, resilient and Page 86 - 89
floors, walls, doors, impact resistant, cleanable and compatible with facility
window, furniture approved disinfectants, water impermeable
Tub/Shower room  Shall have a hand hygiene sink at the Page 351-352
entrance/exit just inside room
 Each room shall have storage space for supplies
and PPE
Waiting rooms  Zones shall be created so that the more Page 352
infectious persons are in a separate area
 Public washrooms shall be provided in close
proximity
Walls For complete information see pages > Page 360-361
Washroom - public  Toilet, sink, and paper towel dispensers shall be Page 352
hands free
 Toilets with tanks shall not be used, due to risk of
condensation
Waste management  One washroom with toilet and sink for each Page 94-95
inpatient. A closed waste management
mechanism with hand hygiene sink shall be
installed where toilet not required (e.g. ICU,
NICU or nursery)
 Each inpatient service shall be equipped with at
least one closed waste management system
Waterless hand hygiene Waterless hand hygiene station shall be provided in each Page 97
stations of the following locations: Page 339
 All entrances and exits to the healthcare facility
 Immediately adjacent to the entrance of each
patient bedroom
 Immediately adjacent to the entrance of each
patient care area (e.g. exam or procedure room)
 Adjacent to the bedside at point of care unless
risk to patient
 Where Personal Protective Equipment (PPE) is
donned or doffed
Shall be mounted approximately 1 m. from floor and shall
be in compliance with fire regulation guidelines
Window treatments  Shall be durable and easy to clean Page 356-357

 Blinds to external windows should be installed
Page 20
between double glazing

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INFECTION

Summary of Changes to Infection Prevention & Control November

Section(S) Revised R= Revised N = New

Throughout the manual:

Section 04H – Additional Precautions

Section 08S – Specific Diseases

3.3 Patient Placement and Accommodation

3.7 Cleaning of Patient Environment

Updated sign Contact Plus Precautions

SURVEILLANCE AND OUTBREAKS

Airborne Precautions IH0200  Airborne Precautions Sign #807900

Antibiotic Resistant Organisms for IS0300

Clostridium difficile – Resident with CDI IS0200

Construction & Renovation Guidelines IX1000

Creutzfeldt-Jakob Disease IS0900

Invasive Group A Streptococcal Infections IS0700

Community- Acquired Infections – infections present or incubating at the time of admission to a

3.0 GUIDING PRINCIPLES

Disclaimer for Figure 1 and

2.4 APIC Text 2012.

EFFECTIVE DATE: September 2006

REVIEWED DATE: February 2015

3.0 GUIDING PRINCIPLES

EFFECTIVE DATE: September 2006

See the glossary in Appendix A for definitions.

Routine Practices are used by ALL healthcare providers

Assess the patient for high risk of contaminating environment:

What type of environment is high risk for patient?

4.3 Hand Hygiene Refer to IF0200 HAND HYGIENE GUIDELINE

Activity Best Practice

Hand Hygiene ▪ Before and after every patient/patient environment contact.

4.4 Personal Protective Equipment (PPE)

4.5 Environmental Controls

Activity Best Practice

Activity Best Practice

Activity BEST PRACTICE

Waste REFER TO IF0300 WASTE MANAGEMENT GUIDELINE

4.6 Administrative/Source Controls

Activity BEST PRACTICE

Aseptic Technique – preventative measures to reduce the risk of introduction of microorganisms

EFFECTIVE DATE: September 2006

REVIEWED DATE: Sept 2014 July 2015

See the glossary in Appendix A for hand hygiene definitions.

3.0 GUIDING PRINCIPLES

Hand hygiene is the responsibility of ALL individuals involved in health care.

3.4 Hand hygiene infrastructure

3.6 When Clostridium difficile infection is suspected or diagnosed:

4.1 4 Moments for Hand Hygiene

Reference: Government of Ontario (2006)

THE 4 MOMENTS FOR HAND HYGIENE IN HEALTHCARE:

1. BEFORE initial patient/patient environment contact

4.2 Additional Moments for Hand Hygiene

4.3 Hand Hygiene Using Alcohol Based Hand Rub (ABHR)

4.4 Hand Hygiene Using Soap and Water

4.5 Hand Hygiene for Patients

4.6 Surgical hand scrubs are performed in the operative setting

4.7 Hand Care

4.8 Nails, Jewelry and Clothing:

4.9 Other Impediments to Effective Hand Hygiene

5.1 AH0700 – Interior Health Administrative Hand Hygiene Policy.

5.4 APIC Text 2009.

EFFECTIVE DATE: September 2006