The Healthcare Infection Control Practices Advisory Committee's 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings builds upon a series of isolation and infection prevention documents promulgated since 1970 (category/disease specific, universal precautions [UP], body substance precautions [BSP]).16 This document reaffirms Standard Precautions as the foundation for preventing transmission during patient care in all health care settings, reaffirms the importance of implementing transmission-based precautions (airborne, droplet, contact) based on the clinical presentation or syndrome and likely pathogens until the infectious etiology has been determined, and provides evidence-based recommendations whenever possible.
Standard Precautions are used for all patient contact, regardless of suspected or confirmed infection status, in any setting in which health care is delivered. Health care personnel should assume that every person is potentially infected or colonized with an organism that could be transmitted in the health care setting and apply the following infection control practices during the delivery of health care. Standard Precautions are also intended to protect the HCW and patient from picking up infectious agents from each other and from the environment and equipment used during patient care. Education and training on the principles and rationale for recommended practices are critical elements of Standard Precautions because they facilitate appropriate decision-making and promote adherence when HCWs are faced with new circumstances.
Standard Precautions include at a minimum the following practices: hand hygiene, personal protective equipment, barriers, sharp device safety, respiratory etiquette and hygiene, medication and solution handling and storage, single use devices, supply storage and handling, environmental cleaning, instrument handling and storage, and instrument reprocessing.
A. Hand Hygiene
The 2002 CDC Hand Hygiene Guideline defines the appropriate use of handwashing, antiseptic handwash, alcohol based hand sanitizers, and surgical hand antisepsis.17
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- Handwashing with Soap and Water
When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water.
Handwashing with soap and water uses friction to remove soil, body substances and reduce the transient microorganism count on the skin. Soap and water handwashing reduces the microorganism load on the skin but does not kill the microorganisms and is dependent on the thoroughness of the friction used and the hand surfaces rubbed.
The CDC recommends that ophthalmic medical personnel performing eye examinations or other procedures involving contact with tears, mucous membranes, other body substances, or contact lenses should wash their hands immediately after a procedure and between patients.17 Handwashing should be encouraged when there is any doubt about the necessity for doing so. When hands are visibly dirty, handwashing is strongly recommended. For routine handwashing, a vigorous rubbing together of all surfaces of the lathered hands is recommended for at least 15 seconds, followed by a thorough rinsing under a stream of water and thorough drying with disposable towel.17 Plain soap (not bar soap) can be used for handwashing for most routine activities. Water faucets can be turned off with a paper towel instead of freshly washed hands and doors opened with paper towel help prevent recontamination.
2. Antiseptic Soap and Water (chlorhexidine preferred)
Antimicrobial soap and water removes soil and kills the transient microbes but is dependent on the thoroughness of the friction.
If adenoviral contamination is suspected, the 2006 Rutala et al. study recommends hand antisepsis using antimicrobial soap and water.5 Chlorhexidine gluconate is the preferred antimicrobial soap. Anytime a patient has a suspected infectious process, antimicrobial soap should be used immediately after patient contact. If antimicrobial soap is unavailable, hands can be washed with regular soap followed by an alcohol-based hand sanitizer.
3. Hand Sanitizer (alcohol-based hand sanitizer-at least 62% ethyl alcohol)
Alcohol-based hand sanitizers are used when there is no visible soil or contact with body substances. The preferred method of hand decontamination/sanitization is with an alcohol-based hand rub. Alternatively, hands may be washed with an antimicrobial soap and water.
Apply enough sanitizer to palm of hand so that all surfaces of the hands and fingers are saturated while rubbing hands together, covering all surfaces of hands and fingers, until they are dry. Hand sanitizers kill the microbes on the hands within 15-30 seconds of application. It very effectively kills MRSA and VRE on contact with the skin.
Hand sanitizing is recommended prior to having direct contact with patients, before donning gloves, after contact with inanimate objects near the patient, after removing gloves, between the dirty and clean steps of a procedure, and prior to accessing clean supplies.
