Infection Control Manual | Yale Environmental Health & Safety

Infection Control

Manual

Revised: March 2023

Yale University

Table                                                                of                                                          Contents 
Foreward .....................................................................................................................................iii 
SECTION 1: Staff Orientation and Education Information ....................................................... 1 
1.1
 
INTRODUCTION ................................................................................................................................................................................ 1 
1.2
 
ROUTES OF TRANSMISSIONS ........................................................................................................................................................ 2 
1.2.1
 
Contact Transmission ................................................................................................................... 2 
1.2.2
 
Vehicle Route ............................................................................................................................... 2 
1.2.3
 
Airborne Transmission .................................................................................................................. 2 
1.2.4
 
Vector-Borne Transmission .......................................................................................................... 2 
1.3
 
STANDARD PRECAUTIONS ............................................................................................................................................................ 2 
1.4
 
TRANSMISSION-BASED PRECAUTIONS ...................................................................................................................................... 3 
1.4.1
 
Airborne Precautions .................................................................................................................... 3 
1.4.2
 
Droplet Precautions ...................................................................................................................... 3 
1.4.3
 
Contact Precautions ...................................................................................................................... 3 
1.4.4
 
Synopsis of Types of Precautions and Patients Requiring the Precautions* ..................................... 4 
1.5
 
EMPIRIC USE OF TRANSMISSION-BASED PRECAUTIONS - PENDING CONFIRMATION OF DIAGNOSIS.......................... 5 
1.6
 
TB EXPOSURE CONTROL PLAN ................................................................................................................................................ 22 
Risk Assessment ................................................................................................................................. 22 
Transmission and Pathogenesis ............................................................................................................ 22 
Guidelines for TB Control ................................................................................................................... 23 
TB Exposure Control Procedures for Suspected or Known Active TB Cases ......................................... 24 
Evaluation of Health Care Workers Post Exposure to Active TB Cases ................................................. 24 
Continuing Risk Assessment at Yale University ................................................................................... 25 
1.7
 
GUIDELINES FOR VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) ..................................................... 25 
1.8
 
MRSA INFECTION CONTROL GUIDELINES ........................................................................................................................... 26 
SECTION 2: Medical Surveillance ............................................................................................ 29 
2.1
 
RECOMMENDED IMMUNIZATIONS FOR HEALTH CARE WORKERS ............................................................................................29 
2.2
 
TUBERCULOSIS TESTING............................................................................................................................................................. 34 
2.3
 
COMMUNICABLE DISEASE WORK RESTRICTIONS FOR HEALTH CARE WORKERS ......................................................................34 
2.4
 
GUIDELINES FOR PREGNANT HEALTH CARE PERSONNEL ............................................................................................... 39 
2.5
 
EMERGENCY PROCEDURES FOR EXPOSURE TO BLOOD AND BODY FLUIDS ............................................................. 40 
2.5.1
 
Needlestick Procedures ............................................................................................................... 41 
2.6
 
POST EXPOSURE PROPHYLAXSIS GUIDELINES FOR EXPOSURE TO OTHER INFECTIOUS AGENTS .................................. 42 
SECTION 3: Handling Waste ............................................................................................................. 45 
3.1
 
MEDICAL WASTE MANAGEMENT ............................................................................................................................................. 45 
3.2
 
GUIDELINES ON THE MANAGEMENT OF INFECTIOUS WASTE ........................................................................................ 46 
3.3
 
TRASH HANDLING .......................................................................................................................................................................... 46 
3.4
 
PROCEDURE FOR TRASH DISPOSAL ........................................................................................................................................ 46 
3.5
 
DISPOSAL OF CHEMOTHERAPY WASTE ................................................................................................................................... 47 
3.6
 
NEEDLES AND SYRINGES AND OTHER SHARP ITEM ............................................................................................................ 47 
3.7
 
DRESSINGS AND TISSUES ...................................................................................................................................................................................48 
3.8
 
AUTOCLAVES .................................................................................................................................................................................. 49 
SECTION 4: Good Work Practices............................................................................................ 50 
4.1
 
HAND WASHING ............................................................................................................................................................................. 50 
4.2
 
GENERAL .......................................................................................................................................................................................... 50 
4.3
 
EYEWASH STATION AND SPILL CLEAN-UP SUPPLIES ........................................................................................................ 51 
4.4
 
REFRIGERATORS ............................................................................................................................................................................ 51 
4.5
 
STORAGE OF STERILE SOLUTIONS ........................................................................................................................................... 51 
4.6
 
STORAGE OF DISPOSABLE SUPPLIES ...................................................................................................................................... 52 
4.7
 
PERISHABLE FOOD AND JUICES ............................................................................................................................................... 52 
4.8
 
DIETARY ........................................................................................................................................................................................... 52 
4.9
 
PRIVATE ROOMS ............................................................................................................................................................................ 52 
4.10
 
ROOMMATES FOR PATIENTS ON TRANSMISSION BASED PRECAUTIONS .................................................................... 53 
4.11
 
AIRBORNE PRECAUTION ROOMS ........................................................................................................................................... 53 
General Considerations .............................................................................................................. 53 
4.12
 
CLEANING PATIENT ROOMS .................................................................................................................................................... 53 
 

SECTION 5: Personal Protective Equipment....................................................................................... 55 
5.1
 
GLOVES ............................................................................................................................................................................................ 55 
Policy and procedure for wearing gloves .............................................................................................. 55 
Clean technique................................................................................................................................... 56 
Sterile technique ................................................................................................................................. 56 
5.2
 
GOWNS.............................................................................................................................................................................................. 57 
Procedure for putting on a gown .......................................................................................................... 57 
Procedure for removing a contaminated gown .............................................................................................. 58 
5.3
 
FACE AND EYE PROTECTION ..................................................................................................................................................... 59 
5.4
 
SURGICAL MASKS .......................................................................................................................................................................... 60 
Procedure for Putting on a Mask .......................................................................................................... 60 
5.5
 
NIOSH APPROVED PARTICULATE MASKS AND RESPIRATORS........................................................................................ 61 
SECTION 6: Decontamination, Spill Response and Housekeeping .................................................... 62 
6.1
 
STERILIZATION OR DISINFECTION OF REUSABLE MEDICAL INSTRUMENTS/DEVICES ...................................................... 62 
Critical Items ...................................................................................................................................... 62 
Semi-Critical Items ............................................................................................................................. 62 
Non-Critical Items............................................................................................................................... 62 
Table 1. Levels of Disinfection According to Types of Microorganism ................................................. 63 
6.2
 
REUSABLE PATIENT-CARE EQUIPMENT ................................................................................................................................. 64 
6.3
 
SPHYGMOMANOMETER AND STETHOSCOPE ......................................................................................................................... 64 
6.4
 
SOILED LINEN & LAUNDRY ........................................................................................................................................................ 65 
6.5
 
H
OUSEKEEPING........................................................................................................................................................................................................
65 
6.6
 
CLEANING SPILLS OF BLOOD AND BODY FLUIDS ON ENVIRONMENTAL SURFACES ......................................................... 65 
Prepare and maintain a spill response kit. ............................................................................................. 66 
SECTION 7: Medications and Safety Injection Practices .................................................................. 67 
         7.1 Storage of Medications-Multi-Dose Vials/Single-Dose Vials………………………………………….…67  
         7.2 Fingerstick Devices………………………………………………………………………………………….…68 
         7.3 Blood Glucose Meter………………………………………………………………………………………..…68 
SECTION 8: Storage and Transporting of Specimens ......................................................................... 69 
8.1
 
HANDLING OF CLINICAL SPECIMENS ...................................................................................................................................... 69 
8.2
 
PROTOCOL ON MANAGEMENT OF SPECIMENS ..................................................................................................................... 69 
SECTION 9: Transportation of Patient ................................................................................................. 70 
9.1
 
TRANSPORTATION PROCESS ....................................................................................................................................................... 70 
9.2
 
GENERAL CONSIDERATIONS AND RESPONSIBILITIES ......................................................................................................... 70 
Unit Receptionist ................................................................................................................................ 70 
Nurse .................................................................................................................................................. 70 
Transport Personnel: ........................................................................................................................... 70 
9.3
 
INFECTION CONTROL CONSIDERATIONS FOR PERSONNEL TRANSPORTING PATIENT ...................................................... 70 
9.4
 
GENERAL CONSIDERATIONS FOR PATIENTS .......................................................................................................................... 71 
SECTION 10: Reporting Communicable Diseases to the State of Connecticut ................................. 72 
SECTION 11: Serve and Assistance Animals… .................................................................................. 74 
11.1
 
Guidelines for Service Animals Visiting Health Care Facilities ....................................... 74 
11.2
 
Staff Responsibilities ...................................................................................................... 74 
11.3
 
Permitted and Restricted Areas for Service Animals and Additional Info for Staff ........... 75 
APPENDIX A: Needle Stick Procedure ................................................................................................................. 75 
APPENDIX B: HIV Counseling Guidelines ........................................................................................................... 85 
APPENDIX Yale Health 1: Quality Control of Multidose Vials/Sterile Solutions ................................................ 86 
APPENDIX Yale Health 2: Laundry ...................................................................................................................... 88 
APPENDIX Yale Health 3: Clean Up Spills ........................................................................................................... 89 
APPENDIX Yale Health 4: Infection Control Protocol ......................................................................................... 91 
APPENDIX Yale Health 5: TB Exposures at Yale Health ..................................................................................... 92 
APPENDIX Yale Health 6: Universal Respiratory Etiquette ................................................................................ 94 
APPENDIX Yale Health 7: Clinical Guidelines for SARS CoV Infection ........................................................... 95 
 APPENDIX Yale Health 8: VaricellaExposureatYale Health .................................................................................... 104 
 APPENDIX Yale Health 9: PnP for Visitors to ICF ............................................................................................. 106 
 APPENDIX Yale Health 10: PnP for Negative Pressure Rooms Inpatient Care and Use.................................. 107 
 APPENDIX Yale Health 11: Guidelines for the Infection Control Management & Prevention of 
      Norovirus Outbreaks… ...................................................................................................................................................... ….
109 

iii

Foreword

In the mid 1990’s, concerns over the lack of uniformity of infection control practices across Yale

University’s clinical areas not monitored by the Yale-New Haven Hospital, prompted the Deputy

Provost to request the establishment of an Infection Control Work Group. Infection control

coordinators, nurses and doctors from various clinical locations as well as representatives from

Yale Environmental Health and Safety were selected to participate in the work group.

The group conducted an initial assessment of infection control programs in each University

clinical area. The Yale University Infection Control Work Group has prepared this manual to

inform the Yale clinical community of standard infection control issues and practices. This

manual will not replace established policy and procedure manuals that are in place at clinical

areas. However, this manual was established with the intent to provide consistent infection

control policies and programs that meet or exceed minimal acceptable standards, across Yale’s

clinical areas and satellite facilities. Areas lacking an established infection control manual can

use the manual as a framework and amend it with site specific information as required.

As this is a document in progress, all are encouraged to review this manual and contact Yale

Environmental Health and Safety concerning any infection control or safety issues.

In addition to preparing this manual, the Yale Infection Control Work Group is available to assist

your site with the following:

▪

help establish an infection control committee for your site;

▪

work with you to identify an on-site infection control coordinator;

▪

assist with the evaluation of new engineering controls designed to minimize occupational

exposures, such as sharps safety devices

Special thanks to those individuals who took time to review this manual and contributed

information and suggestions to improve the presentation. Every two years or as needed, this

manual will be reviewed and updated. The work group will continue to serve as a resource for

infection control, and will periodically monitor locations to ensure that the appropriate practices

are upheld.

SECTION 1: Staff Orientation and Education Information

1.1

Introduction

This manual has been prepared to provide current guidelines for the prevention and control of

infections among patients, employees and visitors. These guidelines provide a rational approach to

isolation and other infection control practices, balancing the theoretical with what is practical and

cost-effective.

All personnel (physicians, nurses, technicians, support staff and others) are responsible for

complying with isolation precautions and other infection control procedures, and for tactfully

calling observed infractions to the attention of offenders. Compliance with infection control

procedures cannot be effectively dictated and enforced by a committee or administration, but must

arise from a personal sense of responsibility to the patient and others in the health-care environment.

Unfortunately, infractions by some are sufficient to negate the conscientious efforts of others, so

constant vigilance is important.

Thus, professional responsibility is the key to detecting and correcting breaches in aseptic

techniques as well as setting an example of a philosophy of total patient care. Physicians, nurses

and others in leadership positions have an excellent opportunity to teach by example. Acting as role

models, they influence the practice of others a great deal.

Patients, as well as their visitors, also have a responsibility for complying with infection control

procedures. Physicians and nurses responsible for their care should inform them of appropriate

infection control procedures. Everyone in contact with patients must practice hand washing, the

single most effective procedure in preventing cross-infection. Even routine activities, such as

examining a patient or taking a blood pressure reading, can transfer organisms to the hands of the

health-care personnel. Hence, it is essential that hands be washed before touching a patient, during

patient care when going from one body site to another, after contact with infective material such as

blood, secretions and excretions, after handling articles and equipment contaminated with body

fluids, and before touching another patient. Patients must also be encouraged to wash their hands

at regular intervals.

Spread of infection requires three elements: a source of infecting organism, a susceptible host and

a means of transmission for the organism. The source of the infecting agent may be patients,

personnel, or, on occasion, visitors, and may include persons with acute diseases, persons in the

incubation period of a disease, or persons who are colonized by the infectious agent, but have no

apparent disease. Another source of infection can be the person’s own endogenous flora

(autogenous infection). Other potential sources are inanimate objects in the environment that have

become contaminated, including equipment and medications.

Patient’s resistance to pathogenic microorganisms varies greatly. Some patients may be immune

to, or able to resist colonization by an infectious agent; others exposed to the same agent may

establish a commensal relationship with the infecting organism and become asymptomatic carriers;

still others may develop clinical disease. Host resistance may be compromised by illness, as in

patients with diabetes mellitus, neoplasia, HIV-infection, leukemia and lymphoma, uremia,

traumatic injury or burns. Alternatively, resistance may be decreased by iatrogenic physical

intervention, most commonly urethral and intravenous catheters, respiratory tract manipulation and

surgical procedures, or medical measures, especially steroids and other immunosuppressive

medication.

Microorganisms are transmitted by various routes, and the same microorganism may be transmitted

by more than one route. For example, varicella-zoster virus (chicken pox) can be spread either by

the airborne route (droplet nuclei) or by direct contact. The differences in

infectivity and in the mode of transmission of the various agents form the basis for the differences

in isolation precautions recommended in this guideline.

1.2

Routes of Transmissions

There are four main routes of transmission — contact, vehicle, airborne, and vector-borne.

1.2.1

Contact Transmission

The most important and frequent means of transmission of nosocomial (hospital acquired)

infections can be divided into three subgroups: direct, indirect and droplet contact.



Direct contact: Direct physical transfer between a susceptible host and an infected or a

colonized person, as occurs when personnel turn patients, give baths, change dressings or

perform other procedures involving direct personal contact.



Indirect contact: This involves personal contact of the susceptible host with a contaminated

intermediate object, usually inanimate, such as bed linens, clothing, instruments and dressings.



Droplet contact: Infectious agents may come in contact with the conjunctiva, nose, or mouth of

a susceptible person as a result of coughing, sneezing or talking by an infected person who has

clinical disease or is a carrier of the organism. This is considered “contact” transmission rather

than airborne since droplets usually travel no more than about three feet.

1.2.2

Vehicle Route

The vehicle route applies in diseases transmitted through such contaminated items as:



Food (e.g., salmonellosis)



Water (e.g., giardiasis)



Drugs (e.g., bacteremia from an infusion of contaminated product)



Blood (e.g., Hepatitis B, Hepatitis C, HIV).

1.2.3

Airborne Transmission

Airborne transmission occurs by the inhalation of aerosols containing an infectious agent.

Organisms carried in this manner can be widely dispersed by air currents before being inhaled by

or deposited on a susceptible host. Tuberculosis is spread via airborne transmission.

1.2.4

Vector-Borne Transmission

Vector-borne transmission occurs when an infected vector bites a susceptible host, most commonly

arthropods (e.g., ticks, mosquitoes). World wide it is of special concern in tropical countries where

mosquito-transmitted malaria is endemic. In the United States, Lyme Disease and Rocky Mountain

Spotted Fever are examples of diseases transmitted by tick vectors, and Eastern Equine Encephalitis

(EEE) and West Nile Virus by mosquitoes.

1.3

Standard Precautions

Standard Precautions are a philosophy for providing medical care that assumes patients may be

infectious. It must be applied to all patients receiving care in University facilities regardless of

diagnostic or infection status. Standard Precautions apply to blood; all body fluids; secretions and

excretions (except sweat), regardless of whether or not they contain visible blood; non-intact skin;

and mucous membranes.

Standard Precautions state that gloves must be used whenever contact is anticipated, changed

between patients, and hands washed after gloves are removed. In addition, gowns (impermeable to

liquids) and shoe covers must be worn when splashes of body fluids or blood are anticipated in

order to reduce the risk of exposure to blood borne pathogens. Masks, face shields, or goggles must

also be worn during procedures that are likely to generate splashes or sprays of blood, body fluids,

or secretions.

1.4

Transmission-Based Precautions

These precautions are designed for patients who are documented or suspected to be infected with

highly transmissible or epidemiologically - important pathogens. These precautions are designed

to be implemented in addition to Standard Precautions:

1.4.1

Airborne Precautions

These precautions are designed for infections that are transmitted by airborne droplet nuclei (<5

microns in diameter) that can remain suspended in the air. Examples of infectious agents that fall

into this category include tuberculosis, Rubeola (measles), and Varicella (chickenpox).

In addition to Standard Precautions:



Patients should be placed in a private room with monitored negative air pressure in relation to

surrounding areas.



The room should have 6-12 air changes per hour with appropriate discharge of air outdoors or

through a high efficiency filtration system before the air is recirculated to other areas of the

building. The door must be kept closed with the patient kept in the room. If a private room is

not available, another patient with the same active infection may be placed in the room

(cohorting).



Personnel who enter the isolation room should be immune to the infection. Non-immune

personnel must wear a respirator (N-95 or better) before entering the room.



Patient transport should be limited to that which is absolutely necessary. Patients should wear

surgical masks if transported outside of the room.

Refer to TB Control Plan for additional information on this agent (see page 17).

1.4.2

Droplet Precautions

Droplet precautions are designed to prevent the transmission of organisms that are transmitted by

large droplet contact with conjunctiva or mucous membranes of the nose or mouth. Droplets greater

than 5 microns in diameter are usually generated with coughing, sneezing, talking, as well as during

procedures such as bronchoscopy or suctioning. These larger droplets generally travel only short

distances (3 feet or less). Examples of organisms in this category include influenza, mycoplasma,

strep pneumonia, mumps, and whooping cough.



Patients should be placed in a private room or, if not available, they may be placed in a room

with a patient who has an active infection with the same organism.



A surgical (or better) mask must be worn when working within 3 feet of the patient.



Patient transport should be limited to that which is absolutely necessary. A surgical mask

should be placed on the patient during transport.

1.4.3

Contact Precautions

These should be used for patients who are infected with organisms that are transmitted by direct

skin to skin contact or by indirect contact with environmental surfaces or patient care items.

These precautions are also used for patients who are colonized with organisms that are

epidemiologically-important. Examples of contact precaution organisms include herpes simplex,

scabies, streptococcus, and gastrointestinal colonization by drug resistant organisms.

In addition to Standard Precautions,



Patients must be placed in a private room or with another patient who has an active infection

with the same organism.



Gloves must be worn when entering the patient’s room. Gloves should be changed after

handling material that may have high concentrations of organisms. Gloves must be removed

before leaving the patient’s room and hands washed with an antimicrobial soap.



Caregivers must ensure that hands do not touch potentially contaminated environmental

surfaces after glove removal.



A gown should be worn if substantial contact with the patient or environmental surfaces is

anticipated or if the patient is incontinent, has diarrhea, an ostomy site, or other drainage not

contained by a dressing. The gown should be removed prior to leaving the room and care taken

to avoid touching surfaces after removing the gown.



Patient transport should be limited to that which is absolutely necessary. Care should be taken

during transport to minimize contact with other patients or environmental surfaces.