4. Surgical Hand Antisepsis
Antiseptic handwash or antiseptic hand rub performed preoperatively by surgical personnel to eliminate transient and reduce resident hand flora. Antiseptic detergent preparations often have persistent antimicrobial activity. These reduce antimicrobial loads, listed in order of effectiveness: (1) alcohol rubs, (2) chlorhexidine, (3) betadine, (4) chlorophenol (PCMX), and (5) triclosan. Follow the manufacturer's use instructions.
5. Hand Care
Maintaining the integrity of the skin is critical in preventing skin breakdown due to frequent use of hand hygiene. Many of the alcohol hand sanitizers contain emollients and moisturizers that prevent breakdown or irritation. Lotion soaps are less irritating to the skin as compared to the antiseptic soaps.
Hand lotions are also helpful but it is important to confirm that the antiseptic soap is compatible with the lotion. Some lotion ingredients reduce or inactivate the efficacy of the antiseptic agent. Lotions should be chlorhexidine compatible.
Jewelry should be minimized or eliminated on the hands and wrists because it is difficult to clean thoroughly between patients and prior to procedures. Hand contamination with potential pathogens is increased with ring-wearing. Dangling or ornate settings should be removed from wrists and fingers. Watch bands may become odorous and should be periodically cleaned.
Non-natural nails (artificial/gels/extenders/acrylic/fiberglass) have been identified with bacterial and fungal contamination and can be a source of microorganism transmission. Artificial nails should be discouraged and should not be worn by staff performing procedures or applying contact lenses.
B. Personal Protective Equipment (PPE)
PPE is required during surgical procedures in the office or ambulatory surgery center, during aerosolizing procedures, and when patient has an infectious process. Wear PPE appropriate to the situation, procedure, organism present or potential exposure.
Prevent contamination of clothing and skin during the process of removing PPE and always perform hand hygiene prior to donning PPE and immediately after removal of PPE. Before leaving the patient's room or cubicle, remove and discard PPE.
PPE protects the HCW from the patient and environment and protects the patient from the HCW and the healthcare environment.
1. Gloves
Disposable gloves should be readily available for all ophthalmic medical personnel and they should be instructed regarding the rationale for wearing gloves and their appropriate usage. It should be noted particularly that gloves:
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- Are not a substitute for hand hygiene, and
- Are for single use only, and should be discarded after each patient encounter
Perform hand hygiene prior to donning gloves and again immediately after glove removal. Gloves may have microscopic flaws which will allow hand contamination to occur.
Wear disposable exam gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin (e.g., eye drainage, mucous membranes of eyes, of a patient incontinent of stool or urine) could occur.
Gloves should be worn for touching blood and blood-contaminated fluids (moist or in a dried state), for handling items or surfaces soiled with such fluids and for performing venipuncture and other vascular access procedures.
Wear gloves with fit and durability appropriate to the task. Nonlatex is preferred due to increasing incidence of patients and HCWs with latex allergies.
Wear disposable medical examination gloves for cleaning the environment or medical equipment.
Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment), using proper technique to prevent hand contamination.
Do not wear the same pair of gloves for the care of more than one patient or different procedures on the same patient.
Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens.
Change gloves during patient care if the hands will move from a contaminated body site (e.g., infected eye to a non-infected eye), or between the dirty and clean steps of a procedure.
2. Gowns
Gowns serve a dual purpose because they protect the wearer from the patient and patient environment and they protect the patient from whatever contamination the HCW may have on their clothing.
White professional coats are not considered PPE and should be changed frequently due to contamination.
Perform hand hygiene prior to donning a gown and after gown removal before leaving the patient environment.
Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing from the patient, environment, or during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions, or aerosolization/spray is anticipated (e.g., cleaning instruments in a sink, incision and drainage procedures, surgical procedures, eye irrigation).
Wear a gown for direct patient contact if the patient has uncontained secretions or excretions.
Do not reuse gowns, even for repeated contacts with the same patient.
3. Mouth, nose, and eye protection
Face protection performs dual functions: it protects the wearer from patient respiratory droplets and fluid generating procedures and it protects the patient from the respiratory droplets of the HCW.