Non-critical patient care equipment should be used only for a single patient. If sharing of

common equipment is absolutely necessary, the equipment must be adequately cleaned and

disinfected before using it for another patient. (See sections on Sterilization of Reusable

medical Instruments/Devices and section on Housekeeping/Decontamination)

Note: Please see Guidelines for VRE and MRSA in addition to Contact Precautions.

1.4.4

Synopsis of Types of Precautions and Patients Requiring the Precautions*

Standard Precautions

Use Standard Precautions for the care of all patients

Airborne Precautions

In addition to Standard Precautions, use Airborne Precautions for patients known or suspected to

have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include:

Measles

Varicella (including disseminated zoster) +

Tuberculosis ++

Droplet Precautions

In addition to Standard Precautions, use Droplet Precautions for patients known or suspected to

have serious illnesses transmitted by large particle droplets. Examples of such illnesses include:

Invasive Haemophilus influenzae type b disease, including meningitis, pneumonia,

epiglottitis, and sepsis

Invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis

Other serious bacterial respiratory infections spread by droplet transmission, including:

Diphtheria (pharyngeal)

Mycoplasma pneumonia

Pertussis

Pneumonic plague

Streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children

Serious viral infections spread by droplet transmission, including: Adenovirus

Influenza Mumps

Parvovirus B19

Rubella

Contact Precautions

In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have

serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's

environment. Examples of such illnesses include:

Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-

resistant bacteria judged by the infection control program, based on current state, regional,

or national recommendations, to be of special clinical and epidemiologic significance

Enteric infections with a low infectious dose or prolonged environmental survival,

including:

Clostridium difficile

For diapered or incontinent patients: enterohemorrhagic Escherichia coli

(O157:H7), Shigella, hepatitis A, or rotavirus

Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and

young children

Skin infections that are highly contagious or that may occur on dry skin, including:

Diphtheria (cutaneous)

Herpes simplex virus (neonatal or mucocutaneous) Impetigo

Noncontained abscesses, cellulitis, or decubiti

Pediculosis

Scabies

Staphylococcal furunculosis in infants and young children

Herpes or Varicella Zoster (disseminated or in the immunocompromised host) +

Viral/hemorrhagic conjunctivitis

Viral hemorrhagic infections (Ebola, Lassa, or Marburg) *

* See Appendix A for a complete listing of infections requiring precautions, including appropriate footnotes.

+ Certain infections require more than one type of precaution.

++ See CDC Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Facilities.

1.5

Empiric Use of Transmission-Based Precautions - Pending Confirmation of Diagnosis

Infection/Condition

Type of

Precaution

Duration of

Precaution

Precautions/Comments

Adenovirus infection (see agent-

specific guidance under gastroenteritis,

conjunctivitis, pneumonia)

Amebiasis

Standard

Person to person transmission is rare. Transmission

in settings for the mentally challenged and in a family

group has been reported [1045]. Use care when

handling diapered infants and mentally challenged

persons [1046].

Anthrax

Standard

Infected patients do not generally pose a

transmission risk.

Anthrax

Cutaneous

Standard

Transmission through non-intact skin contact with

draining lesions possible, therefore use Contact

Precautions if large amount of uncontained drainage.

Handwashing with soap and water preferable to use of

waterless alcohol based antiseptics since alcohol does

not have sporicidal activity [983].

Anthrax

Pulmonary

Standard

Not transmitted from person to person

Anthrax

Environmental: aerosolizable

spore-containing powder or other

substance

Until

environment

completely

decontaminated

Until decontamination of environment complete [203].

Wear respirator (N95 mask or PAPRs), protective

clothing; decontaminate persons with powder on them

(Occupational Health Guidelines for Remediation

Workers at Bacillus anthracis-Contaminated Sites ---

United States, 2001--2002

(https://www.cdc.gov/mmwr/preview/mmwrhtml/mm51

3 5a3.htm))

Hand hygiene: Handwashing for 30-60 seconds with

soap and water or 2% chlorhexidene gluconate after

spore contact (alcohol handrubs inactive against

spores [983].

Post-exposure prophylaxis following environmental

exposure: 60 days of antimicrobials (either doxycycline,

ciprofloxacin, or levofloxacin) and post-exposure

vaccine under IND

Antibiotic-associated colitis (see

Clostridium difficile)

Arthropod-borne

viral encephalitides (eastern,

western, Venezuelan equine

encephalomyelitis; St Louis,

California encephalitis; West Nile

Virus) and

viral fevers (dengue yellow fever

Standard

Not transmitted from person to person except rarely by

transfusion, and for West Nile virus by organ

transplant, breastmilk or transplacentally [530, 1047].

Install screens in windows and doors in endemic

areas.

Use DEET-containing mosquito repellants and

clothing to cover extremities.

Blastomycosis, North American,

cutaneous or pulmonary

Standard

Not transmitted from person to person

Botulism

Standard

Not transmitted from person to person

Bronchiolitis (see respiratory infections

in infants and young children)

Contact +

Standard

Duration of

illness

Use mask according to Standard Precautions.

Brucellosis (undulant, Malta,

Mediterranean fever)

Standard

Not transmitted from person to person except rarely

via banked spermatozoa and sexual contact [1048,

1049]. Provide antimicrobial prophylaxis following

laboratory exposure [1050].

Campylobacter gastroenteritis (see

gastroenteritis)

Candidiasis, all forms including

mucocutaneous

Standard

Cat-scratch fever (benign inoculation

lymphoreticulosis)

Standard

Not transmitted from person to person

Cellulitis

Standard

Chancroid (soft chancre) (H. ducreyi)

Standard

Transmitted sexually from person to person

Chickenpox (see >varicella)

Chlamydia trachomatis

Conjunctivitis

Standard

Chlamydia trachomatis

Genital (lymphogranuloma

venereum)

Standard

Chlamydia trachomatis

age)

Standard

Chlamydia pneumoniae

Standard

Outbreaks in institutionalized populations

reported, rarely [1051, 1052].

Cholera (see gastroenteritis)

Closed-cavity infection

Open drain in place; limited or

minor drainage

Standard

Contact Precautions if there is copious

uncontained drainage

Closed-cavity infection

No drain or closed drainage

system in place

Standard

Clostridium botulinum

Standard

Not transmitted from person to person

Clostridium difficile (see gastroenteritis,

C. difficile)

Contact +

Standard

Duration of

illness

Clostridium perfringens

Food poisoning

Standard

Not transmitted from person to person

Clostridium perfringens

Gas gangrene

Standard

Transmission from person to person rare; one

outbreak in a surgical setting reported [1053]. Use

Coccidioidomycosis (valley fever)

Pneumonia

Standard

Not transmitted from person to person except under

extraordinary circumstances, (e.g., inhalation of

aerosolized tissue phase endospores during

necropsy, transplantation of infected lung) because

the infectious arthroconidial form of Coccidioides

immitis is not produced in humans [1054, 1055].

Colorado tick fever

Standard

Not transmitted from person to person

Congenital rubella

Contact +

Standard

Until 1 yr of age

Standard Precautions if nasopharyngeal and

urine cultures repeatedly neg. after 3 mos. of age

Conjunctivitis

Acute bacterial

Standard

Conjunctivitis

Acute bacterial

Chlamydia

Standard

Conjunctivitis

Acute bacterial

Gonococcal

Standard

Conjunctivitis

Acute viral (acute hemorrhagic)

Contact +

Standard

Duration of

illness

Adenovirus most common; enterovirus 70 [1056],

Coxsackie virus A24 [1057] also associated with

community outbreaks. Highly contagious; outbreaks in

eye clinics, pediatric and neonatal settings, institutional

settings reported. Eye clinics should follow Standard

Precautions when handling patients with conjunctivitis.

Routine use of infection control measures in the

handling of instruments and equipment will prevent the

occurrence of outbreaks in this and other settings.

[460, 814, 1058, 1059 461, 1060].

Corona virus associated with SARS

(SARS-CoV) (see severe acute

respiratory syndrome)

Coxsackie virus disease (see

enteroviral infection)

Creutzfeldt-Jakob disease (CJD, vCJD)

Standard

Use disposable instruments or special

sterilization/disinfection for surfaces, objects

contaminated with neural tissue if CJD or vCJD

suspected and has not been R/O; No special

burial procedures [1061]

Croup (see respiratory infections in

infants and young children)

Crimean-Congo Fever (see Viral

Hemorrhagic Fever)

Standard

Cryptococcosis

Standard

Not transmitted from person to person, except rarely

via tissue and corneal transplant [1062, 1063]

Cryptospor d os s (see gastroenter t s)

Diphtheria

Cutaneous

Contact +

Standard

Until off

antimicrobial

treatment and

culture-negative

Until 2 cultures taken 24 hours apart negative

Diphtheria

Pharyngeal

Droplet +

Standard

Until off

antimicrobial

treatment and

culture-negative

Until 2 cultures taken 24 hours apart negative

Ebola virus (see viral hemorrhagic

fevers)

Ebola Virus Disease for Healthcare

Workers [2014]: Update: Updated

recommendations for healthcare workers can

be found at Ebola: U.S. Healthcare Workers

and Settings

Echinococcosis (hydatidosis)

Standard

Not transmitted from person to person

Echovirus (see enteroviral infection)

Encephalitis or encephalomyelitis (see

specific etiologic agents)

Endometritis (endomyometritis)

Standard

Enterobiasis (pinworm disease,

oxyuriasis)

Standard

Enterococcus species (see multidrug-

resistant organisms if epidemiologically

significant or vancomycin resistant)

Enterocolitis, C. difficile (see C.

difficile, gastroenteritis)

Enteroviral infections (i.e., Group A

and B Coxsackie viruses and Echo

viruses) (excludes polio virus)

Standard

Use Contact Precautions for diapered or incontinent

children for duration of illness and to control

institutional outbreaks

Epiglottitis, due to Haemophilus

influenzae type b

Droplet +

Standard

Until 24 hours

after initiation of

effective

therapy

See specific disease agents for epiglottitis due to

other etiologies)

Epstein-Barr virus infection, including

infectious mononucleosis

Standard

Erythema infectiosum (also see

Parvovirus B19)

Escherichia coli gastroenteritis (see

gastroenteritis)

Food poisoning

Botulism

Standard

Not transmitted from person to person

Food poisoning

C. perfringens or welchii

Standard

Not transmitted from person to person

Gastroenteritis

Standard

Use Contact Precautions for diapered or incontinent

persons for the duration of illness or to control

Gastroenteritis

Adenovirus

Standard

Use Contact Precautions for diapered or incontinent

persons for the duration of illness or to control

Gastroenteritis

Campylobacter species

Standard

Use Contact Precautions for diapered or incontinent

persons for the duration of illness or to control

Gastroenteritis

Cholera (Vibrio cholerae)

Standard

Use Contact Precautions for diapered or incontinent

persons for the duration of illness or to control

Gastroenteritis

C. difficile

Contact +

Standard

Duration of

illness

Discontinue antibiotics if appropriate. Do not share

electronic thermometers [853], 854; ensure consistent

Gastroenteritis

Cryptosporidium species

Standard

Use Contact Precautions for diapered or incontinent

persons for the duration of illness or to control

Gastroenteritis

E. coli

Standard

Use Contact Precautions for diapered or incontinent

persons for the duration of illness or to control

Gastroenteritis

E. coli

Standard

Use Contact Precautions for diapered or incontinent

persons for the duration of illness or to control

Gastroenteritis

Giardia lamblia

Standard

Use Contact Precautions for diapered or incontinent

persons for the duration of illness or to control

Gastroenteritis

Noroviruses

Standard

Use Contact Precautions for diapered or incontinent

persons for the duration of illness or to control

Gastroenteritis

Salmonella species (including S.

typhi)

Standard

Use Contact Precautions for diapered or incontinent

persons for the duration of illness or to control

institutional outbreaks

Gastroenteritis

Shigella species (Bacillary

dysentery)

Standard

Use Contact Precautions for diapered or incontinent

persons for the duration of illness or to control

institutional outbreaks

Gastroenteritis

Vibrio parahaemolyticus

Standard

Use Contact Precautions for diapered or incontinent

persons for the duration of illness or to control

institutional outbreaks

Gastroenteritis

Viral (if not covered elsewhere)

Standard

Use Contact Precautions for diapered or incontinent

persons for the duration of illness or to control

institutional outbreaks

Gastroenteritis

Yersinia enterocolitica

Standard

Use Contact Precautions for diapered or incontinent

persons for the duration of illness or to control

institutional outbreaks

German measles (see rubella; see

congenital rubella)

Giardiasis (see gastroenteritis)

Gonococcal ophthalmia neonatorum

(gonorrheal ophthalmia, acute

conjunctivitis of newborn)

Standard

Gonorrhea

Standard

Granuloma inguinale (Donovanosis,

granuloma venereum)

Standard

Guillain-Barre' syndrome

Standard

Not an infectious condition

Haemophilus influenzae (see disease-

specific recommendations)

Hand, foot, and mouth disease (see

enteroviral infection)

Hansen's Disease (see Leprosy)

Hantavirus pulmonary syndrome

Standard

Not transmitted from person to person

Helicobacter pylori

Standard

Hepatitis, viral

Type A

Standard

Provide hepatitis A vaccine post-exposure as

recommended [1065]

Hepatitis, viral

Type A-Diapered or incontinent

patients

Contact +

Standard

Maintain Contact Precautions in infants and children <3

years of age for duration of hospitalization; for children

3-14 yrs. of age for 2 weeks after onset of symptoms;

>14 yrs. of age for 1 week after onset of symptoms

[833, 1066, 1067].

Hepatitis, viral

Type B-HBsAg positive; acute or

chronic

Standard

See specific recommendations for care of patients in

hemodialysis centers 778

Standard

See specific recommendations for care of patients

Herpangina (see enteroviral infection)

Hookworm

Standard

Herpes simplex (Herpesvirus hominis)

Encephalitis

Standard

Herpes simplex (Herpesvirus hominis)

Mucocutaneous, disseminated or

primary, severe

Contact

Standard

Until lesions dry

and crusted

Herpes simplex (Herpesvirus hominis)

Mucocutaneous, recurrent (skin,

oral, genital)

Standard

Herpes simplex (Herpesvirus hominis)

Neonatal

Contact

Standard

Until lesions dry

and crusted

Also, for asymptomatic, exposed infants delivered

vaginally or by C-section and if mother has active

infection and membranes have been ruptured for more

than 4 to 6 hours until infant surface cultures obtained at

24-36 hours. of age negative after 48 hours incubation

[1069, 1070]

Herpes zoster (varicella-zoster)

(shingles)

Disseminated disease in any

patient

Localized disease in

immunocompromised

patient until disseminated

infection ruled out

Airborne

Contact +

Standard

Duration of

illness

Susceptible HCWs should not enter room if immune

caregivers are available; no recommendation for

protection of immune HCWs; no recommendation for

type of protection, i.e. surgical mask or respirator; for

susceptible HCWs.

Herpes zoster (varicella-zoster)

(shingles)

Localized in patient with intact

immune system with lesions that

can be contained/covered

Standard

Duration of

illness (with

wound lesions,

until wounds

stop draining)

Susceptible HCWs should not provide direct patient

care when other immune caregivers are available.

Histoplasmosis

Standard

Not transmitted from person to person

Human immunodeficiency virus (HIV)

Standard

Post-exposure chemoprophylaxis for some blood

exposures [866].

Human metapneumovirus

Contact

Standard

Duration of

illness (with

wound lesions,

until wounds

stop draining)

HAI reported [1071], but route of transmission not

established [823]. Assumed to be Contact transmission

as for RSV since the viruses are closely related and

have similar clinical manifestations and epidemiology.

Wear masks according to Standard Precautions.

Impetigo

Contact

Standard

Until 24 hours

after initiation of

effective

therapy

Infectious mononucleosis

Standard

Influenza

Human (seasonal influenza)

See Prevention Strategies for Seasonal Influenza in

Hea thcare Sett ngs

Influenza

Avian (e.g., H5N1, H7, H9

strains)

See [This link is no longer active:

www.cdc.gov/flu/avian/professional/infect-control.htm.

Similar information may be found at Interim Guidance

for Infection Control Within Healthcare Settings When

Caring for Confirmed Cases, Probable Cases, and

Cases Under Investigation for Infection with Novel

Influenza A Viruses Associated with Severe Disease

(https://www.cdc.gov/flu/avianflu/novel-flu-infection-

control.htm), accessed May 2016.] for current avian

Influenza guidance.

Influenza

Pandemic Influenza (also a

human Influenza virus)

Droplet

See [This link is no longer active:

http://www.pandemicflu.gov. Similar information may be

found at Interim Guidance for Infection Control Within

Healthcare Settings When Caring for Confirmed Cases,

Probable Cases, and Cases Under Investigation for

Infection with Novel Influenza A Viruses Associated with

Severe Disease (https://www.cdc.gov/flu/avianflu/novel-

flu-infection- control.htm), accessed May 2016.] for

current pandemic Influenza guidance.

Kawasaki syndrome

Standard

Not an infectious condition

Lassa fever (see viral hemorrhagic

fevers)

Legionnaires' disease

Standard

Not transmitted from person to person

Leprosy

Standard

Leptospirosis

Standard

Not transmitted from person to person

Lice

Head (pediculosis)

Contact +

Standard

Until 24 hours

after initiation

of effective

therapy

See [This link is no longer active: http://www.cdc.gov/

ncidod/dpd/parasites/lice/default.htm.

Similar

information may be found at CDC’s Parasites - Lice

(https://www.cdc.gov/parasites/lice/index.html),

accessed May 2016.]

Lice

Body

Standard

Transmitted person to person through infested clothing.

Wear gown and gloves when removing clothing; bag

and wash clothes according to CDC guidance [This link

is no longer active: http://www.cdc.gov/ncidod/dpd/

parasites/lice/default.htm. Similar information may be

found at CDC’s Parasites - Lice

(https://www.cdc.gov/parasites/lice/index.html),

accessed May 2016.]

Lice

Pubic

Standard

Transmitted person to person through sexual contact.

See CDC’s [This link is no longer active:

http://www.cdc.gov/ncidod/dpd/parasites/lice/default.ht

m. Similar information may be found at CDC’s

Parasites - Lice

Malaria

Standard

Not transmitted from person to person except through

transfusion rarely and through a failure to follow

Standard Precautions during patient care 1076-1079.

Install screens in windows and doors in endemic areas.

Use DEET-containing mosquito repellants and clothing

to cover extremities.

Marburg virus disease (see viral

hemorrhagic fevers)

Measles (rubeola)

Airborne +

Standard

4 days after

onset of rash;

duration of

illness (with

wound lesions,

until wounds

stop draining)

in immune

compromised

Measles Update [November 2011]: Updated

recommendations can be found at Immunization

of Healthcare Personnel: Recommendations of

the Advisory Committee on Immunization

Practices (ACIP)

(https://www.cdc.gov/mmwr/pdf/rr/rr6007.pdf).

Susceptible HCWs should not enter room if immune

care providers are available; no recommendation for

face protection for immune HCW; no recommendation

for type of face protection for susceptible HCWs, i.e.,

mask or respirator [1027, 1028]. For exposed

susceptibles, post-exposure vaccine within 72 hours or

immune globulin within 6 days when available [17,

1032, 1034]. Place exposed susceptible patients on

Airborne Precautions and exclude susceptible

healthcare personnel.

Melioidosis, all forms

Standard

Not transmitted from person to person.

Meningitis

Aseptic (nonbacterial or viral;

also see enteroviral infections)

Standard

Contact for infants and young children.

Meningitis

Bacterial, gram-negative enteric,

in neonates

Standard

Meningitis

Fungal

Standard

Meningitis

Haemophilus Influenzae, type b

known or suspected

Droplet +

Standard

Until 24 hours

after initiation

of effective

therapy

Meningitis

Listeria monocytogenes (See

Listeriosis)

Standard

Meningitis

Neisseria meningitidis

(meningococcal) known or

suspected

Droplet +

Standard

Until 24 hours

after initiation

of effective

therapy

See meningococcal disease below.

Meningococcal disease: sepsis,

pneumonia, Meningitis

Droplet +

Standard

Until 24 hours

after initiation

of effective

therapy

Postexposure chemoprophylaxis for household

contacts, HCWs exposed to respiratory secretions;

postexposure vaccine only to control outbreaks

15, 17

Molluscum contagiosum

Standard

Monkeypox

Airborne +

Contact +

Standard

Airborne-Until

monkeypox

confirmed and

smallpox

excluded

Contact-Until

lesions

See CDC’s Monkeypox website

(https://www.cdc.gov/poxvirus/monkeypox/)

[Current

version of this document may differ from original.] for

most current recommendations. Transmission in

hospital settings unlikely [269]. Pre- and post-exposure

smallpox vaccine recommended for exposed HCWs

Mucormycosis

Standard

Multidrug-resistant organisms

(MDROs), infection or colonization

(e.g., MRSA, VRE, VISA/VRSA,

ESBLs, resistant S. pneumoniae)

Contact +

Standard

MDROs judged by the infection control program, based

on local, state, regional, or national recommendations,

to be of clinical and epidemiologic significance. Contact

Precautions recommended in settings with evidence of

ongoing transmission, acute care settings with

increased risk for transmission or wounds that cannot

be contained by dressings. See recommendations for

management options in Management of Multidrug-

Resistant Organisms In Healthcare Settings, 2006

(https://www.cdc.gov/infectioncontrol/guidelines/mdro/)

[870]. Contact state health department for guidance

regarding new or emerging MDRO.

Mumps (infectious parotitis)

Droplet +

Standard

Until 9 days

After onset of swelling; susceptible HCWs should not

provide care if immune caregivers are available.

Note: (Recent assessment of outbreaks in healthy 18- 24

year olds has indicated that salivary viral shedding

occurred early in the course of illness and that 5 days of

isolation after onset of parotitis may be appropriate in

community settings; however the implications for

healthcare personnel and high-risk patient populations

remain to be clarified.)

Mycobacteria, nontuberculosis

(atypical)

Not transmitted person-to-person

Mycobacteria, nontuberculosis

(atypical)

Pulmonary

Standard

Mycobacteria, nontuberculosis

(atypical)

Wound

Standard

Mycoplasma pneumonia

Droplet +

Standard

Duration

Parainfluenza virus infection,

respiratory in infants and young

children

Contact +

Standard

Duration

illness

Viral shedding may be prolonged in immunosuppressed

patients [1009, 1010]. Reliability of antigentesting to

determine when to remove patients with prolonged

hospitalizations from Contact Precautions uncertain.

Parvovirus B19 (Erythema infectiosum)

Droplet +

Standard

Maintain precautions for duration of hospitalization when

chronic disease occurs in an immunocompromised

patient. For patients with transient aplastic crisis or red-

cell crisis, maintain precautions for 7 days. Duration of

precautions for immunosuppressed patients with

persistently positive PCR not defined, but transmission

has occurred [929].

Pediculosis (Lice)

Contact +

Standard

Until 24 hours

after initiation

of effective

therapy after

treatment

Pertussis (whooping cough)

Droplet +

Standard

Until 5 days

Single patient room preferred. Cohorting an option.

Post-exposure chemoprophylaxis for household

contacts and HCWs with prolonged exposure to

respiratory secretions [863]. Recommendations for

Tdap vaccine in adults under development.

Tdap Vaccine Recommendations [2011]

Update: Current recommendations can be found

at Tdap / Td ACIP Vaccine Recommendations

(www.cdc.gov/vaccines/hcp/acip-recs/vacc-

specific/tdap-td.html).

Pinworm infection (Enterobiasis)

Standard

Plague (Yersinia pestis)

Bubonic

Standard

Plague (Yersinia pestis)

Pneumonic

Droplet +

Standard

Until 48 hours

Antimicrobial prophylaxis for exposed HCW [207].

Pneumonia

Adenovirus

Droplet +

Contact +

Standard

Duration

illness

Outbreaks in pediatric and institutional settings reported

[376, 1084-1086]. In immunocompromised hosts, extend

duration of Droplet and Contact Precautions due to

prolonged shedding of virus [931]

Pneumonia

Bacterial not listed elsewhere

(including gram-negative

bacterial)

Standard

Pneumonia

B. cepacia in patients with CF,

including respiratory tract

colonization

Contact +

Standard

Unknown

Avoid exposure to other persons with CF; private room

preferred. Criteria for D/C precautions not established.

See CF Foundation guideline [20]

Pneumonia

Haemophilus influenzae, type b

Adults

Standard

Pneumonia

Haemophilus influenzae, type b

Infants and children

Droplet +

Standard

Until 24 hours

after initiation

of effective

therapy

Pneumonia

Legionella spp.

Standard

Pneumonia

Meningococcal

Droplet +

Standard

Until 24 hours

after initiation

of effective

therapy

See meningococcal disease above

Pneumonia

Multidrug-resistant bacterial (see

multidrug-resistant organisms)

Pneumonia

Mycoplasma (primary atypical

Pneumonia)

Droplet

Duration

illness

Pneumonia

Pneumococcal pneumonia

Standard

Use Droplet Precautions if evidence of transmission

within a patient care unit or facility [196-198, 1087]

Pneumonia

Pneumocystis jiroveci

(Pneumocystis carinii)

Standard

Avoid placement in the same room with an

immunocompromised patient.

Pneumonia

Staphylococcus aureus

Standard

For MRSA, see MDROs

Pneumonia

Streptococcus, group A

Adults

Droplet +

Standard

Until 24 hours

after initiation

of effective

therapy

See streptococcal disease (group A streptococcus)

below

Contact precautions if skin lesions present

Pneumonia

Streptococcus, group A

Infants and young children

Droplet +

Standard

Until 24 hours

after initiation

of effective

therapy

Contact Precautions if skin lesions present

Pneumonia

Varicella-zoster (See Varicella-

Zoster)

Pneumonia

Viral

Adults

Standard

Pneumonia

Viral

Infants and young children

(see resp ratory nfect ous

Pressure ulcer (decubitus ulcer,

pressure sore) infected

Major

Contact +

Standard

Duration of

illness (with

wound

lesions, until

wounds stop

If no dressing or containment of drainage; until drainage

stops or can be contained by dressing

Pressure ulcer (decubitus ulcer,

pressure sore) infected

Minor or limited

Standard

If dressing covers and contains drainage

Prion disease (See Creutzfeld-Jacob

Disease)

Psittacosis (ornithosis) (Chlamydia

psittaci)

Standard

Not transmitted from person to person

Q fever

Standard

Rabies

Standard

Person to person transmission rare; transmission via

corneal, tissue and organ transplants has been reported

[539, 1088]. If patient has bitten another individual or

saliva has contaminated an open wound or mucous

membrane, wash exposed area thoroughly and

administer postexposure prophylaxis. [1089]

Rat-bite fever (Streptobacillus

moniliformis disease, Spirillum minus

disease)

Standard

Not transmitted from person to person

Relapsing fever

Standard

Not transmitted from person to person

Resistant bacterial infection or

colonization (see multidrug-resistant

organisms)

Respiratory infectious disease, acute

(if not covered elsewhere)

Adults

Standard

Respiratory infectious disease, acute

(if not covered elsewhere)

Infants and young children

Contact +

Standard

Duration of

illness (with

wound

lesions, until

wounds stop

Also see syndromes or conditions listed in Table 2

Respiratory syncytial virus infection, in

infants, young children and

immunocompromised adults

Contact +

Standard

Duration of

illness (with

wound

lesions, until

wounds stop

draining)

Wear mask according to Standard Precautions [24] CB

[116, 117]. In immunocompromised patients, extend the

duration of Contact Precautions due to prolonged

shedding [928]). Reliability of antigen testing to

determine when to remove patients with prolonged

hospitalizations from Contact Precautions uncertain.

Reye's syndrome

Standard

Not an infectious condition

Rheumatic fever

Standard

Not an infectious condition

Rhinovirus

Droplet +

Duration of

Droplet most important route of transmission [104

Ringworm (dermatophytosis,

dermatomycosis, tinea)

Standard

Rarely, outbreaks have occurred in healthcare settings,

(e.g., NICU [1093], rehabilitation hospital [1094]. Use

Contact Precautions for outbreak.

Ritter's disease (staphylococcal

scalded skin syndrome)

Contact +

Standard

Duration of

illness (with

wound

lesions, until

wounds stop

See staphylococcal disease, scalded skin syndrome

below

Rocky Mountain spotted fever

Standard

Not transmitted from person to person except through

transfusion,

rarely

Roseola infantum (exanthem subitum;

caused by HHV-6)

Standard

Rotavirus infection (see gastroenteritis)

Rubella (German measles) ( also see

congenital rubella)

Droplet +

Standard

Until 7 days

after onset

of rash

Susceptible HCWs should not enter room if immune

caregivers are available. No recommendation for

wearing face protection (e.g., a surgical mask) if

immune. Pregnant women who are not immune should

not care for these patients [17, 33]. Administer vaccine

within three days of exposure to non-pregnant

susceptible individuals. Place exposed susceptible

patients on Droplet Precautions; exclude susceptible

healthcare personnel from duty from day 5 after first

exposure to day 21 after last exposure, regardless of

post-exposure vaccine.

Rubeola (see measles)

Salmonellosis (see gastroenteritis)

Scabies

Contact

Until 24

Scalded skin syndrome,

staphylococcal

Contact

Duration of

illness (with

wound

lesions, until

wounds stop

See staphylococcal disease, scalded skin syndrome

below)

Schistosomiasis (bilharziasis)

Standard

Severe acute respiratory syndrome

Airborne +

Droplet +

Contact +

Duration of

illness (with

wound lesions,

until wounds

stop draining)

plus 10 days

after resolution

of fever,

provided

respiratory

Airborne preferred; D if AIIR unavailable. N95 or higher

respiratory protection; surgical mask if N95 unavailable;

eye protection (goggles, face shield); aerosol-

generating procedures and "supershedders" highest

risk for transmission via small droplet nuclei and large

droplets [93, 94, 96]. Vigilant environmental disinfection

(see [This link is no longer active:

www.cdc.gov/ncidod/sars. Similar information may be

found at CDC Severe Acute Respiratory Syndrome

(SARS) (https://www.cdc.gov/sars/index.html),

Sporotrichosis

Standard

Spirillum minor disease (rat-bite fever)

Standard

Not transmitted from person to person

Staphylococcal disease (S aureus)

Skin, wound, or burn

Major

Contact

Duration of

illness (with

wound

lesions, until

wounds stop

No dressing or dressing does not contain drainage

adequately

Staphylococcal disease (S aureus)

Skin, wound, or burn

Minor or limited

Standard

Dressing covers and contains drainage adequately

Staphylococcal disease (S aureus)

Enterocolitis

Standard

Use Contact Precautions for diapered or incontinent

children for duration of illness

Staphylococcal disease (S aureus)

Multidrug-resistant (see

multidrug-resistant organisms)

Staphylococcal disease (S aureus)

Pneumonia

Standard

Staphylococcal disease (S aureus)

Scalded skin syndrome

Contact

Duration of

illness (with

wound

lesions, until

wounds stop

Consider healthcare personnel as potential source of

nursery, NICU outbreak [1095].

Staphylococcal disease (S aureus)

Toxic shock syndrome

Standard

Streptobacillus moniliformis disease

(rat-bite fever)

Standard

Not transmitted from person to person

Streptococcal disease (group A

streptococcus)

Skin, wound, or burn

Major

Contact +

Droplet +

Standard

Until 24 hours

after initiation

of effective

therapy

No dressing or dressing does not contain drainage

adequately

Streptococcal disease (group A

streptococcus)

Skin, wound, or burn

Minor or limited

Standard

Dressing covers and contains drainage adequately

Streptococcal disease (group A

streptococcus)

Endometritis (puerperal sepsis)

Standard

Streptococcal disease (group A

streptococcus)

Pharyngitis in infants and young

children

Droplet

Until 24 hours

after initiation

of effective

therapy

Streptococcal disease (group A

streptococcus)

Droplet

Until 24 hours

after initiation

Streptococcal disease (group A

streptococcus)

Serious invasive disease

Droplet

Until 24 hours

after initiation

of effective

therapy

Outbreaks of serious invasive disease have occurred

secondary to transmission among patients and

healthcare personnel [162, 972, 1096-1098]

Contact Precautions for draining wound as above;

follow rec. for antimicrobial prophylaxis in selected

conditions [160].

Streptococcal disease (group B

streptococcus), neonatal

Standard

Streptococcal disease (not group A or

B) unless covered elsewhere

Multidrug-resistant (see

multidrug-resistant organisms)

Strongyloidiasis

Standard

Syphilis

Latent (tertiary) and seropositivity

without lesions

Standard

Syphilis

Skin and mucous membrane,

including congenital, primary,

secondary

Standard

Tapeworm disease

Hymenolepis nana

Standard

Not transmitted from person to person

Tapeworm disease

Taenia solium (pork)

Standard

Tapeworm disease

Other

Standard

Tetanus

Standard

Not transmitted from person to person

Tinea (e.g., dermatophytosis,

dermatomycosis, ringworm)

Standard

Rare episodes of person-to-person transmission

Toxoplasmosis

Standard

Transmission from person to person is rare; vertical

transmission from mother to child, transmission through

organs and blood transfusion rare

Toxic shock syndrome (staphylococcal

disease, streptococcal disease)

Standard

Droplet Precautions for the first 24 hours after

implementation of antibiotic therapy if Group A

streptococcus is a likely etiology

Trachoma, acute

Standard

Transmissible spongiform

encephalopathy (see Creutzfeld-Jacob

disease, CJD, vCJD)

Trench mouth (Vincent's angina)

Standard

Trichinosis

Standard

Trichomoniasis

Standard

Trichuriasis (whipworm disease)

Standard

Tuberculosis (M. tuberculosis)

Pulmonary or laryngeal disease,

confirmed

Airborne

Discontinue precautions only when patient on effective

therapy is improving clinically and has three

consecutive sputum smears negative for acid-fast

bacilli collected on separate days (MMWR 2005; 54:

RR-17 Guidelines for Preventing the Transmission of

Mycobacterium tuberculosis in Health-Care Settings,

2005

(https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a

1.htm?s_cid=rr5417a1_e)) [12].

Tuberculosis (M. tuberculosis)

Pulmonary or laryngeal disease,

suspected

Airborne

Discontinue precautions only when the likelihood of

infectious TB disease is deemed negligible, and either

there is another diagnosis that explains the clinical

syndrome or

the results of three sputum smears for AFB are

negative. Each of the three sputum specimens

should be collected 8-24 hours apart, and at least

one should be an early morning specimen

Tuberculosis (M. tuberculosis)

Skin-test positive with no

evidence of current active

disease

Standard

Tularemia

Draining lesion

Standard

Not transmitted from person to person

Tularemia

Pulmonary

Standard

Not transmitted from person to person

Typhoid (Salmonella typhi) fever (see

gastroenteritis)

Typhus

Rickettsia prowazekii (Epidemic

or Louse-borne Typhus)

Standard

Transmitted from person to person through close

personal or clothing contact

Typhus

Rickettsia typhi

Standard

Not transmitted from person to person

Urinary tract infection (including

pyelonephritis), with or without urinary

catheter

Standard

Vaccinia

Only vaccinated HCWs have contact with active

vaccination sites and care for persons with adverse

vaccinia events; if unvaccinated, only HCWs without

contraindications to vaccine may provide care.

Vaccinia

Vaccination site care (including

autoinoculated areas)

Standard

Vaccination recommended for vaccinators; for newly

vaccinated HCWs: semi-permeable dressing over

gauze until scab separates, with dressing change as

fluid accumulates, ~3-5 days; gloves, hand hygiene for

dressing change; vaccinated HCW or HCW without

Vaccinia (adverse events following

vaccination)

Generalized vaccinia

Contact

Until lesions

dry and

crusted, scabs

separated

For contact with virus-containing lesions and exudative

material

Vaccinia (adverse events following

vaccination)

Progressive vaccinia

Contact

For contact with virus-containing lesions and exudative

material

Vaccinia (adverse events following

vaccination)

PostVaccinia encephalitis

Standard

Vaccinia (adverse events following

vaccination)

Blepharitis or conjunctivitis

Contact +

Standard

Use Contact Precautions if there is copious drainage

Vaccinia (adverse events following

vaccination)

Iritis or keratitis

Standard

Vaccinia (adverse events following

vaccination)

Vaccinia-associated erythema

multiforme (Stevens Johnson

Syndrome)

Standard

Not an infectious condition

Vaccinia (adverse events following

vaccination)

Secondary bacterial infection

(e.g., S. aureus, group A beta

hemolytic streptococcus)

Standard +

Contact

Follow organism-specific (strep, staph most frequent)

recommendations and consider magnitude of drainage

Varicella Zoster

Airborne +

Contact +

Standard

Until lesions

dry and

crusted

Susceptible HCWs should not enter room if immune

caregivers are available; no recommendation for face

protection of immune HCWs; no recommendation for type

of protection, i.e., surgical mask or respirator for

susceptible HCWs. In immunocompromised host with

varicella Pneumonia, prolong duration of precautions for

duration of illness. Post-exposure prophylaxis: provide

post-exposure vaccine ASAP but within 120 hours; for

susceptible exposed persons for whom vaccine is

contraindicated (immunocompromised persons, pregnant

women, newborns whose mother's varicella onset is

<5days before delivery or within 48 hours after delivery)

provide VZIG, when available, within 96 hours; if

unavailable, use IVIG, Use Airborne for exposed

susceptible persons and exclude exposed susceptible

healthcare workers beginning 8 days after first exposure

until 21 days after last exposure or 28 if received VZIG,

regardless of postexposure vaccination. [1036].

Viral hemorrhagic fevers due to Lassa,

Ebola, Marburg, Crimean-Congo fever

viruses

Standard +

Droplet +

Contact

Duration of

illness (with

wound

lesions, until

wounds stop

draining)

Ebola Virus Disease Update [2014]: Updated

recommendations for healthcare workers can be

found at Ebola: U.S. Healthcare Workers and

Settings

(https://www.cdc.gov/vhf/ebola/healthcare-us/).

Single-patient room preferred. Emphasize:

use of sharps safety devices and safe work

practices,

hand hygiene;

barrier protection against blood and body fluids

upon entry into room (single gloves and fluid-

resistant or impermeable gown, face/eye protection

with masks, goggles or face shields); and

appropriate waste handling.

Use N95 or higher respirators when performing

aerosol-generating procedures. Largest viral load in

final stages of illness when hemorrhage may occur;

additional PPE, including double gloves, leg and shoe

coverings may be used, especially in resource-limited

settings where options for cleaning and laundry are

limited. Notify public health officials immediately if

Ebola is suspected [212, 314, 740, 772]. Also see

Table 3 for Ebola as a bioterrorism agent.

Viral respiratory diseases (not covered

elsewhere)

Adults

Standard

Viral respiratory diseases (not covered

elsewhere)

Infants and young children (see

respiratory infectious disease,

acute)

Whooping cough (see pertussis)

Wound infections

Major

Contact +

Standard

Duration of

illness (with

wound

lesions, until

wounds stop

No dressing or dressing does not contain drainage

adequately

Wound infections

Minor or limited

Standard

Dressing covers and contains drainage adequately

Yersinia enterocolitica Gastroenteritis

(see gastroenteritis)

Zoster (varicella-zoster) (see herpes

Table 1. History of Guidelines for Isolation Precautions in Hospitals*

Year (Ref)

Document Issued

Comment

1970

Isolation Techniques for

Introduced seven isolation precaution categories with

color-coded cards: Strict, Respiratory, Protective,

Enteric, Wound and Skin, Discharge, and Blood

No user decision-making required

Simplicity a strength; over isolation prescribed for some

infections

1975

Isolation Techniques for

1100

Use in Hospitals, 2nd ed.