Use full face protection (a face shield that fully covers the front and sides of the face, a mask with attached shield, or a mask and goggles), in addition to gloves and gown, to protect the mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions, and with unmasked coughing patients (e.g., cleaning instruments in a sink, incision and drainage procedures, surgical procedures, eye irrigation, etc.).
A HCW should wear a mask for close patient contact (when within 3-6 feet of patient) when they are exhibiting cold or cough symptoms.
Offer patients with cough or cold symptoms a mask during close patient contact (within 3-6 feet of patient).
Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed. Protective eyeglasses and goggles must have side protectors.
Personal eyeglasses and contacts are not considered protective by OSHA.
4. Caps and Shoe Covers
Caps and shoe covers are not usually necessary in an ambulatory eye care setting unless in an ambulatory surgery center environment. Hair sheds bacteria, and hair covering caps prevent shedding into the surgical procedure site. Shoe covers protect the shoes from body substance exposure, which rarely occurs in the ophthalmologic setting.
C. Respiratory Hygiene/Cough Etiquette
The strategy is targeted at patients and accompanying family members and friends with undiagnosed transmissible respiratory infections, and applies to any person with signs of illness including cough, congestion, rhinorrhea, or increased production of respiratory secretions when entering a health care facility. Patients who have asthma, allergic rhinitis, or chronic obstructive lung disease also may be coughing and sneezing. While these patients often are not infectious, cough etiquette measures are prudent and recommended by the CDC. The absence of fever does not always exclude a respiratory infection. Health care personnel are advised to observe Droplet Precautions (i.e., wear a mask with eye protection) and hand hygiene when examining and caring for patients with signs and symptoms of a respiratory infection. Individuals with influenza are contagious 1-2 days before onset of symptoms.
Control measures for patients include:
Covering the mouth/nose with a tissue when coughing and prompt disposal of used tissues and/or offering a surgical mask to the coughing person when tolerated.
Rescheduling the coughing patient unless presenting symptoms indicate medical necessity.
Control measures for HCWs include:
Wearing a mask with eye protection when within 3-6 feet of the patient when the coughing patient is unable to cover mouth and nose with tissue or mask.
Respiratory etiquette also includes preventing the HCW's respiratory droplets from infecting the patient. It is courtesy and good practice for the HCW to wear a mask if the following personal conditions exist while working: sore/scratchy throat, cough, runny nose, halitosis, cold symptoms. Wearing the mask prevents the patient from breathing the droplets of the HCW and prevents potential exposure. Healthcare workers who have a respiratory infection are advised to avoid direct patient contact, especially with high-risk patients.
D. Sharp Safety Devices
OSHA requires sharp safety devices be used for all procedures unless a safety device is not available on the market. This means that scalpel blade/handles, needles/syringes must have a safety feature and must be activated immediately after use.
Activated sharps must be disposed of in a sharps container and disposed of according to the state and local ordinances.
Non safety sharps must not be "used up" before implementing safety devices.
No recapping of contaminated needles with hands. If recapping is necessary, use a recapping device that prevents hand contact with the cap or the needle.
Safe Injection Practices
Safe injection practices apply to the use of needles, cannulas that replace needles, and, where applicable intravenous delivery systems. The CDC recommends the following for injection safety:
Use aseptic technique to avoid contamination of sterile injection equipment.
Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae, and syringes are sterile, single-use items; they should not be reused for another patient or to access a medication or solution that might be used for a subsequent patient.
Use fluid infusion and administration sets (i.e., intravenous bags, tubing, and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient's intravenous infusion bag or administration set.
Use single-dose vials for parenteral medications whenever possible.
Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use.
If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile.
Do not keep multidose vials in the immediate patient treatment area, and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable.
Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients.
E. Biomedical Waste Management
Consult the state and local county for biomedical waste management regulations.
Sharps disposal containers are to be replaced when two-thirds full.
Sharp disposal container lids are to be secured and sealed prior to disposal transport.
Red bags should be available for blood-soaked dressings.
Blood and other liquid body fluids may be disposed of in the sewer. Use PPE (gown, gloves, face protection) when disposing down hopper or toilet.
Prevent placement of sharps containers over trash containers.