1983

CDC Guideline for Isolation

Provided two systems for isolation: category-specific

and disease- specific

Protective Isolation eliminated; Blood Precautions

expanded to include Body Fluids

Categories included Strict, Contact, Respiratory, AFB,

Enteric, Drainage/Secretion, Blood and Body Fluids

Emphasized decision-making by users

1985-88

Developed in response to HIV/AIDS epidemic

Dictated application of Blood and Body Fluid

precautions to all patients, regardless of infection status

Did not apply to feces, nasal secretions, sputum, sweat,

tears, urine, or vomitus unless contaminated by visible

blood

Added personal protective equipment to protect HCWs

from mucous membrane exposures

Handwashing recommended immediately after glove

removal

Added specific recommendations for handling needles

and other sharp devices; concept became integral to

OSHA’s 1991 rule on occupational exposure to blood-

borne pathogens in healthcare settings

1987

Emphasized avoiding contact with all moist and

potentially infectious body substances except sweat

even if blood not present

Shared some features with Universal Precautions

Weak on infections transmitted by large droplets or by

contact with dry surfaces

Did not emphasize need for special ventilation to

1996

Guideline for Isolation

Prepared by the Healthcare Infection Control Practices

Advisory Committee (HICPAC)

Melded major features of Universal Precautions and

Body Substance Isolation into Standard Precautions to

be used with all patients at all times

Included three transmission-based precaution

categories: airborne, droplet, and contact

Listed clinical syndromes that should dictate use of

empiric isolation until an etiological diagnosis is

established

Derived from Garner ICHE 1996

1.6

TB Exposure Control Plan

Yale University has a procedure in place to prevent and control tuberculosis (TB) in our patients,

employees and students. TB is a potentially severe, contagious disease that primarily affects the

lungs, but can also damage other parts of the body. It is usually transmitted by airborne droplets

containing TB bacteria that are spread by infected persons whenever they cough, speak, or sneeze.

On rare occasions, blood and body fluids may become contaminated with TB. Control measures

include understanding the mode of transmission, signs and symptoms of infection, medical

surveillance and therapy, and site-specific protocols.

In conjunction with the facility Infection Control Coordinator, area managers and supervisors must

conduct a risk assessment of their workplace to determine the risk for occupational transmission of

TB and implement an appropriate exposure control plan. Yale Environmental Health and Safety

and the Employee Health can assist with TB risk assessments.

Risk Assessment

The number of reported TB cases in Connecticut has continued to decline for the past several years.

These rates are monitored by the Connecticut Department of Public Health Tuberculosis Control

Program.

Transmission and Pathogenesis

Tuberculosis is an airborne communicable disease caused by Mycobacterium tuberculosis, the

tubercle bacillus. It is spread primarily by tiny airborne particles (1 - 5 microns in diameter), known

as droplet nuclei, that are generated when a person with infectious TB (pulmonary or laryngal)

sneezes, coughs, speaks, or sings. If another person inhales these droplet nuclei, transmission may

occur. Infection begins with multiplication of tubercle bacilli in alveolar macrophages, some of

which spread through the bloodstream; however, the immune system response usually prevents the

development of disease. Persons infected with TB but who do not develop active TB are often

asymptomatic and not infectious; such persons usually have a positive reaction to the tuberculin

skin test. Only about 10% of infected persons develop active TB disease at some time in their lives,

but the risk is considerably higher for persons who are immunosuppressed, especially those with

HIV infection. Although the majority of TB cases are pulmonary, TB can occur in almost any

anatomical site or as disseminated disease. Extrapulmonary TB can be transmitted through blood

and body fluids.

An extremely serious aspect of TB that has developed over the past two decades is multidrug

resistant strains (MDR TB) that are usually resistant to at least isoniazid and rifampin. Infection

with MDR-TB has a 50 to 80% mortality rate. MDR-TB can usually be prevented by initially

treating TB patients with four drugs and by administering TB medications on a directly observed

basis. Persons at higher risk for MDR-TB include those: recently exposed to MDR-TB, especially

the immunocompromised; TB patients who failed to take medications as prescribed; TB patients

who were prescribed an ineffective treatment regimen; and persons previously treated for TB.

Guidelines for TB Control



Employees at risk should be tested for TB exposure by a tuberculin skin test (PPD) or

QuantiFERON serum test at least annually. New employees will be referred to the Employee

Health office (Yale Health, 55 Lock Street, (432-0071) upon being hired for baseline PPD

testing. Employees with potential exposure must be tested within 2 weeks of hire. Employees

with a history of a previous positive PPD or serum test will not be retested but should provide

documentation of a negative chest x-ray as part of their evaluation. Employees exempt from

the tuberculin skin test must be informed about symptoms of TB and the need for immediate

evaluation of any pulmonary symptoms suggestive of TB by their health care provider to

determine if active disease has developed.



University employees and students in contact with patients or clients in hospitals, clinics, or

long term facilities must be tested for TB exposure by a tuberculin skin test (PPD) or

QuantiFERON serum test on an annual basis. This includes students who deliver care, conduct

research or consult individuals. In addition, students who volunteer in correctional facilities,

hospices, shelters for the homeless, or drug/alcohol treatment facilities should be tested on an

annual basis.



Employees and students who test positive on PPD or blood testing will be referred for a chest

x-ray and evaluated for signs of active TB infection. If no signs of active infection (such as

fatigue, fever, chills, night sweats, loss of appetite, weight loss, productive sputum, coughing

up blood (hemoptasis), chest pain, hoarse voice) are present, the employees will be referred for

prophylactic treatment as appropriate following established CDC recommendations.



Health care providers, employees and students (as designated in the above statements) should

be educated through infection control staff about the transmission of TB and appropriate

methods of protection. OSHA compliant TB training will be provided to those in covered risk

groups. Awareness level training will be provided periodically to students and volunteers

working in a health care setting.



Health care providers should concentrate on identifying TB infection among our patient

population.

The following guidelines are recommended for testing groups of patients at high risk for TB

infection:



Patients with history of combined cough, fever, weight loss, night sweats, hemoptysis for

greater than 2 weeks.



Patients with radiographic abnormalities suggestive of TB infection.



Recent contacts with infectious TB cases.



Patients infected with HIV.



Groups at high risk for TB infection such as foreign born persons who arrived within the past

5 years from Asia, Africa, Latin America and Caribbean, medically underserved populations,

long term residents of hospitals, nursing homes, homeless shelters, and correctional facilities.



Patients with underlying medical conditions that increase the risk of TB such as silicosis,

diabetes mellitus, long term corticosteroid therapy, immunosuppressive therapy, injecting

drug use, underlying malignancies, end stage renal disease, post gastrectomy, or intestinal by

pass. In addition, anergy testing should also be performed on any patient suspected of being

immunocompromised.



Patients who are identified as having a positive skin test should have a chest x-ray and be

evaluated for signs of active TB by their health care provider. Patients should be referred when

appropriate for curative or prophylactic treatment under CDC guidelines.

TB Exposure Control Procedures for Suspected or Known Active TB Cases

Ask the person/patient presenting symptoms to cover their nose and mouth.

Provide a surgical mask for the person to wear to contain droplets. Recognize the signs and

symptoms of active TB - these include: fatigue, fever, chills, night sweats, loss of appetite and

weight loss. The advanced stages of TB disease include: sputum-producing cough, coughing up

blood, chest pain, and hoarseness of voice.

Isolate patient from other visitors and employees

If available, place any patient strongly suspected of active TB in a room with:



negative air pressure in relation to the surrounding areas that can be monitored,



6 to 12 room air exchanges per hour,



air discharged directly outdoors or through monitored high efficiency particulate aerosol

(HEPA) filters before recirculation to other areas in the facility.

In facilities without an available negative pressure isolation room, post a sign at the entrance of the

room. The sign will have a red and white stop sign with the statement “No Admittance without

Wearing a Type N95 or More Protective Respirator”.

If a facility does not have a negative air flow room

Provide a surgical mask for patient to wear to contain droplets. Any patient who is strongly

suspected of having active TB should be given a molded surgical mask, instructed to keep it on,

and escorted to a private exam room. These areas are not appropriate for strict isolation but can be

used as a separate waiting area for a short duration until transport can be arranged. Post a sign at

the entrance of the room. The health care provider evaluating the patient should make arrangements

to transfer the patient to a facility with an appropriate isolation room to complete the remainder of

the TB work up (i.e. Yale-New Haven Hospital). Ambulance as well as emergency room personnel

at the admitting facility must be notified of the suspected diagnosis so that appropriate precautions

can be taken.

Immediately notify your supervisor and infection control nurse

Any known case of tuberculosis in a patient or employee must be reported to the Infection

Control Nurse for appropriate reporting to local and state health departments.

The examining room used as a holding area should be closed and terminally cleaned after the

patient has left and then disinfected with an institutionally approved disinfectant.

Wear a respirator for close or prolonged contact

When in close contact with a suspected active TB case, wear a NIOSH certified N-95 mask or a

HEPA respirator. The employee must be fit tested before using N-95 or HEPA respirator, before

wearing a respirator, personnel must be evaluated by Employee Health (432-0071) at the Yale

Health (55 Lock Street) and must contact Yale Environmental Health and Safety (785- 3550) at

135 College Street for training regarding respirator selection, fit testing, and use.

Evaluation of Health Care Workers Post Exposure to Active TB Cases

Health care workers who have been exposed to active TB cases are recommended to have an

initial baseline TB test at time of exposure and a follow up test at 3 months post-exposure.

Health care workers with PPD or blood test conversion from negative to positive post-exposure

will be advised to have a chest x-ray and referred for appropriate prophylactic therapy.

Continuing Risk Assessment at Yale University

TB test conversion rates among employees as well as active TB cases among patients will be

reviewed annually by Employee Health and Infection Control Staff for the purpose of risk

assessment. Any evidence of TB test conversion clusters or patient to patient transmission of

TB will be the impetus for further investigation to maintain compliance with TB control

guidelines. Yale Environmental Health and Safety will be responsible to provide training and fit

testing (respiratory protection) to employees who may be at risk of occupational exposure to TB.

The Yale Health –Dept. of Employee Health will provide the medical surveillance of employees

at risk of occupational exposure to tuberculosis for screening and post-exposure follow-up.

The facility Infection Control Committee will coordinate risk assessment and compliance.

Human Resources will notify OEHS & UHS of potential occupationally exposed newly hired

employee.

1.7

Guidelines for Vancomycin Resistant Enterococcus (VRE) and Multi Resistant

Staphylococcal Aureus (MRSA) Management



The source patient colonized or infected with VRE should immediately be placed on Contact

Precautions in a private room (or in the same room as another VRE infected patient).



Contact Precautions for VRE require that gloves be worn when entering the room; gowns

should also be worn if substantial contact with the patient or environmental surfaces (including

furniture, bed rails, etc.) is anticipated or if the patient is incontinent.



Hands should be washed with antimicrobial soap containing chlorhexidine (i.e., Hibiclens)

after removal of gloves and gowns.



Non-critical patient care items such as stethoscopes, thermometers or sphygmomanometers

should be dedicated for the exclusive use of the patient on Contact Precautions.



Items (i.e., wheel chairs, stretchers,) that cannot be specially dedicated to the source patient

should be first cleaned and then disinfected with an institutionally-approved disinfectant after

each use.



Patient(s) on Contact Precautions who need to be transported outside of the ICF but within the

building should be accompanied by a staff member who can inform the receiving department

of the Contact Precautions. Any contaminated surfaces in the receiving department should be

disinfected as above) after use by the affected patient(s).



The charge nurse should insure that any outside facility or agency (including ambulance) is

notified of Contact Precautions prior to receiving the patient.



The Infection Control Nurse may order follow up stool cultures on the source patient for VRE

to determine when Contact Precautions may be discontinued. The guidelines for

discontinuation of Contact Precautions pertaining to VRE are 3 sequential negative specimens

from multiple body sites taken at least one week apart.



Contact Precautions may not be discontinued until it has been discussed with and approved by

the Infection Control Nurse or their designee.



If any evidence of transmission of VRE to other patients is detected, such as finding a positive

culture in the roommate of the source patient, the Infection Control Nurse will do further

investigation in collaboration with the ICF staff.



The Infection Control Nurse with the primary providers’ assistance may order a stool culture

(or rectal swab) for VRE on the roommate of a patient who has been newly found to have VRE.

Additional screening of patients on the unit may be performed at the discretion of the Infection

Control Nurse.



After discharge of a patient with VRE, housekeeping should be instructed to clean and

disinfect all environmental surfaces in the room (including phones, doorknobs etc.) using the

institutionally-approved disinfectant. It is the responsibility of the ICF charge nurse to ensure

that this step is completed and that the Infection Control Nurse is notified. The Infection Control

Nurse may elect to perform routine environmental surveillance cultures at his or her discretion.

1.8

Infection Control MRSA Program

Clinical Staff

CDC handouts on MRSA to clinical staff to increase education and awareness

Health care worker education done at safety fair

Work with pharmacy to look at programs to foster and monitor

appropriate use of antimicrobials

Include history of MRSA infection or current colonization on electronic medical record

problem list

Suspect MRSA infection when clinical picture is consistent, culture any open, draining or

suspect wounds to look for MRSA as well as other bacterial pathogens.

Focus on communication - inform all transferring or receiving agencies or facilities of

patient’s MRSA status

Transmission precautions

Contact precautions are recommended for treatment of patients with MRSA infections. This

includes:

Inpatient

•

Private room (if not available may have patients with same MRSA

infection housed in the same room)

•

Glove use when entering room

•

Change gloves after contact with material that might have high concentration of

organisms

•

Remove gloves before leaving room and wash with antimicrobial soap

•

Gowns should be worn if substantial contact with patient or environmental

surfaces is expected and removed prior to leaving the room.

•

Patients should remain in their private rooms and should only be transported

when absolutely necessary, minimizing contact between patient and

environmental surfaces. Patients should be escorted by a staff member for all

transportation within the facility.

•

Non-critical patient care items should only be used for that patient. If sharing of

equipment is necessary, the equipment must be cleaned and disinfected before

using it on another patient.

•

Masks should be used for any splash generating procedures.

Ambulatory

•

Standard precautions are used for patients infected or colonized with MRSA.

•

Gloves and gowns must be used for contact with any secretions or drainage.

Environmental Measures:

Inpatient

•

Clean and disinfect surfaces and equipment that may be contaminated, especially

those that are close to the patient such as bed rails, over the bed tables and other

frequently touched surfaces such as door knobs, bed pans, bathrooms on a more

frequent schedule than routine cleaning

•

Upon discharge of patient, terminally clean the room with special focus on

frequently touched areas.

Ambulatory

•

Clean exam tables after use by patient with open wound or drainage as well as

any other environmental surfaces in exam room where patient may have had

contact between surfaces and wound

Tracking

Laboratory reports will be analyzed to track the incidence of MRSA in our facility.

Categories to be tracked will be: total number of infections (this will separated by patient to

avoid duplication of reporting), antibiotic susceptibility data for MRSA infections, and site

information for MRSA infections. If analysis shows a significant upward trend in the

incidence of new MRSA infections or if there is any evidence of a health care associated

infection or outbreak, prevention efforts will be intensified (see below)

Prevention of transmission

Follow CDC hand hygiene recommendations, stress hand washing in all clinical areas

Patient education programs - Educational posters in residential and athletic areas,

education directed at patients who are infected or colonized prior to discharge.

Intensified Prevention Efforts in setting of increased transmission

Intensify efforts if any evidence of increased transmission or health care associated

outbreaks, including one or more of the measures below in addition to those previously

outlined:

•

Consider obtaining active surveillance cultures from at risk inpatient populations, obtain

cultures on roommates of patients subsequently diagnosed with MRSA, and obtain cultures

on patients previously infected or colonized with MRSA. Cultures should be obtained from

areas of skin breakdown or draining wounds, plus anterior nares. Continue surveillance

on a weekly basis until transmission ceases or frequency decreases.

•

If surveillance data points to a health care worker as a possible ongoing source of

transmission, consider obtaining health care worker cultures or consultation with an expert

in Infectious Disease.

•

Consider assignment of dedicated nursing and ancillary staff, including environmental staff

to infected patients. Use either disposable or patient dedicated equipment for the infected

patients.

•

Intensify training and monitoring of the use of contact precautions and on the proper use of

environmental measures.

•

Obtain environmental cultures of equipment or other surfaces if evidence points to an

environmental source of ongoing transmission.

•

Consider consultation with an expert in Infectious Disease or Epidemiology for further

recommendations and discussion of decolonization options for patients or staff.

SECTION 2: Medical Surveillance

2.1

Recommended Immunizations for Health Care Workers

Adopted from AJIC Vol. 26 No 3June 1998 CDC Personnel Health Guideline: Guideline for Infection

Control in Health Care Personnel and current CDC Adult Immunization Guidelines:

All health care workers should be immunized against the following diseases that may be encountered in

their workplace: hepatitis B, measles, mumps, rubella, and diphtheria-tetanus. In addition, non-immune

workers should be vaccinated against Varicella-zoster. Health care workers should also receive the

influenza vaccine on a yearly basis to prevent transmission of the disease to their high-risk patients. Table

1 outlines the recommended vaccinations along with their indications and contraindications. There are

some additional vaccinations listed in the table which may be indicated in certain situations for health care

workers, but which are not routinely recommended. Health Care workers are also recommended to receive

one adult tetanus-diphtheria-pertussis booster as an adult and repeat diphtheria-tetanus boosters as

recommended by CDC.

Table 1. Immunobiologics and schedules for health care personnel: Immunizing agents strongly recommended for health care personnel

Generic name

Primary booster

Dose schedule

Indications

Major precautions

and contraindications

Special considerations

Hepatitis B-

recombinant vaccine

Two doses IM in the

deltoid muscle 4 wk

apart; 3rd dose 5 mo.

after 2nd; booster

doses not necessary if

titer is positive

Health care personnel at risk of

exposure to blood and body fluids

No apparent adverse effects to

developing fetuses, not

contraindicated in pregnancy;

history of anaphylactic reaction to

common bakers yeast

No therapeutic or adverse effects on HBV-

infected persons; cost-effectiveness of

prevaccination screening for susceptibility

to HBV depends on costs of vaccination and

antibody testing and prevalence of immunity

in the group of potential vaccines;

health care personnel who have ongoing

contact with patients or blood should be

tested 1-2 mo. after completing the

vaccination series to determine serologic

response

Influenza vaccine

(inactivated whole or

split virus)

Annual single-dose

vaccination IM with

current (either whole-

or split-virus) vaccine

All health care workers

History of anaphylactic

hypersensitivity after egg ingestion

No evidence of maternal or fetal risk when

vaccine was given to pregnant women with

underlying conditions that render them at

high risk for serious influenza

complications.

Measles live-virus

vaccine

One dose SC; 2

dose

at least 1 mo. later

All health care workers must have

either two doses of live vaccine on or

after their 1st birthday, (b) physician-

diagnosed measles, or (c) laboratory

evidence of immunity.

Pregnancy; immunocompromised*

state; (including HIV-infected

persons with severe

immunosuppression) history of

anaphylactic reactions after gelatin

ingestion or receipt of neomycin; or

recent receipt of immune globulin

MMR is the vaccine of choice if recipients

are also likely to be susceptible to rubella

and/or mumps; persons vaccinated between

1963 and 1967 with (a) a killed measles

vaccine alone, (b) killed vaccine followed

by live vaccine, or (c) a vaccine of unknown

type should be revaccinated with two doses

of live measles vaccine

Mumps live- virus

vaccine

Two dose of live

mumps virus vaccine

Susceptible health care workers should

receive 2 doses of live mumps vaccine

unless they have laboratory evidence of

immunity, or physician diagnosed

mumps.

Pregnancy; immunocompromised*

state; history of anaphylactic

reaction after gelatin ingestion or

receipt of neomycin

MMR is the vaccine of choice if recipients

are also likely to be susceptible to measles

and rubella

HDCV, Human diploid cell rabies vaccine; rabies vaccine absorbed; IPV, inactivated poliovirus vaccine; OPV, oral poliovirus vaccine; ID, intradermally. *Persons immunocompromised because of

immune deficiencies, HIV infection, leukemia, lymphoma, generalized malignancy, or immunosuppressive therapy with corticosteroids, alkylating drugs, antimetabolites, or radiation.

Table 1. Continued

Generic name

Primary booster

Dose schedule

Indications

Major precautions

and contraindications

Special considerations

Rubella live- virus

vaccine

One dose SC; no

booster

Health care personnel, both male and

female, who lack documentation of

receipt of live vaccine on or after their

birthday, or of laboratory evidence

of immunity.

Pregnancy; immunocompromised*

state; history of anaphylactic

reaction after receipt of neomycin

Women pregnant when vaccinated or who

become pregnant within 3 mo. of

vaccination should be counseled on the

theoretic risks to the fetus, the risk of

rubella vaccine-associated malformations in

these women is negligible; MMR is the

vaccine of choice if recipients are also

likely to be susceptible to measles or

mumps

Varicella-zoster live-

virus vaccine

Two 0.5 ml doses SC

4-8 wk apart if 13 yr.

Health care personnel without

laboratory evidence of Varicella

immunity or evidence of previous

vaccination.

Pregnancy, immunocompromised*

state, history of anaphylactic

reaction after receipt of neomycin or

gelatin; salicylate use should be

avoided for 6 wk after vaccination

Because 71%-93% of persons without a

history of varicella are immune, serologic

testing before vaccination may be cost-

effective

Hepatitis A Vaccine

Two doses of vaccine

IM, either

(HAVRIX

) 6-12

mo. apart or

(VAQTA

) 6 mo.

apart

Not routinely indicated for U.S. health

care personnel; however, persons who

work with HAV-infected primates or

with HAV in a laboratory setting

should be vaccinated

History of anaphylactic reaction to

alum or the preservative 2-phenoxy-

ethanol; vaccine safety in pregnant

women has not been evaluated, risk

to fetus is likely low and should be

weighed against the risk of hepatitis

A in women at high risk

Health care personnel who travel

internationally to endemic areas should be

evaluated for vaccination

HDCV, Human diploid cell rabies vaccine; rabies vaccine absorbed; IPV, inactivated poliovirus vaccine; OPV, oral poliovirus vaccine; ID, intradermally. *Persons immunocompromised because of

immune deficiencies, HIV infection, leukemia, lymphoma, generalized malignancy, or immunosuppressive therapy with corticosteroids, alkylating drugs, antimetabolites, or radiation.

Table 1. Continued

Generic name

Primary booster

Dose schedule

Indications

Major precautions

and contraindications

Special considerations

Meningo-coccal

One dose in volume

Not routinely indicated for health care

Vaccine safety in pregnant women

May be useful in certain outbreak

(MCV4 or MPSV)

and by route specified

workers in the United States except to

has not been evaluated; vaccine

situations

by manufacturer; need

microbiologists who are routinely

should not be given during

for boosters is

exposed to isolates

pregnancy unless risk of infection is

unknown

high.

Polio vaccine

IPV, two doses SC

given 4-8 wk apart

followed by 3rd dose

6-12 mo. after

Health care personnel in close contact

with persons who may be excreting

wild virus and laboratory personnel

handling specimens that may contain

wild poliovirus

History of anaphylactic reaction

after receipt of streptomycin or

neomycin; because safety of vaccine

has not been evaluated in pregnant

women, it should not be given

during pregnancy

Use only IPV for immunosuppressed

persons or personnel who care for

immunosuppressed patients.

Tetanus and

Two doses IM 4 wk

All adults; tetanus prophylaxis in

First trimester of pregnancy; history

Diphtheria

apart; 3

dose 6-12

wound management

of a neurologic reaction or

(Td)

mo. after 2nd dose;

immediate hypersensitivity reaction;

booster every 10 yr.

individuals with severe local

(Arthus-type) reaction after

previous dose of Td vaccine should

not be given further routine or

emergency doses of Td for 10 yr.

*The term immunocompromised includes persons who are immunocompromised from immune deficiency diseases, HIV infection, leukemia, lymphoma, or generalized malignancy, or

immunosuppressed as a result of therapy with corticosteroids, alkylating drugs, antimetabolites, or radiation.

Table 1. Continued

Generic name

Primary booster

Dose schedule

Indications

Major precautions

And contraindications

Special considerations

Tetanus-diphtheria

acellular pertussis

One dose as an adult

Adults should have one dose in place of

regular diphtheria-tetanus booster at

greater than or equal to 10 years after

last Td booster. Adults who have

contact with children under 12 months

old and health care workers are

recommended to get one Tdap if more

than 2 years have passed since last

tetanus booster.

Anyone with unstable neurological

condition should defer, see other

precautions under Adult diphtheria-

tetanus

Typhoid vaccines:

oral

Four oral doses on

alternate days;

(Ty21a) vaccine

manufacturer’s

recommendation is

revaccination with the

entire four-dose series

every 5 yr.

Personnel in laboratories who

frequently work with Salmonella typhi

History of severe local or systemic

reaction to a previous dose of

typhoid vaccine; Ty2la vaccine

should not be given to

immunocompromised* personnel or

those currently taking antibiotocs

Vaccination should not be considered

as an alternative to the use of proper

procedures when handling specimens

and cultures in the laboratory

Typhoid vaccines:

Inactivated

one injection with

booster needed every 2

years

Vaccinia vaccine

One dose administered

with a bifurcated

needle; boosters every

10 yr.

Personnel who directly handle cultures

of or animals contaminated with

recombinant Vaccinia viruses or

orthopox viruses (monkeypox, cowpox,

Vaccinia, etc.) that infect human beings

Pregnancy, presence or history of

eczema, or immunocompromised’

status in potential vaccines or in

their household contacts

Vaccination may be considered for

health care personnel who have direct

contact with contaminated dressings or

other infectious material from

volunteers in clinical studies involving

recombinant Vaccinia virus

*The term immunocompromised includes persons who are immunocompromised from immune deficiency diseases, HIV infection, leukemia, lymphoma, or generalized malignancy, or

immunosuppressed as a result of therapy with corticosteroids, alkylating drugs, antimetabolites, or radiation.

2.2

Tuberculosis Testing

Employees and students at risk should be tested for TB exposure by a tuberculin skin test (PPD) or

a QuantiFERON serum test on an annual basis. New employees will be referred to the Employee

Health Department upon being hired for baseline PPD testing. A 2-step PPD will be done on

employees who are at higher risk for previous TB infection as defined by the CDC and who do not

have a history of a previous negative PPD within the last 2 years. Employees with a history of a

previous positive PPD test will not be retested but should provide documentation of a negative

chest x-ray as part of their evaluation for the positive PPD. Employees exempt from the tuberculin

skin test must be informed about symptoms of TB and the need for immediate evaluation of any

pulmonary symptoms suggestive of TB by a primary or trained health care provider to determine if

symptoms of TB disease have developed.

All University employees and students in contact with patients or clients in hospitals, clinics or long

term facilities must be tested for TB exposure by a tuberculin skin test (PPD) or QuantiFERON

serum on an annual basis. This includes students who deliver care conduct research or consult

individuals. In addition, any student who volunteers in correctional facilities, hospices, shelters for

the homeless or drug/alcohol treatment facilities should be retested on an annual basis.

Employees and students who test positive on PPD testing will be referred for a chest x-ray and will

be evaluated for any signs of active TB infection. If no signs of active infection (such as fatigue,

fever, chills, night sweats, loss of appetite, weight loss, sputum production, coughing up blood —

hemoptysis. chest pain, hoarse voice) are present the employees will be referred for prophylactic

treatment when appropriate following established CDC recommendations.

If an employee is exposed to someone with active TB through their job, they should contact the

Employee Health Department at 432-7978 at Yale Health to arrange for a tuberculosis skin test

now and again at 3 months. If the employee’s skin test remains negative, they can return for annual

skin testing if they are in a job category which has potential exposure. If the skin test shows

evidence of recent infection, they will be referred for a Chest X-ray and a discussion of appropriate

treatment or prophylaxis.

2.3

Communicable Disease Work Restrictions for Health Care Workers

Adopted from the AJIC Vol. 26 No 3June 1998 CDC Personnel Health Guideline: Guideline for Infection Control in Health Care

Personnel

Table 2 summarizes the suggested work restrictions for health care workers who are infected with

infectious diseases of importance in health care settings. In some cases, state and local regulations

may regulate the restrictions in a given area. Employees who are suffering from any of these listed

infections should report it to their supervisor, who should then report it to the infection control

coordinator and the Department of Employee Health for further guidance or advice on the

restrictions and return to duty.

Table 2. Summary of suggested work restrictions for health care personnel exposed to or infected with infectious diseases of importance in health

care setting (modified from ACIP recommendations).

Disease/Problem

Work Restriction

Duration

Conjunctivitis

Restrict from patient contact and contact with

the patient’s environment

Until discharge ceases

Cytomegalovirus infections

No restriction

Diarrheal diseases

Acute stage (diarrhea with other symptoms)

Convalescent stage, Salmonella spp.

Norovirus – restrict from work while

symptomatic and until 48-72 hours after

resolution

Restrict from patient contact, contact with the

patient’s environment, or food handling

Restrict from care of high-risk patients

Until symptoms resolve

Until symptoms resolve; consult with local and

state health authorities regarding need for

negative stool cultures

Diphtheria

Exclude from duty

Until antimicrobial therapy completed and 2

cultures obtained 24 hours apart are negative

Enterovial infections

Restrict from care of infants, neonates, and

immunocompromised patients and their

environments

Until symptoms resolve

Hepatitis A

Restrict from patient contact, contact with

patient'’ environment, and food handling

Until 7 days after onset of jaundice

Hepatitis B

Personnel with chronic hepatitis B surface

antigemia who do not perform exposure

prone procedures

Personnel with acute or chronic hepatitis B e

antigenemia who perform exposure-prone

procedures

No restriction; refer to state regulations;

standard precautions should always be

observed

Do not perform exposure-prone invasive

procedures until counsel from an expert review

panel has been sought; panel should review and

recommend procedures the worker can

perform, taking into account specific procedure

as well as skill and technique of worker;

refer to state regulations

Until hepatitis B e antigen is negative

Hepatitis C

No recommendation

†Those susceptible to Varicella and who are at increased risk of complications of Varicella, such as neonates and immunocompromised persons of any age.

‡ High-risk patients as defined by the ACIP for complications of influenza.

Table 2 Continued

Disease/Problem

Work Restriction

Duration

Herpes simplex

Genital

Hands (herpetic whitlow)

Oralfacial

No restriction

Restrict from patient contact and contact with

the patient’s environment

Evaluate for need to restrict from care of high-

risk patients

Until lesions heal

Human immunodeficiency virus

Do not perform exposure-prone invasive

procedures until counsel from an expert review

panel has been sought; panel should review and

recommend procedures the worker can

perform, taking into account specific

procedures as well as skill and technique of the

worker; standard precautions should always be

observed; refer to state regulations

Measles

Active

Postexposure (susceptible personnel)

Exclude from duty

Until 7 days after the rash appears

From 5

day after 1

exposure through 21

day

after last exposure and/or 7 days after rash

appears

Meningococcal infections

Exclude from duty

Until 24 hours after start of effective therapy

Mumps

Active

Postexposure (susceptible personnel)

Exclude from duty

Until 9 days after onset of parotitis

From 12

day after 1

exposure through 26

day after last exposure or until 9 days after

onset of parotitis

Pediculosis

Restrict from patient contact

Until treated and observed to be free of adult

and immature lice

Table 2 Continued Revised: 10/29/01

Disease/Problem

Work Restriction

Duration

Pertussis

Active

Postexposure (asymptomatic personnel)

Postexposure (symptomatic personnel)

Exclude from duty

No restriction, prophylaxis recommended

Exclude from duty

From beginning of catarrhal (inflammation of

mucous membranes) stage through 3

wk after

onset of paroxysms or until 5 days after start of

effective antimicrobial therapy

Until 5 days after start of effective

antimicrobial therapy

Rubella

Active

Postexposure (susceptible personnel)

Exclude from duty

Until 5 days after rash appears

From 7

day after 1

exposure through 21

day

after last exposure

Scabies

Restrict from patient contact

Until cleared by medical evaluation

Staphylococcus aureus infection

Active, draining skin lesions

Carrier state

Restrict from contact with patients and

patient’s environment or food handling

No restriction, unless personnel are

epidemiologically linked to transmission of the

organism

Until lesions have resolved

Streptococcal infection,

Group A

Restrict from patient care, contact with

patient’s environment, or food handling

Until 24 hours after adequate treatment started

Tuberculosis

Active disease

PPD converter

Exclude from duty

No restriction

Until proved noninfectious

Varicella

Active

Postexpsoure (susceptible personnel)

Exclude from duty

Until all lesions dry and crust

From 10

day after 1

exposure through 21

day (28

day if VariZIG given) after last

exposure

Table 2 Continued

Disease/Problem

Work Restriction

Duration

Zoster

Localized, in healthy person

Generalized or localized in

immunosuppressed person

Postexposure (susceptible personnel)

Cover lesions; restrict from care of high-risk

patients†

Restrict from patient contact

Until all lesions dry and crust

From 8

day after 1

exposure through 21

day

(28

day if VariZIG given) after last exposure

or, if Varicella occurs, until all lesions dry and

crust

Viral respiratory infections, acute febrile

Consider excluding from the care of high risk

patients‡ or contact with their environment

during community outbreak of RSV and

influenza

Until acute symptoms resolve

*Unless epidemiologically linked to transmission of infection

†Those susceptible to Varicella and who are at increased risk of complications of Varicella, such as neonates and immunocompromised persons of any age.

‡ High-risk patients as defined by the ACIP for complications of influenza.

2.4

Guidelines for Pregnant Health care Personnel

Adopt from AJIC Vol. 26 No 3June 1998 CDC Personnel Health Guideline: Guideline for Infection Control in Health Care Personnel

Pregnant health care workers are at no greater risk than other personnel for acquiring an infectious

disease as a result of caring for patients. However, since some infections can pose a risk

to the fetus due to perinatal transmission, pregnant workers should adhere to Standard and

Transmission Based Precautions regardless of their individual immune status with respect to

certain diseases. Pregnant workers should also be aware of their own immune status with respect

to communicable diseases and be up–to-date on vaccinations that are available for these diseases.

Table 3. Pregnant health care personnel: Pertinent facts to guide management of

occupational exposures to infectious agents

Agent

Potential Effect

on Fetus

Rate of

Perinatal

Transmission

Maternal

Screening

Prevention

1. Cytomegalo-

virus

Hearing loss;

congenital

syndrome*

15% after

primary maternal

infection;

symptomatic 5%

Antibody provides

some but not

complete protection

against clinical

disease; routine

screening not

recommended

Standard precautions

2. Hepatitis B

Hepatitis;

development of

chronic

infection in

infant

HBeAg

seropositive 90%;

HBeAg negative

0-25%

HBsAg routine

screening

recommended

Vaccine and HBIG to

infant; standard

precautions

3. Hepatitis C

Hepatitis

2% - 5%

Anti-HCV; HCV

RNA in reference

labs; routine

screening not

recommended

Standard precautions

4. Herpes

simplex

Mucocutaneous

lesions, sepsis,

encephalitis;

congenital

malformations

(rare)

Unlikely from

nosocomial

exposure;

primary 33%-

50%, recurrent

Antibody testing

not useful;

inspection for

lesions at delivery

Standard precautions

5. Human

immunodefici-

ency virus

(HIV)

AIDS by 2-3 yr.

8%-30%

Antibody by

enzyme

immunoassay,

Western blot

Avoid high-risk behaviors;

consider postexposure

prophylaxis after high-risk

needlestick exposure;

intrapartum and postnatal

zidovudine for HIV-

seropositive mothers and

their babies; standard

precautions

6. Influenza

Inconsistent

Rare

None

Vaccine (safe during

pregnancy); droplet

precautions

Table 3 Continued

Agent

Potential

Effect on

Fetus

Rate of Perinatal

Transmission

Maternal

Screening

Prevention

7. Measles

Prematurity;

abortion

Rare

History, antibody

Vaccine†; airborne

precautions

8. Parovirus

B19

Hydrops,

stillbirth

Rare, 3% - 9%

maximum adverse

outcome

IgM and IgG

antibody

prepregnancy;

antibody protection

Droplet precautions

9. Rubella

Congenital

syndrome*

45% - 50% overall;

90% in 1

12 wk

Antibody

Vaccine†; droplet

precautions for acute

infection; contact

precautions for

congenital rubella

10.

Tuberculosis

Hepatomegaly

, pulmonary,

CNS

Rare

Skin test

Isoniazid ethambutol

for disease; airborne

precautions

11. Varicella-

zoster

Malformations

(skin, limb,

CNS, eye);

chickenpox

Total 25%;

congenital

syndrome (0-4%)

Antibody

Vaccine†; VariZIG

within 10 days of

exposure if

susceptible; airborne

and contact

precautions

Modified from Siegel JD. Risk and exposure for the pregnant health-care worker. In: Olmatead RN, editor. APIC

infection control and applied epidemiology; principles and practices. St Louis: Mosby; 1996. p. 22-2-22-3 (table

22-1). HBeAg, Hepatitis Be antigen; CNS, central nervous system.

*Congenital syndrome: varying combinations of jaundice, hapatospienomegaly, microcephaly, ONS

abnormalities, thrombocytopenia, anemia, retinopathy, and skin and bone lesions.

†Live-virus vaccines are given routinely before pregnancy.

2.5

Emergency Procedures for Exposure to Blood and Body Fluids



Employees exposed to blood or body fluids by a needlestick, cut, bite, or splash to a mucous

membrane or non-intact skin should immediately wash the affected area with soap and water

for 15 minutes. If the splash is to the eyes or mucous membrane, the area should be flushed

with water for 15 minutes.



Employees should immediately report the exposure incident to their supervisor and seek

medical attention.



Employees or students should immediately report for medical care at Yale Health Plan

(Employee Health Office 432-7978, Student Medicine 432-0312 or Acute Care 432-0123).

It is important to begin any recommended treatment within 1 to 2 hours after exposure.



If the exposure occurs at the Yale-New Haven Hospital and the employee wishes to be seen on

site, they should report to Personnel Health Service (7:30 A.M. to 4:30 P.M., Monday through

Friday) or the Yale-New Haven Hospital Emergency Room if the episode occurs outside of

regular daytime working hours.

2.5.1 Needlestick Procedures



The exposed employee/student should immediately be tested for baseline HIV, Hepatitis B

Surface Ab, and Hepatitis C Ab following established testing guidelines.



The exposed person will be counseled regarding the risk of seroconversion for HIV; symptoms

of disease (acute retroviral syndrome), precautions to prevent secondary spread, and possible

indication for antiviral prophylaxis. See needlestick PnP for current prophylaxis

recommendations (Appendix B)



Workers who receive antiviral prophylaxis should also have baseline CBC and renal and

hepatic function tests drawn.



The suspected source patient for the exposure should be immediately approached to give

consent for a baseline HIV, Hepatitis B S Ag, Hepatitis B S Ab, Hepatitis B core Ab, and

Hepatitis C Ab. The attending primary care provider for the source patient should be notified

to obtain this testing. The Yale Health Plan or Personnel Health providers can assist with this

process. If the source patient does not give consent for testing, the institution’s needlestick

committee should convene as soon as possible to take the necessary steps to obtain testing.



If antiviral prophylaxis for HIV is indicated, the employee/student will be given a 96-hour

packet of prophylactic medication that is available at each institution.



The exposed person will then be instructed to follow up with the appropriate department (either

Employee Health at 432-7978 or Student Medicine at 432-0312) on the next business day to

receive further instructions.



Anyone receiving antiviral prophylaxis should be reevaluated at 2 weeks and 4 weeks post-

exposure for CBC, LFT’s, and renal function to check for any symptoms of drug toxicity that

might indicate the need for reduction of dosage or change in medication. Expert consultation

with an infectious disease specialist should be obtained for situations that might require a

change in the protocol.



Exposed person should be retested for HIV antibody at 6 weeks, 12 weeks and 6 months post-

exposure. Testing may be extended for a year if recommended by the medical provider on a

case-by-case basis.



Appropriate prophylaxis for Hepatitis B exposure should be included in all evaluations where

indicated. If the source patient has evidence of HepC infection, the employee should have

follow up testing for HepC including a HepC viral RNA at 4 weeks and HepC Ab at 3 and 6

months.



If the source patient’s HIV status subsequently becomes known, the decision about antiviral

prophylaxis can be modified as clinically indicated.



Those exposed to blood or bodily fluids should make sure an incident report is filed within 24

hours; employees should also make sure a Supervisor’s Report of Injury is filed.

See appendix for information concerning HIV Counseling Guidelines and Risk Categories.

2.6 Post Exposure Prophylaxis guidelines for exposure to other infectious agents

Adopt from AJIC Vol. 26 No 3June 1998 CDC Personnel Health Guideline: Guideline for Infection Control in Health Care Personnel

The following table outlines prophylactic regimens that may be prescribed in situations where a

health care worker is exposed to an infectious agent or communicable disease. Health care workers

who are exposed to any of these infections through their work should notify their supervisor, who

will then refer them to the Department of Employee Health for evaluation and discussion of

prophylaxis.

Table 4. Immunobiologics and schedules for health care personnel: Diseases for which postexposure prophylaxis may be indicated for

health care personnel

Disease

Prophylaxis

Indications

Major precautions

contraindications

and

Special

considerations

Diphtheria

Benzathine penicillin, 1.2 mU IM, single

For health care personnel exposed

Also administer one

dose, or erythromycin (1 gm/day) PO x 7

to diphtheria or identified as

dose Td to previously

days

carriers

immunized if no Td

has been given in 5

yr.