Biomedical waste includes:
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- Liquid or semi-liquid blood or other potentially infectious material that cannot be disposed of in the sanitary sewer system without danger of spraying or splashing
- Contaminated items which would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed
- Items caked with dried blood or other potentially infectious materials which are capable of releasing these materials during handling
- Contaminated objects capable of penetrating the skin (needles, syringes, scalpels, lancets, slides, razors, ampules, broken glass, capillary tubes, glass pipettes, other sharp instruments)
F. Single Use Devices
The FDA regulates Single Use Devices and has specific requirements for use. Supplies, medications, devices, and instruments that have the words "single use only" or "single patient use" must be discarded immediately after use on the patient. Single use items may not be cleaned and disinfected and used on other patients.
G. Environmental Barriers
Environmental barriers help protect the environment from contamination from body substances. For example, a disposable chux (blue pad) can be used to collect irrigation fluid or placed under an arm during an IV start, or used to establish a clean area for a procedure set-up. Barriers are discarded between patients.
H. Supply Storage and Handling
Perform hand hygiene prior to accessing clean and sterile supplies.
Check all supplies for expiration dates and discoloration.
Rotate stock so items that expire soon are in front of those with a later expiration date.
Store supplies away from sinks, under the sink cabinets, and other water sources to avoid contamination. Items with water spotting must be discarded and not used.
Store supplies in a clean and covered manner. Prevent dust contamination.
Use individually wrapped items instead of loose in glass or metal jars or drawers. Loose unwrapped items become contaminated rapidly from handling and improper storage. Examples include cotton applicators, tongue blades, cotton pads/balls, and gauze pads. If loose items are used, store in small amounts in plastic baggies, in freshly cleaned containers, or in original packaging. Do not store loose in a drawer due to cross contamination potential. Throw plastic baggies away when empty.
Avoid "topping off" jars or containers of antiseptics, creams, solutions, etc. The best practice is to discard the used container and open a new one to prevent cross contamination. Topping off means refilling a partially filled container and has been identified with outbreaks due to container contamination.
Never store supplies in cardboard packing boxes. Bugs and dust cause contamination of supplies. Remove from packing box in a designated dirty area and then transport supplies in a clean manner to where they will be stored.
Keep drawers and cupboards and closets clean and dust free.
I. Medication, Eye Drops and Solutions Use, Handling and Storage
Perform hand hygiene prior to accessing medications and solutions and immediately before drawing up or administering the medication.
Check expiration dates prior to administration.
Eyedrops: The bottle tip should not come into direct contact with the patient's tears or conjunctiva. If the tip does touch the patient, the bottle must be discarded. Discard the bottle when used on patient with an infectious eye process.
The United States Pharmacopoeia (USP) 797 policy (governing pharmacies that prepare compounded sterile preparations) states the following:
Multiple-dose containers (e.g., vials) are formulated for removal of portions on multiple occasions because they contain antimicrobial preservatives. The beyond-use date after initially entering or opening (e.g., needle-punctured) multiple-dose containers is 28 days (see Antimicrobial Effectiveness Testing <51>), unless otherwise specified by the manufacturer. If the vial is labeled as a multidose vial or container then the dating should not exceed 28 days UNLESS the manufacturer has data to support longer dating. Discard open vials of medication every 28 days as per USP 797.
Spike IV or irrigation bags/containers no sooner than one hour prior to initiation of administration as per USP 797.
Discard vials or solutions labeled with "single patient use" or "single use" or "preservative free" after use on single patient.
Use aseptic technique to avoid contamination of sterile injection equipment.
Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient or to access a medication or solution that might be used for a subsequent patient.
Use fluid infusion and administration sets (i.e., IV bags, tubing and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient's IV infusion bag or administration set.
Use single-dose vials for parenteral medications whenever possible.
Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use.
If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile.
Do not keep multidose vials in the immediate patient treatment area, store in accordance with the manufacturer's recommendations, and discard if sterility is compromised or questionable.
Do not use bags or bottles of IV solution as a common source of supply for multiple patients.
Draw up medication just prior to the procedure. Do not draw up for multiple patients.
Many eye ointments and eye drops are now available in single dose or smaller-sized containers.
Never store or carry medications in personal clothing or pockets.