Hepatitis A

Begin Hepatitis A vaccination serioes for

persons 1-40 years old (If < 1 year or >

40 years old, can use IgG 0.02mg/kg

within 2 weeks)

May be indicated for health care

personnel exposed to feces of

infected persons during outbreaks

Hepatitis B

HBIG 0.06 ml/kg IM as soon as possible

(and within 7 days) after exposure (with

dose 1of hepatitis B vaccine given at

different body site); complete doses #2

and #3 of HepB series

HBV-susceptible health care

personnel with percutaneous or

mucous-membrane exposure to

blood known to be HBsAg

seropositive

Meningococc

al disease

Rifampin, 600 mg PO every 12 hours for

2 days, or ceftriaxone, 250 mg IM, single

dose, or ciprofloxacin, 500 mg PO, single

dose

Personnel with direct contact with

respiratory secretions from infected

persons without the use of proper

precautions (e.g., mouth-to-mouth

resuscitation, endotracheal

intubation, endotracheal tube

management, or close examination

of oropharynx

Rifampin and ciprofloxacin

not recommended during

pregnancy

Pertussis

Azithromycin, 500mg x1, then 250mg

x 4 days

Erythromycin, 500 mg qid PO, or

trimetho-prim-sulfamethoxazole, 1 tablet

bid PO, for 14 days after exposure

Personnel with direct contact with

respiratory secretions or large

aerosol droplets from respiratory

tract of infected persons.

PO, Orally; Td, tetanus-diphtheria toxoid; IG, immune globulin; IgA, immunoglobulin A; qid, four times daily; bid, twice daily; HRIG, human rabies immunoglobulin; HDCV, human diploid cell rabies

vaccine; RVA, rabies vaccine absorbed.

*Persons immunocompromised because of immune deficiencies, HIV infection, leukemia, generalized malignanacy, or immunosuppressive therapy with corticosteroids, alkylating drugs, antimetabolites, or

radiation.

†Some persons have recommended 125 U/10 kg regardless of total body weight.

Table 4. Continued

Disease

Prophylaxis

Indications

Major

precautions

contraindications

and

Special considerations

Rabies

For those never vaccinated: HRIG 20

Personnel who have been bitten by

human being or animal with rabies or

have had scratches, abrasions, open

wounds, or mucous membranes

contaminated with saliva or other

potentially infective material (e.g.,

brain tissue)

Personnel who have

IU/kg, half infiltrated around wound, and

previously been

HDCV or RVA vaccine, 1.0 ml, IM

vaccinated, give HDCV

(deltoid area), 1 each on days 0, 3, 7, 14.

or RVA vaccine, 1.0

ml, IM, on days 0 and

3; no HRIG is

necessary

Varicella

If within 3-5 days immediate vaccination

Personnel known or likely to be

Serologic testing may

zoster virus

with Varicella vaccine series.

susceptible to Varicella and who have

help in assessing

Alternatively for high risk patients,

close and prolonged exposure to an

whether to administer

VZIG for persons 50 kg: 125 U/10kg

IM; for persons 50 kg: 625 U†

infectious health care worker or

patient, particularly those at high risk

for complications, such as pregnant or

VZIG; if Varicella is

prevented by the use of

VZIG, vaccine should

immunocompromised persons

be offered later

PO, Orally; Td, tetanus-diphtheria toxoid; IG, immune globulin; IgA, immunoglobulin A; qid, tour times daily; bid, twice daily; HRIG, human rabies immunoglobulin; HDCV, human diploid cell rabies vaccine;

RVA, rabies vaccine absorbed, VZIG Varicella Zoster Immune globulin.

*Persons immunocompromised because of immune deficiencies, HIV infection, leukemia, generalized malignanacy, or immunosuppressive therapy with corticosteroids, alkylating drugs, antimetabolites, or

radiation.

†Some persons have recommended 125 U/10 kg regardless of total body weight.

SECTION 3: Handling Waste

3.1

Medical Waste Management

The purpose of this section is to provide practical guidelines for employees who handle, manage,

transport and dispose of waste.

There is no epidemiological evidence that clinical waste, when properly disposed, is more infective

to the community than residential waste. However, it does present a greater risk to waste-handlers

until it reaches the final disposal location. Medical waste must always, therefore, be handled

carefully. Infection capability is dependent on:

the presence of a human pathogen

a pathogen with sufficient virulence in sufficient dose to cause disease



the availability of a potential host’s portal of entry

the resistance of the host

The following waste shall be declared as medical waste and shall be subject to the special waste-

handling described below

contaminated sharps

unused, discarded hypodermic needles, suture needles, scalpel blades and syringes

used intravenous equipment

isolation wastes from patients infected with these viruses

Kyasanur Forest Disease

Junin

Marburg

Russian spring-summer encephalitis

Congo-Crimean Hemorrhagic fever

Omsk hemorrhagic fever

Lassa

Machupo

Ebola

cultures and stocks of infectious agents

human blood and blood products

dressings, paper tissues and other disposable items saturated or dripping with blood or items

caked with dried blood

pathological wastes

Medical waste must be collected and transported in leak proof and impervious bags or containers

prior to autoclaving or incineration. Items other than the infective waste described, even if the item

has had contact with blood, exudates or secretions, may be disposed of with all other trash. All trash

must be collected and transported to the collection bin in leak proof, impervious bags. Bulk blood,

suctioned fluids, excretions and secretions must be carefully poured down a drain connected to a

sanitary sewer, and bleach must be poured into the drain before disposing of contaminated fluid and

also after disposing of contaminated fluid.

3.2

Guidelines on the Management of Infectious Waste

Medical Waste

Wearing gloves place contaminated dressings, tissues and other articles soiled by respiratory,

oral, blood or wound secretions in a receptacle lined with an impervious plastic bag. Double-

bag in a red plastic bag for disposal.

Place waste in the designated area for Medical waste removal.



Dispose of urine, feces, secretions and excretions into the patient’s toilet or hopper sink.



Do not dispose of wastes in the patient’s sink.

Blood and Blood Products

Wash hands (See section on hand washing).

Follow standard precautions.

Clean up any spillage of blood immediately with a solution of 5.25 sodium hypochlorite

(bleach) and water. Use one part bleach to nine parts water, or another EPA registered

disinfectant.

These recommendations are for the protection of patient care personnel, specimen transporting

personnel, laboratory personnel, and everyone who works in the institution. When handling blood,

employees should be aware the potential exists for the acquisition of Hepatitis B, Hepatitis C, HIV,

Cytomegalovirus (CMV), other viruses and biological agents which are blood borne.

3.3

Trash handling



All material for disposal, except material designated as “infectious,” will be disposed of using

the ordinary trash removal system which terminates with the trash removal from facility and

off-loading at an approved municipal landfill.

Gross liquid content found in various containers to be discarded should be eliminated by the

individual, generating the waste, prior to the introduction of the container into the trash disposal

system.

Containers (e.g., bed pans, emesis basins, urinals, urinal hats, respiratory suction tubing, suction

canister liners & tubing) holding urine, feces, vomitus or nasogastric drainage are discarded in

regular trash after emptying fluids into sanitary sewer system, and rinsing container.

All trash shall be placed in a high tensile strength, impervious, liquid-tight bag prior to being

sent down a trash chute.

3.4

Procedure for Trash Disposal

Use plastic liners in all wastebaskets.

Discard paper and disposable items into the plastic liner in the wastebasket. When full, the

plastic liner should be sealed and disposed of into another larger bag, and not reused.

Do not discard needles and syringes into the wastebasket.

Close bag tightly and secure with tie or tape.

3.5

Disposal of chemotherapy waste

The following procedures are recommended for laboratory and clinic personnel for the safe

handling and disposal of chemotherapy drugs and related waste.

Under laws enacted by the federal government, criteria were developed by which wastes could be

determined hazardous. Chemotherapy drugs have been listed as hazardous wastes.

Because of similarity of structure, mode of action, and toxicity all chemotherapy drugs should be

handled and disposed of as hazardous waste. The University Environmental Health and Safety

Department has detailed recommendations for the handling of hazardous waste. These

recommendations can be found on the EHS web site or by contacting the department at 203-785-

3550.These recommendations must be followed since Yale is considered a large generator of

hazardous waste and, as such, is highly regulated by the EPA and Connecticut DEP. The law allows

for civil and criminal penalties to be assessed against institutions and/or individuals that improperly

dispose of hazardous wastes.

Empty syringes, vials, etc. should be placed in the appropriate sharps disposal container. A

container is considered empty if it contains no more than 3 percent by weight of the total

capacity of the container. This definition is important since containers of chemotherapy drugs

do not have to be disposed of as hazardous waste if they meet this definition.

Syringes are always considered biological waste. Any chemotherapy drugs in the syringe

should be emptied into a waste container. The empty syringe is then placed into the appropriate

sharps disposal container.

Waste containers for prepared excess chemotherapy drugs should be kept in each lab, clinic or

office. The container should be compatible with the drug, have a secure lid, and a label

identifying the contents. More than one type of excess drug can be put into each container if a

log sheet is kept on the type of drug and the amount put in. This is important for the final

disposal of this material since unknown material is very expensive to dispose of and these costs

would be charged back to the doctor or department.

Vials that are not empty (>3 percent by weight of the capacity of the container) should be placed

into a plastic lined box. When the box is full, tape the top shut, tag with a hazardous waste tag,

and call Environmental Services Section (5-3551) to arrange for disposal.

Vials containing sterile water should be emptied into the sink and the bottles should be placed

in the appropriate sharps disposal container.

3.6

Needles and Syringes and Other Sharp item

Personnel should use caution when handling all used needles and syringes because it is usually not

known which patient’s blood is contaminated with the hepatitis virus, HIV or other blood borne

diseases. To prevent needle-stick injuries, used needles should not be recapped; bent,

broken, or removed. Place used needle and syringes into an appropriate sharps disposal container

after use. The sharps disposal container used for needles/syringes or other intravascular sharps must

be a rigid puncture-resistant, leak proof on sides and bottom, the container lid opening must be a

one way system to prevent spillage and retrieval of items from container, and appropriately labeled

with the international biohazard symbol and word biohazard

(see figure below).

BIOHAZARD

Procedures for Used Needles, Syringes, Knife Blades and other intravascular Sharps -- These

guidelines should be followed by all personnel:

Sharp instruments and disposable items:

Only safety needles should be used unless ICC has approved an exception for a particular

procedure.

Needles must not be recapped, purposely bent or broken by hand, removed from disposable

syringes, or otherwise manipulated by hand.

Needles, syringes and other sharps must have the facility-approved protective safety

mechanism employed immediately after use.

After syringes and needles, scalpel blades and other sharp items are used they must be placed

in appropriate sharps disposal containers for disposal.

Such containers must be easily accessible to personnel needing them and located in all areas

where sharps are commonly used. Sharps containers must be constructed so that they will not

spill their contents and will not themselves allow injuries when handled.



These containers must also be located in patient’s examination or treatment rooms and any

other setting where blood is drawn and needles are used.

Disposal of knife blades:

Safety scalpels with disposable handles must be used unless a department hs been granted and

exception by ICC.

Deposit blade or blade with disposable handle in the sharps container.

Other Sharps

Non-intravascular sharp items ( e.g., glass slides, glass tubes, vacutainers, glass medication

vials, vaccine vials) are deposited into the designated puncture-resistant medical waste

containers.

3.7

Dressings and Tissues

Wound dressings are to be disposed of in a manner so as to “confine and contain” any blood and

body fluid that may be present.

Small dressings can be enclosed in the disposable glove used by the caregiver removing the

dressing. While holding the dressing, the glove should be pulled off inside out over the dressing.

The dressing will be contained in the inverted glove. The dressing and glove can be safely

discarded into the regular trash container located in the patient/clinic room.

Larger dressings should be removed using gloves on both hands. The gloves, dressings and

other trash from the dressing change procedure should be placed directly into an impervious

plastic bag located at the bedside. The bag should be zipped or tied closed and deposited into

the regular trash.

Dressings, paper tissues and other disposable items saturated or dripping with blood or items

caked with dried blood must be placed in red biohazard bag and disposed as regulated medical

waste.

Any waste item that is caked, dried, soaked or dripping with blood is deposited into red

biohazard bag, if the item is capable of puncturing the bag then place the item in a puncture

resistant red medical waste container.

Other body fluids (semen, vaginal secretions, cerebrospinal fluids, synovial fluids, pleural fluid,

pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid

that is visibly contaminated with blood, and all body fluids in situations where it is difficult or

impossible to differentiate between body fluids) are empty from container when feasible, by

patient care area staff, by pouring into the sanitary sewer system (soiled utility room or toilet

facility) and deposit containers and/or sealed units in red medical waste container: Containers

that cannot be emptied are stoppered to prevent leakage and placed in red medical waste

container.

3.8

Autoclaves

Autoclaves can sterilize all items that are heat stable (not damaged by steam or high temperature)

or used to decontaminate waste items. In gravity autoclaves, cycles of 250°F (121°C), 15 to 18 lbs.

pressure for one hour may be required for decontamination. In the newer vacuum autoclaves,

decontamination may require 270°F (132°C), 27 to 30 lbs. pressure for 45 minutes. Use chemical

and biological indicators to verify your autoclave technique and sterilization. Contact Yale

Environmental Health and Safety (785-3550) for more information on the Biological Indicator test

kit. Personal protection equipment (PPE) such as rubberized aprons, full-face shields and heat and

liquid resistant gloves must be worn when operating autoclaves.

When autoclaves cannot be used, an alternative method such as chemical decontamination may be

employed. Items must be soaked in a tuberculocidal disinfectant or a 10% bleach (sodium

hypochlorite) solution for at least 30 minutes. Heavily soiled items must be cleaned first.

Whatever the temperature and time requirement for decontamination, the contents of each load

must be positioned so that steam penetrates into, or heated air flows freely among all items to be

decontaminated. Tightly sealed or stoppered materials may not be effectively decontaminated and

may become dangerously pressurized causing injury when removed

A routine autoclave maintenance program is recommended. Regular chemical "tape" monitoring of

temperature and periodic monitoring with a biological indicator should be performed to evaluate

the effectiveness of the autoclave. Place biological indicators at locations inside the load, the area

slowest to heat up, throughout the autoclave are the best indication of sterilization. Biological

indicators may be processed by either in-office biological monitoring (use of an incubator) or mail-

in spore testing (processed by a lab vendor). Autoclaves should be tested periodically. Contact Yale

Environmental Health and Safety for assistance in testing your autoclave.

Items containing chemicals (such as phenol-chloroform) should not be placed in an autoclave or a

hot air oven (remove chemicals first).

Autoclave records should be kept on-hand for at least three years.

Questions should be addressed to Yale Environmental Health and Safety — 785-3550

SECTION 4: Good Work Practices

This section contains information essential to understanding and properly using Standard

Precautions. These techniques and recommendations should be applied to all patient care

procedures. For example, gowns are appropriate for patient-care personnel when soiling with bodily

fluids is likely, whether or not the patient is known or suspected to be infected.

4.1

Hand washing

Hand washing is the single most important means of preventing the spread of infection. Personnel

should always wash their hands, even when gloves are used, before and after taking care of any

patient.

YUHS Policy and Procedure is to wash hands before and after each patient contact.

Basic Hand Washing

Start with acceptable antimicrobial liquid hand soap. Turn water on and wet hands

thoroughly.

Vigorously lather with soap, covering well beyond areas of contamination.

Use friction, one hand upon the other with fingers interlaced for at least 15 seconds.

Rinse hands thoroughly under running water, holding elbows higher than hands to allow

water to flow to the fingertips.

Dry hands with a clean, dry paper towel.

Use a paper towel to turn off the water faucet.

4.2

General

Eating, drinking, application of cosmetics or lip balm, and handling of contact lenses is

prohibited in work areas where there is reasonable likelihood of occupational exposure to

blood, body fluids, chemicals, radioactive materials, and all other hazardous materials.

Personal food and drink are prohibited from storage in refrigerators, freezers, cabinets, or on

shelves or countertops in the areas designated for patient care.



Use protective covering on chairs, wheelchairs, stools, and exam tables that have direct

contact with patient’s skin.

Cover stretchers and exam/treatment tables with a clean sheet and/or disposable exam table

paper before each patient use. Wipe the surface with an institutionally-approved disinfectant

(such as, tuberculocidal disinfectant or a 10% bleach solution) daily and when visibly soiled

with blood or body fluids.

Clean non-patient specific portable equipment (blood pressure cuffs) with an approved

disinfectant-detergent in accordance with the manufacturer's instructions when visibly soiled

and according to the equipment cleaning policy.

Place contaminated reusable instruments in designated containers before removal to another

area for cleaning.



Family/visitors of Inpatient Care patients will be advised to check with the patient’s nurse

before bringing gifts of food or drink, as some patients are on special diets.

Due to infection control considerations, plants and flowers are not allowed in patient care

areas or in clean and dirty utility rooms.

Dispose of sharps in the designated sharps container. Contaminated needles must not be bent,

recapped, broken, or removed by hand from the syringe. Always engage the sharp safety

mechanism before disposal immediately after use.

Check all sterile supplies weekly for inventory rotation. Supply delivery will follow first in

first out procedure.



Prepare fresh solutions of disinfectant according to manufacturer’s instructions. Place a date on

the container as to when the solution was prepared. If using bleach solution, (10% in water) it

must be prepared daily.

Minimize splashing, spraying, or generation of droplets during procedures involving blood or

other potentially infectious materials.

Keep goggles, gowns, and gloves available and easily accessible in all exam rooms and other

direct patient care areas.

Label and date all patient food items.

Do not store clean supplies on the floor, in the soiled utility room, or next to sinks where

splashing of water or soiling may occur. Designate and maintain areas for clean and dirty

supplies.

Medical supplies must not be stored in corrugated boxes.

4.3

Eyewash Station and Spill Clean-Up Supplies

Employees need to know where the emergency eyewash, chemical and biological spill supplies,

and other safety equipment is located. Eyewash stations will be tested according to policy by

clinical personnel to be certain that water flows through it.

4.4

Refrigerators:

There must be separate refrigerators for food, specimens and medications, each with a cleaning

schedule. Signs must be affixed to indicate its designated use. A biohazard label must be affixed to

the outside of refrigerators used to store specimens. Refrigerators must be monitored for

temperature and cleanliness, which includes daily or twice daily temperature checks, weekly and

as needed cleaning, and routine inspection of contents. Laboratory specimens requiring

refrigeration while awaiting transport may not be stored in the same refrigerator as medications,

juices or water stored for the purpose of dispensing with medication.

4.5

Storage of Sterile Solutions:

Upon opening sterile solutions, staff may write the date on the label. All open solutions will be

discarded on the first working day of the month or upon expiration date, whichever is the earliest.

Sterile stock solutions should be checked prior to use for turbidity, leaks, cracks, particle matter,

discoloration, and expiration date.

When pouring from a container of sterile solution, first pour and then discard a small amount.

Unused remaining sterile solutions must be discarded after 24 hours or as per explicit instructions

of the pharmacist.

YUHS Personnel refer to policy Quality Control of Multidose Vials - Appendix # 1

4.6

Storage of Disposable Supplies

Single-use disposable type sterile and non-sterile supplies must be inspected upon receipt and again

just prior to use for intact packaging, evidence of water damage or other contamination or

tampering.

Store supplies in a clean, dry, enclosed area (e.g., cupboard, closet) in their original cartons. Never

store clinical supplies under the sink since they may receive moisture damage/contamination during

routine cleaning procedures and from water leakage. Disposable supplies may only be used once

and not reprocessed, re-sterilized, or reused. After use, promptly dispose items in the appropriate

waste container.

4.7

Perishable Food and Juices

Cans of juices or milk must be checked for expiration date and discarded at expiration date. Before

opening a can, wipe the surface with a moistened paper towel to avoid introducing contaminants.

A dedicated refrigerator is required for the storage of patient food and juices, and must be monitored

at least daily for temperature and cleanliness.

4.8

Dietary

No special dishes or other precautions are necessary when visiting, serving or interviewing

patients, except when those patients are on Transmission Based Precautions.

Disposable dishware and trays are not required for any patient except those on Transmission

Based Precautions.

No special precautions are needed when passing or collecting menus (except for those patients

on Transmission Based Precautions), unless the menus are visibly soiled. If soiled, wear gloves

to handle and dispose of the soiled menus. Promptly wash hands.



No special precautions are needed when passing trays or delivering nourishment to patients

(except those on Transmission Based Precautions). For collecting trays, gloves should be worn.

All disposable items should be removed from trays and discarded into the appropriate waste

receptacle in the patient’s room. Only reusable items should be returned to the Food Service.

▪

Because it is unsanitary to mix clean and contaminated materials, bedpans and urinals

must be removed from patient bed tables prior to mealtime. The table will be washed

with facility approved disinfectant.

▪

In order for food trays to be collected by Food Service Personnel, they must be free of

direct patient care items.

▪

Employees in the dish-room must wear gloves, discard them and wash their hands before

working in “clean” food areas.

▪

See specific policies related to dietary services.

4.9

Private Rooms

Private rooms are required for all patients who soil the room with body substances, as well as for

patients who are likely to have an infectious disease transmissible by the airborne route. Few

patients require private rooms, so in choosing roommate combinations, nurses should assess the

risk of transmission between patients. When practicing Standard Precautions, roommate selection

should be based on the likelihood of soiling of articles in the room.

4.10

Roommates for Patients on Transmission Based Precautions

If infected or colonized patients are not placed in private rooms, they should be placed with

appropriate roommates. Infected patients should not share a room with a patient who is likely to

become infected or in whom consequences of infection are likely to be severe (e.g.,

immunosuppressed patient).

In general, patients infected by the same microorganism may share a room. Such grouping (or

cohorting) of patients is especially useful during outbreaks when there is a shortage of private

rooms.

4.11

Airborne Precaution Rooms

General Considerations

Any patient requiring airborne precaution rooms will be masked, placed in a private room and if

appropriate be admitted to Inpatient Care isolation rooms or immediately transferred to Yale New

Haven Hospital.

4.12

Cleaning Patient Rooms

Routine Cleaning

Patient rooms and other treatment area must be cleaned and disinfected prior to the introduction of

a new patient. This cleaning and disinfecting must be in compliance with established housekeeping

policies using only approved cleaning and disinfecting agents. Cleaning equipment used in rooms

of patients whose infection requires a private room should be disinfected before being used in other

patient rooms, i.e. dirty water should be discarded, wiping cloths and mop heads should be

laundered. If cleaning cloths and mop heads are contaminated with infective material or blood, they

should be bagged and sent to the laundry.

Environmental surfaces such as walls, floors and other surfaces are not associated with transmission

of infections to patients or health-care workers. Therefore, extraordinary attempts to disinfect or

sterilize these environmental surfaces are not necessary. However, cleaning and removal of soil

should be done routinely.

Cleaning schedules and methods vary according to the department, the type of surface to be cleaned

and the amount and type of soil present. Horizontal surfaces (e.g. bedside tables and hard-surfaced

flooring) in patient-care areas are usually cleaned on a regular basis, when soiling or spills occur,

and when a patient is discharged. Cleaning of walls, blinds and curtains is performed semi-annually

and when they are visibly soiled.

Disinfectant-detergent formulations registered by the Environmental Protection Agency (EPA) can

be used for cleaning environmental surfaces, but the actual physical removal of microorganisms

by scrubbing is probably as important as any antimicrobial effect of the cleaning agent used.

The manufacturer’s instructions for appropriate use should be followed.

Staff Responsibilities in Terminal Cleaning of the Isolation Room or Cubicle

Clean, bag and remove all supplies from the room before Housekeeping arrives to terminally

clean the room.



Empty all non-disposable receptacles such as drainage bottles into the toilet. If the receptacles

are disposable, empty and discard them according to facility’s policy.

Housekeeping will clean other patient care supplies such as reusable equipment according to

facility policy.

Discard all opened or unopened disposable items into trash receptacle.

Terminal Cleaning

Although microorganisms may be present on walls, floors and tabletops in rooms used for patients

on isolation precautions, these environmental surfaces, unless visibly contaminated, are rarely

associated with transmission of infections to other patients when such equipment is not

appropriately decontaminated and reprocessed. Therefore, terminal cleaning should primarily be

directed toward those items that have been in direct contact with the patient or in contact with the

patient’s infective material (excretions, secretions, blood or body fluids). The disinfectant-

detergent solution used during terminal cleaning should be facility approved. Terminal cleaning of

rooms (or cubicles) consists of the following:

Housekeeping personnel should use the same precautions to protect themselves during terminal

cleaning that they use if the patient were still in the room.

All disposable items should be discarded. Articles grossly contaminated with infective material

should be bagged and disposed of in accordance with Yale University’s policy on disposal of

infectious wastes.

All equipment not sent for sterilization or discarded should be cleaned according to facility policy.

All surfaces of furniture and mattress covers should be cleaned according to facility policy.

All floors should be mopped with a disinfectant- detergent solution. Routine washing of walls,

blinds and curtains is not indicated; however, these should be washed if they are visibly soiled.

Cubicle curtains should be changed if visibly soiled or according to facility policy.

Airing a room from which a patient has been discharged is not an effective terminal disinfection

procedure and is not necessary.

SECTION 5: Personal Protective Equipment

Personal protective equipment (PPE) also known as barrier protection, is used to prevent blood and

other potentially infectious materials from making direct contact with an employee’s clothing or

body. The type and amount of PPE required depends upon the task to be performed and the

anticipated exposure.

5.1

Gloves

Gloves reduce the possibility personnel will become infected with microorganisms that are

infecting patients; gloves reduce the likelihood personnel will transmit their own endogenous

microbial flora to patients; gloves reduce the possibility personnel will become transiently

colonized with microorganisms which can be transmitted to other patients.

When gloves are indicated, disposable single-use gloves (sterile or non-sterile, depending on the

purpose for use) should be worn. Use sterile gloves for procedures involving contact with normally

sterile areas of the body. Use examination gloves for procedures involving contact with mucous

membranes, unless otherwise indicated, and for other patient care or diagnostic procedures that do

not require the use of sterile gloves.

Since no one glove can provide protection against all hazards, the gloves selected must be of

appropriate material, usually intact vinyl or nitrile, of appropriate quality for the procedures

performed, and of appropriate size for each health-care worker. Employers must not wash or

disinfect surgical or examination gloves for reuse. Washing with surfactants may cause “wicking,”

i.e. the enhanced penetration of liquids through undetected holes in the glove. Direct glove contact

with disinfecting agents (i.e., bleach, ethanol or isopropanol, gluturaldehyde) will cause glove

deterioration and must be avoided. General-purpose utility (rubber) gloves worn by maintenance,

housekeeping, laundry or other non-medical personnel may be decontaminated and reused. Do not

use gloves if they are peeling, cracked, or discolored, or if they have punctures, tears, or other

evidence of deterioration.

Used gloves should be discarded into an appropriate receptacle. When there is direct contact with

a patient’s secretions or excretions, gloves should be changed if care of the patient has not been

completed.

Policy and procedure for wearing gloves

Wear gloves on both hands for touching blood and body fluids, mucous membranes, or non-

intact skin of all patients, for handling items or surfaces soiled with blood or body fluids.

Change gloves immediately if they are torn or punctured.



Change gloves after contact with each patient’s blood or body fluids or after contact with

items or surface soiled with blood or body fluids.

Remove gloves before leaving the exam/patient room, dirty utility areas or other work areas.

Change gloves and wash hands between patient contact.

Wash hands after removing gloves.

Using gloves is essential in the following circumstances

During phlebotomy, injections, intravenous administration, wear gloves on both hands. Gloves

will reduce the incidence of blood contamination of hands, but they cannot prevent penetrating

injuries caused by needles or other sharp instruments.



Any time the health-care worker has cuts, abraded skin, chapped hands, dermatitis or the

like. Workers with chapped or abraded skin must contact their supervisor before initiating work

with potentially infectious materials. Waterproof bandages and double gloving

should be employed to protect the employee. If the employee cannot provide adequate

protection, she/he should not work with potentially infectious materials. This restriction should

remain in effect until the condition is resolved.

During instrumental examination of oropharynx, gastrointestinal tract and genitourinary tract.

When examining abraded or non-intact skin or patients with active bleeding.

During invasive procedures.

During all cleaning of body fluids and decontaminating procedures.

Clean technique

Slip the gloves onto the right hand first and then the left, making sure they fit securely over

the cuffs of the isolation gown.

Take an extra pair of gloves, protected by a clean paper towel, into the isolation room. The

extra gloves can be used in case the original pair tears or becomes soiled.

Sterile technique

Remove all jewelry, including rings (a plain wedding band is permitted)

Wash hands thoroughly with an antiseptic and dry them off with a paper towel. Use a paper

towel to turn off the faucet. (refer to page 49 for handwashing technique).

Open the package containing the sterile gloves.

Carefully open the inner wrapper, maintaining aseptic technique, being careful not to

contaminate the gloves by touching them (see diagram below).



Grasp the folded edge (inside surface) of the right glove’s cuff with the left hand (see

diagram below).

•

Slip the right hand inside the glove. To avoid contamination, the fingers on the left hand should

touch only the inside of the glove. If the glove becomes contaminated, discard it and obtain a

new one

Slip the fingers of the gloved hand under the cuff (touching only the outer surfaces) of the

glove, as shown below.

Insert the left hand into the glove and pull the glove on with the right hand. Avoid touching

the skin with the gloved hand.

Keep thumb

up and back

Adjust both gloves so they fit properly. Make sure no gaps exist between the fingertips and

the ends of the gloves.

Inspect the gloves for nicks and tears before and during the procedure. Obtain a new pair of

sterile gloves if a break in technique, nick or tear occurs.

5.2

Gowns

In general, gowns are recommended to prevent soiling of clothing when taking care of patients.

Gowns, aprons or lab coats are required when splashes to the skin or clothing with body fluid are

likely to occur. Gowns, including surgical gowns, shall be made of or lined with impervious

material and shall protect all areas of exposed skin. Gowns will also be worn when arms come into

contact with a patient’s blood or body fluids or non-intact skin.

When gowns are indicated, they should be worn only once and then discarded in an

appropriate receptacle.

Clean, freshly laundered or disposable gowns may be worn in most circumstances.

In some instances, as with extreme burns or extensive wounds, sterile gowns should be worn

when changing dressings.

Supplies of gowns are to be readily available.

The gown should be large enough to cover the clothing entirely and protect all areas of

exposed skin.

Procedure for putting on a gown

Slide the gown over the hands and arms by holding arms forward and slightly above head.

Fasten the gown at the back of the neck; then grasp the gown at the waistline in the back and

overlap the edges as much as possible. While holding the overlapping edge with one hand,

grasp one end of the belt with the other hand and pull it around the back and fasten.

Procedure for removing a contaminated gown

Untie belt in the back of the gown, and remove gloves if applicable. Wash and dry hands using

sink inside room. Unfasten the neck of the gown and pull off the first sleeve by slipping the

fingers under the cuff.

Do not

touch

Do not touch outside surface of cuff; the outside is contaminated and the hands are now clean.

Remove the second sleeve by grasping it through the first sleeve like this:



Without touching the outer surface of the gown, fold it with the outer contaminated surfaces

together. Then, roll the gown into a ball, being careful to touch only the inner uncontaminated

surface of the gown. If gown is non-disposable, place it into the patient’s linen hamper. If gown

is disposable, discard it into the patient’s covered waste receptacle. Always remember to hold

the contaminated gown away from the uniform.

Wash hands before leaving room and use a paper to turn off the faucets.

5.3

Face and Eye Protection

Face and eye protection must be worn whenever there is potential for the generation of splashes,

spray, splatter or droplets of blood or other potentially infectious material in the eyes, nose, mouth,

or other facial areas. Eye protection may prevent damage to the eye in addition to preventing

exposure to infectious materials. Certain disinfectants and other chemical can damage the eye or

cause blindness if splashed in the eye.

One or more devices may provide face and eye protection. Remember that the nose and mouth

must be protected if eye protection is worn, and vice-versa.

Product selection should be based upon acceptability to the wearer and the protection afforded. Eye

protection may be provided by safety glasses or normal glasses with side shields, goggles or chin

length face shields. Nose and mouth protection may be provided by surgical masks and face shields.

Face shields provide full-face protection against splashes and sprays to the face.

Some face shields are strong enough to provide protection against impact injuries.

Note that face shields do not offer mucous membrane protection from infectious

aerosols.

Goggles are another alternative for eye protection. Goggles form a face seal and

provide protection on the sides and top of the eyes

Safety glasses with side shields provide protection against splashes and sprays.

Note that splashes may reach the eye because glasses are not flush with the

user’s face. Also safety glasses do not offer eye protection from infectious

aerosols.

5.4

Surgical Masks

Surgical masks protect the mucous membranes of the mouth and nose. Surgical

masks are generally protective against droplets, splashes and sprays. Masks must

cover both the nose and the mouth, and fit the face closely, so that air passes through

the mask before being inhaled. Some surgical masks are available with attached eye

shields.

Moisture from expired air may eventually saturate the mask, making breathing difficult or fogging

eyeglasses. If this occurs, change the mask, discarding it as medical waste if contaminated with

human blood or other potentially infectious materials. Uncontaminated masks may be discarded in

the general trash. Surgical masks offer limited protection from infectious aerosols.

The use of masks and protective eye wear or face shields is required when contamination of

mucosal membranes (eyes, mouth or nose) with body fluid splashes or aerosolization is likely to

occur, such as during suctioning, surgical or dental procedures.

Procedure for Putting on a Mask

If the mask has a metal strip, position it over the nose with the metal strip facing outward; if

the mask does not have a metal strip, position it properly covering the mouth and nose.



Tie the mask’s top strings just above the top of the ears or place ties behind ears.

Pull down the lower part of the mask over the mouth and chin.

Tie the bottom strings around the neck.

Press the metal strip over the nose so the mask fits comfortably and snugly.

Change mask when it becomes moist, difficult to breath through or damaged.

Wash hands before touching mask and/or removing it. Discard mask in waste receptacle in

room before leaving room.

If both gown and mask are worn, remove gown first, wash hands, remove mask and discard

mask in waste receptacle in room. Wash hands prior to leaving room and use a paper towel to

turn off the faucets.

5.5

NIOSH Approved Particulate Masks and Respirators

Different respirators offer different levels of protection by varying their aerosol filter efficiency:

95%, 99% and 99.97%. NIOSH approved particulate masks and respirators for airborne precaution

use are the N95, N99 or N100. All respirator wearers must complete a medical surveillance

questionnaire. Training and fit testing is also required for all respirator wearers prior to use. A

respirator wearer would need to be refitted with the respirator if the wearer has a weight change of

20 pounds or more, significant facial scarring in the area of the facepiece seal, significant dental

changes (such as multiple extractions without prosthesis or acquiring dentures), reconstructive or

cosmetic surgery or any other condition that may interfere with facepiece sealing. Fit testing is

required initially and annually on all respirators with tight fitting face pieces. Respirator

information, training, and fit testing is available through the Yale Office of Environmental Health

and Safety; medical questionnaires are administered through the Employee Health office.

Respirators should be put on before entering the room of the patient on airborne precautions and

taken off, placed in a protective labeled bag in the anteroom. Discarded at the end of shift.

Employees who perform duties that may require respirator use must be trained and fit tested as per

the Yale University Respiratory Protection Program.

SECTION 6: Decontamination, Spill Response and Housekeeping

6.1

Sterilization or Disinfection of Reusable Medical Instruments/Devices:

Medical devices, equipment, and surgical materials are divided into three general categories,

1.critical items, 2. Semi-critical items, and 3. Non-critical items, based on the potential risk of

infection involved in their use.

Critical Items

Critical items are instruments or objects that are introduced directly into the bloodstream or into

other normally sterile areas of the body. Examples of critical items are surgical instruments, cardiac

catheters, implants, pertinent components of the heart-lung oxygenator, and the blood compartment

of a hemodialyzer. Sterility at the time of use is required for these items; consequently, one of

several accepted sterilization procedures is generally recommended.

Semi-Critical Items

Items in the second category are classified as semi-critical in terms of the degree of risk of infection.

Examples are noninvasive flexible and rigid fiber-optic endoscopes, endotracheal tubes, anesthesia

breathing circuits, and cystoscopes. Although these items come in contact with intact mucous

membranes, they do not ordinarily penetrate body surfaces. If steam sterilization can be used, it is

often cheaper to sterilize many of these items, but sterilization is not absolutely essential; at a

minimum, a high-level disinfection procedure that can be expected to destroy vegetative

microorganisms, most fungal spores, tubercle bacilli, and small non-lipid viruses is recommended.

In most cases, meticulous physical cleaning followed by an appropriate high-level disinfection

treatment gives the user a reasonable degree of assurance that the items are free of pathogens.

Non-Critical Items

Non-critical items are those that either do not ordinarily touch the patient or touch only intact skin.

Such items include crutches, bed boards, blood pressure cuffs, and a variety of other medical

accessories. These items rarely, if ever, transmit disease. Consequently, depending on the particular

piece of equipment or item, washing with a detergent may be sufficient.

The level of disinfection achieved depends on several factors, principally contact time, temperature,

type and concentration of the active ingredients of the chemical germicide, and the nature of the

microbial contamination. Some disinfection procedures are capable of producing sterility if the

contact times used are sufficiently long; when these procedures are continued long enough to kill

all but resistant bacterial spores, the result is high-level disinfection. Other disinfection procedures

that can kill many types of viruses and most vegetative microorganisms (but cannot be relied upon

to kill resistant microorganisms such as tubercle bacilli, bacterial spores, or certain viruses) are

considered to be intermediate- or low-level disinfection.

The tubercle bacillus, lipid and non-lipid viruses, and other groups of microorganisms in Table I

are used in the context of indicator microorganisms that have varying degrees of resistance to

chemical germicides and not necessarily because of their importance in causing nosocomial

infections. For example, cells of M. tuberculosis or M. bovis, which are used in routine efficacy

tests, are among the most resistant vegetative microorganisms known and, after bacterial

endospores, constitute the most severe challenge to a chemical germicide. Thus, a tuberculocidal

chemical germicide may be used as a high or intermediate-level disinfectant targeted to many types

of nosocomial pathogens but not specifically to control respiratory tuberculosis.

Table 1. Levels of Disinfection According to Types of Microorganism

Bacteria

Fungi

Viruses

Levels

Vegetative

Tubercle

Bacillus

Spores

Lipid &

Medium size

Non-lipid &

small

High

Intermediate

Low

Includes asexual spores but not necessarily chlamydospores or sexual spores.

Plus sign indicates that a killing effect can be expected when the normal use-concentrations of chemical disinfectants or pasteurization

are properly employed; a negative sign indicates little or no killing effect.

0nly with extended exposure times are high-level disinfectant chemicals capable of actual sterilization.

Some intermediate-level disinfectants can be expected to exhibit some sporicidal action.

Some intermediate-level disinfectants may have limited virucidal activity

In general, reusable medical devices or patient-care equipment that enters normally sterile tissue or

the vascular system or through which blood flows should be sterilized before each use. Sterilization

means the use of a physical or chemical procedure to destroy all microbial life, including highly

resistant bacterial endospores. The major sterilizing agents used in hospitals are

a) moist heat by steam autoclaving, b) ethylene oxide gas, and c) dry heat. However, there are a

variety of chemical germicides (sterilants) that have been used for purposes of reprocessing

reusable heat-sensitive medical devices and appear to be effective when used appropriately, i.e.,

according to manufacturer's instructions. These chemicals are rarely used for sterilization, but

appear to be effective for high-level disinfection of medical devices that come into contact with

mucous membranes during use (e.g., flexible fiber-optic endoscopes).

Disinfection means the use of a chemical procedure that eliminates virtually all recognized

pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial endospores) on

inanimate objects. There are three levels of disinfection: high, intermediate, and low. High-level

disinfection kills all organisms, except high levels of bacterial spores, and is effected with a

chemical germicide cleared for marketing as a sterilant by the Food and Drug Administration.

Intermediate-level disinfection kills mycobacterium, most viruses, and bacteria with a chemical

germicide registered as a "tuberculocide" by the Environmental Protection Agency (EPA). Low-

level disinfection kills some viruses and bacteria with a chemical germicide registered as a hospital

disinfectant by the EPA.

Heat stable reusable medical devices that enter the blood stream or enter normally sterile tissue

should always be reprocessed using heat-based methods of sterilization (e.g., steam autoclave or

dry heat oven).

Laparoscopic or arthroscopic telescopes (optic portions of the endoscopic set) should be subjected

to a sterilization procedure before each use; if this is not feasible, they should receive high-level

disinfection. Heat stable accessories to the endoscopic set (e.g., trocars, operative instruments)

should be sterilized by heat-based methods (e.g., steam autoclave or dry heat oven).

Reusable devices or items that touch mucous membranes should, at a minimum, receive high- level

disinfection between patients. These devices include reusable flexible endoscopes, endotracheal

tubes, anesthesia breathing circuits, and respiratory therapy equipment.

Medical devices that require sterilization or disinfection must be thoroughly cleaned to reduce

organic material or bio-burden before being exposed to the germicide, and the germicide and the

device manufacturer's instructions should be closely followed.

Except on rare and special instances (as mentioned below), items that do not ordinarily touch the

patient or touch only intact skin are not involved in disease transmission, and generally do not

necessitate disinfection between uses on different patients. These items include crutches, bed

boards, blood pressure cuffs, and a variety of other medical accessories. Consequently, depending

on the particular piece of equipment or item, washing with a detergent or using a low-

level disinfectant may be sufficient when decontamination is needed. If non-critical items are

grossly soiled with blood or other body fluids:

In patient-care areas, visibly soiled areas should first be cleaned and then chemically

decontaminated. For disinfection, the pre-cleaned areas should be moistened with the

appropriate germicide and allowed to air dry.

In the laboratory, large spills of cultured or concentrated infectious agents should be flooded

with a liquid germicide before cleaning, then decontaminated with fresh germicidal chemical

after organic material has been removed. It is not necessary to flood spills of blood or other

body fluids with germicide before cleaning.

Gloves should always be worn during cleaning and decontaminating procedures. Eye and face

protection may be needed if spraying or splattering is likely to occur to the face. Eye protection

may prevent damage to the eye in addition to preventing exposure to infectious materials. Certain

disinfectants and other chemical can damage the eye or cause blindness if splashed in the eye. Use

goggles or safety glasses and mask or full face shield to protect the mucous membranes of the face.

Exceptional circumstances that require non-critical items to be either dedicated to one patient or

patient cohort, or subjected to low-level disinfection between patient uses are those involving

Patients infected or colonized with vancomycin-resistant enterococci or other drug-resistant

microorganisms judged by the infection control program, based on current state, regional, or

national recommendations, to be of special or clinical or epidemiologic significance or

Patients infected with highly virulent microorganisms, e.g., viruses causing hemorrhagic fever

(such as Ebola or Lassa).

If you have questions about a low- or intermediate-level disinfectant, contact the manufacturer,

your local or state health department, or the Antimicrobial Program Branch, Registration Division,

Environmental Protection Agency (EPA), (703) 308-6411. Or, you may call the EPA disinfectant

hotline at 1-800-447-6349. The EPA is the federal regulatory agency for low- or intermediate-level

disinfectants.

If you have questions about high-level disinfectants (sterilants), or how to clean, disinfect or

sterilize a particular medical device, first contact the manufacturer of the product. If you are unable

to obtain sufficient information in this manner, contact the Food and Drug Administration (FDA)

regional office or the FDA Center for Devices and Radiological Health in Hartford at (860) 240-

4289/90 in Bridgeport at (203) 579-5822/3. FDA is the federal regulatory agency for safe and

effective use of medical devices and is now also responsible for regulation of chemical sterilants.

6.2

Reusable Patient-Care Equipment

Yale Health Personnel refer to Central Sterile Department Policy and Procedures located in the

Located in the Endoscopy Suite, 4

floor, Room 4277 (Decontamination) and room 4275

(Sterilization), for equipment reprocessing.

6.3

Sphygmomanometer and Stethoscope

No special precautions are indicated unless this equipment is contaminated (or likely to be

contaminated) with infective material. If soiled, wipe the stethoscope, cuff, gauge, bulb, and other

component parts with a cloth moistened with a disinfectant solution. See Contact Precautions for

additional information.

6.4

Soiled Linen & Laundry

It is the responsibility of the Housekeeping staff to remove all soiled/dirty linen and all trash from

the unit.

There is a method for disposal of linen soiled with blood and body secretions to reduce risk of staff

contact with the soiled linen. In accordance with standard precautions, employees are required to

wear gloves and gowns if necessary, while handling all soiled linen. All patient laundry is

considered to be soiled with blood or body fluids and should be handled using Standard Precautions.

All soiled linen is placed in the linen hampers

The risk of disease transmission from soiled linen is negligible. However, soiled linens may carry

large numbers of organisms that may contaminate the air and immediate environment if they are

“fluffed” or agitated.

All linen will be handled as potentially infectious. Linen will be transported in high tensile strength,

impervious bags. Soiled linen should be handled as little as possible and with minimum agitation

in order to prevent microbial dissemination into the air and onto employees handling the linen.

Soiled linen should not come into contact with attire. Hold the soiled linen away from your clothes.

If linen saturated wear a gown and booties to prevent further transmission. It should be placed in

bags as close as possible as the location it was used. It should not be sorted or rinsed in patient care

areas. Soiled linen must be collected and transported in impervious bags to prevent leakage. Bags

must be secured when filled (not overfilled) to prevent spillage during transportation. Soiled

laundry must be collected in covered hampers in patient care areas. Gloves must be worn when

handling linen.

YUHS Personnel refer to policy Laundry - Appendix # 2

6.5

Housekeeping

All waste baskets in the rooms of patients shall be lined with plastic liners. When full these bags

shall be removed, using gloves, closed (placed in a second plastic bag that is closed), and

transported to the dumpster.

Bathrooms shall be cleaned in the usual manner using gloves and germicide/disinfectant solution.

Gloves shall be worn when cleaning showers and bathtubs, using the germicidal disinfectant

solution once each day. Tub cleaning with germicidal disinfectant solution will be followed by

scrubbing with a cleaner and rinsed thoroughly.

Housekeeping Staff shall wear gloves when removing all trash. The trash in the specially

marked waste containers in the treatment rooms is to be double bagged and removed by

Housekeeping Staff wearing gloves.

All horizontal surfaces shall be cleaned in accordance with a germicidal solution in

accordance with manufacturer's recommendations daily and as required.

Floors shall be mopped thoroughly and cleaned with germicidal solution once a week and as

required.

Wall shall be spot cleaned with detergent and germicide solution when soiled and shall be

periodically cleaned according to prescribed housekeeping routine.

Institutionally approved germicide can be obtained through the Purchasing department.

6.6

Cleaning Spills of Blood and Body Fluids on Environmental Surfaces

All spilled blood and other body fluids are handled and managed safely to maintain a safe

environment. Household bleach (5.25 sodium hypochlorite) or an appropriate tuberculocidal

disinfectant shall be used to clean all spills of human blood and other potentially infectious

materials.

YUHS Personnel refer to policy Clean Up of Spills - Appendix # 3

If spill response /mess kits are unavailable in facility, either obtain prepared spill kit or assemble

your own spill response kit.

Prepare and maintain a spill response kit.

Basic equipment is some disinfect and solidifying agent, paper towels, household rubber gloves,

biohazard bags, and forceps to pick up broken glass and PPE. The contents of the kit are kept in a

plastic container. There are commercial available spill kits for cleaning blood and body fluids.

References:

Favero MS, Bond WW. Sterilization, disinfection, and antisepsis in the hospital. In: Manual of

Clinical Microbiology, 1991; chapter 24:183-200. American Society for Microbiology.

Washington, DC.

Garner JS, Favero MS. Guidelines for handwashing and hospital environmental control, 1985.

MMWR, 1987;36(25 Supplement). MMWR 1988;37(24)

Rutala WA. APIC guideline for selection and use of disinfectants. Am J Infect Control

1996;24:313-342.

SECTION 7: Medications and Safe Injection Practices

7.1 Storage of Medications – Multi-Dose Vials/Single-Dose Vials

Single-dose vials: Approved for use on a single patient for a single procedure or injection.

Multi-dose vials: Use a new sterile needle and syringe each time entering the vial. Do not keep multi-dose

vials in the immediate patient treatment area.

The rubber stopper should be wiped with alcohol each time the vial is entered. If multiple-dose

vials are used, the date and time of opening should be written on the label with the initials of the

person who opened it. Multi-dose vials must be examined for precipitate matter and evidence of

discoloration prior to each use. Vials are stored in accordance with manufacturer recommendations.

YUHS Personnel refer to policy Quality Control of Multi-dose Vials - Appendix Yale Health #1

Medications should be stored in areas with restricted access and secured in a locked cabinet.

Medications should not be stored on counter tops next to the sink. The person administering unit

dose medications should always check to be certain that the package is sealed and that the expiration

date has not passed.

Only supplies used for medication and patient treatment shall be stored in the treatment room or

dedicated refrigerator. The medication refrigerator must be checked for outdated medications and

kept clean. The temperature (36 F –40F) of the medication refrigerator must be monitored daily. A

log must be maintained to include daily temperature checks, weekly and as needed cleaning and

routine inspection of contents.

Horizontal surfaces in the treatment room shall be wiped with a germicide solution weekly and as

needed and sinks shall be scoured and germicide solution applied daily.

Sterile water and saline for irrigation should be labeled with the date and time it was opened. The

bottles should be discarded at the end of 24 hours.

Hydrogen peroxide must be dated when opened and discarded at the end of the week. Contact

Environmental Affairs (203-432- 6545) for information on disposal procedures.

Note: Controlled Substances must be kept in a secured locked area. Clinics who utilize controlled

substances must have an updated license with the State and Federal Drug Enforcement Agency.

An Inventory must be kept of all controlled substances. A copy of this inventory must be sent to

the State DEA by May 1

of each year.

7.2 Fingerstick Devices

• Two types of devices:

• Auto-disabling single use

• Reusable

• Single use, auto-disabling devices are disposable and, by design, prevent re-use

• Use in settings where assisted BGM is performed.

• Reusable devices cannot be adequately cleaned and disinfected.

• Never use for more than one person.

• Even when not visibly soiled, have been responsible for transmitting hepatitis when stored with other

devices.

• Use new pair of gloves for each new test.

• Perform hand hygiene before and after glove use.

• Avoid handling test strip containers with soiled gloves to avoid contamination.

• If a new test strip is needed, discard soiled gloves and perform hand hygiene before obtaining a new test

strip.

7.3 Blood Glucose Meter

• When possible, should be assigned to an individual person and should not be shared.

• If the meter must be shared, clean and disinfect after every use, per manufacturer’s instructions:

• Use the disinfectant recommended by the manufacturer.

• Typically, an EPA approved disinfectant (effective against Human HIV-1 and Hepatitis B Virus)

• Follow recommended dwell time (or contact time) specified on label.

• If manufacturer does not specify how the device should be cleaned and disinfected, it should not be shared.

• Always maintain aseptic technique:

• Hand hygiene and glove use

• Separate clean and dirty

• Cleaning of environment

SECTION 8: Storage and Transporting of Specimens

8.1

Handling of Clinical Specimens

All clinical specimens, regardless of patient origin, will be subject to the application of Standard

Precautions and handled as potentially infectious.

All specimens will be packaged in a lab provided approved sealable plastic bag prior to

transportation to the lab so that lab slips will not come in direct contact with specimen

container. *This bag must be sealed when delivered to the lab.

Urine, vomitus and feces from patients can be safely flushed down the toilet into the

municipal sewage system.

Care should be taken when collecting specimens to avoid contamination of the outside of the

container. Contaminated materials used in laboratory tests should be decontaminated before

reprocessing or be placed in bags and disposed of in accordance with institutional policies for

disposal of infectious waste. Bagging is intended to prevent inadvertent exposure of laboratory

or transport personnel to infective material and prevent contamination of the environment.

All blood or body fluid specimens must be transported from one area to another using

appropriate leak proof specimen transport container or placed in the specimen refrigerator or

specimen pick-up container that are labeled with the biohazard label.

8.2

Protocol on Management of Specimens

Wear gloves when collecting and handling specimens.

Collect specimens in appropriate container following specimen requirements (spinning,

freezing, etc.)

Close container tightly. Leakage leads to contamination of specimen and personnel.

Label specimen container including all appropriate information. All specimens must be

labeled in the presence of the patient utilizing 2 identifiers

Fill out laboratory requisition form completely.

Contact appropriate Lab (Yale, Quest)

Place container in the lab specific sealable plastic bag.

Attach requisition to bagged specimen.

Transport specimens in an upright in the YUHS approved transport container/cooler.

Deliver specimen promptly to the appropriate pick-up storage container or specimen

refrigerator that is labeled with the Biohazard label.

Wash hands with soap and water after contact with secretions, excretions, blood and articles

contaminated with bodily fluids. See Section 2.5 Emergency Procedures for Exposure to Blood

and Body Fluids for additional information concerning exposures to potentially infectious

materials.

For spills, disinfect area promptly with tuberculocidal disinfectant or 10% household bleach

(1:10 dilution: 1 part bleach to 9 parts water). Wear gloves for clean up. Refer to spill policy.

SECTION 9: Transportation of Patient

9.1

Transportation Process

Patient infected with virulent or epidemiologically important microorganisms should leave their

room only for essential purposes. When special studies are ordered, the individual requesting the

study should indicate on the requisition the patient is on transmission based precautions. The patient

and transport personnel should use acquisition barriers (masks, impervious dressings, etc.) to

prevent transmission. Personnel in the area to which the patient is to be taken should be notified

of the impending arrival of the patient and of precautions to be used to Prevent transmission of

infection. Patient should be alerted to the potential spread of their disease and informed as to how

they can assist in maintaining a barrier against transmission of their infection to others.

9.2

General Considerations and Responsibilities

The preparation of transportation of patient to other departments or institutions and the notification

concerning the impending arrival of the patient is a multi-disciplinary responsibility that requires

collaboration and teamwork. The nurse, the unit receptionist and transport personnel are jointly

responsible for the following actions:

Unit Receptionist:

Notify the department to which the patient is being transported (e.g. Diagnostic Imaging,

Physical Therapy, etc.) that the patient is on transmission based precautions.

Nurse:

Instruct the transporter in transmission based precautions when the transporter arrives on the

patient-care unit to transport the patient to another area of the hospital. Before entering the

room, put on essential protective barriers as indicated by the transmission based precautions

(such as gloves, gown, face shield, mask or respirator). Explain to the patient what special

precautions will be taken before he/she leaves the room. Put the mask on the patient if required

under the specific transmission based precautions. Assist the patient into wheelchair or

stretcher.

Transport Personnel:



Receive instructions from the nurse when he/she arrives on site. Bring clean wheelchair or

stretcher to the patient’s room. The vehicle should be protected by a clean sheet. Before

entering the room, put on essential protective barriers. Assist the patient into wheelchair or

stretcher. Remove gloves and wash hands with an antiseptic solution when transportation is

complete. Push transport vehicle outside room and transport patient to designated area as

expeditiously as possible.

9.3

Infection Control Considerations for Personnel Transporting Patients on Contact

Precautions Only

During the transportation process, the following infection control procedures should be

considered:

When transporting the patient to another department, if soiling of the uniform is likely to occur,

wear a gown to protect clothing and wear gloves for touching infective material; if soiling is

not likely, no special precautions are required other than GOOD HAND WASHING.

Transport patient to area of destination as expeditiously as possible utilizing the service

elevator when possible, limiting contact with others.

Wash hands after direct contact with the patient, contaminated equipment and before

touching another patient.



Discard the sheet in contaminated laundry in patient’s room.

Spray and wipe the chair, stretcher, or wheelchair and wipe with a disinfectant according to

cleaning and reprocessing of non-critical patient care equipment and medical devices.

9.4

General Considerations for Patients

Help the patient to bed.

Push wheelchair or stretcher to door.

Wash hands upon leaving the isolation area.

SECTION 10: Reporting Communicable Diseases to the State of Connecticut

REPORTABLE DISEASES, EMERGENCY ILLNESSES and HEALTH CONDITIONS - 2017

The Commissioner of the Department of Public Health (DPH) is required to declare an annual list of Reportable Diseases,

Emergency Illnesses and Health Conditions. The Reportable Disease Confidential Case Report form (PD-23) or other disease

specific form should be used to report the disease, illness, or condition. Reports (mailed, faxed, or telephoned into the DPH) should

include the full name and address of the person reporting and attending physician, name of disease, illness or condition, and full

name, address, date of birth, race/ethnicity, gender and occupation of the person affected. Forms can be found on the DPH website.

See page 4 for a list of persons required to report Reportable Diseases, Emergency Illnesses and Health Conditions. Mailed reports

must be sent in envelopes marked “CONFIDENTIAL.” Changes for 2017 are noted in bold and with an asterisk (*).

Category 1 Diseases: Report immediately by telephone on the day of recognition or strong suspicion of disease for those

diseases marked with a telephone (). Also mail a report within 12 hours.

Category 2 Diseases: Diseases not marked with a telephone are Category 2 diseases. Report by mail within 12 hours of

recognition or strong suspicion of disease.

Acquired Immunodeficiency Syndrome (1,2) HIV-1 / HIV-2 infection in: (1) Rotavirus

Acute flaccid myelitis ▪ persons with active tuberculosis disease Rubella (including congenital)

 Anthrax ▪ persons with a latent tuberculous Salmonellosis

Babesiosis infection (history or tuberculin skin test  SARS-CoV

 Botulism >5mm induration by Mantoux technique) Shiga toxin-related disease (gastroenteritis)

 Brucellosis ▪ persons of any age Shigellosis

California group arbovirus infection ▪ pregnant women Silicosis

Campylobacteriosis HPV: biopsy proven CIN 2, CIN 3 or AIS  Smallpox

Carbon monoxide poisoning (3) or their equivalent (1) St. Louis encephalitis virus infection

Chancroid Influenza-associated death (7)  Staphylococcal enterotoxin B pulmonary

Chickenpox

Influenza-associated hospitalization (7) poisoning

Chickenpox-related death Lead toxicity (blood level ≥ 15 µg/dL)  Staphylococcus aureus disease, reduced or

Chikungunya Legionellosis

resistant susceptibility to vancomycin (1)

Chlamydia (C. trachomatis) (all sites) Listeriosis Staphylococcus aureus methicillin-

 Cholera Lyme disease resistant disease, invasive, community

Cryptosporidiosis Malaria acquired (4*,10)

Cyclosporiasis  Measles Staphylococcus epidermidis disease,

Dengue  Melioidosis reduced or resistant susceptibility

 Diphtheria  Meningococcal disease to vancomycin (1)

Eastern equine encephalitis virus infection Mercury poisoning Syphilis

Ehrlichia chaffeensis infection Mumps Tetanus

Escherichia coli O157:H7 gastroenteritis Neonatal bacterial sepsis (8) Trichinosis

Gonorrhea Neonatal herpes (≤ 60 days of age)  Tuberculosis

Group A Streptococcal disease, invasive (4*) Occupational asthma  Tularemia

Group B Streptococcal disease, invasive (4*)  Outbreaks: Typhoid fever

Haemophilus influenzae disease, invasive (4*) ▪ Foodborne (involving ≥ 2 persons) Vaccinia disease

Hansen’s disease (Leprosy) ▪ Institutional  Venezuelan equine encephalitis virus infection

Healthcare-associated Infections (5) ▪ Unusual disease or illness (9) Vibrio infection (parahaemolyticus,

Hemolytic-uremic syndrome (6) Pertussis vulnificus, other)

Hepatitis A  Plague  Viral hemorrhagic fever

Hepatitis B: Pneumococcal disease, invasive (4*) West Nile virus infection

acute infection (2)  Poliomyelitis  Yellow fever

HBsAg positive pregnant women  Q fever

Zika virus infection Hepatitis C:  Rabies

acute infection (2)  Ricin poisoning

positive rapid antibody test result Rocky Mountain spotted fever

FOOTNOTES:

Report only to State.

6. On request from the DPH and if adequate serum is available, send serum from

As described in the* CDC case definition.

patients with HUS to the DPH Laboratory for antibody testing.

Includes persons being treated in hyperbaric chambers for suspected CO

7. Reporting requirements are satisfied by submitting the Hospitalized and Fatal

poisoning.

Cases of Influenza-Case Report Form in a manner specified by the DPH.

Invasive disease: from sterile fluid (blood, CSF, pericardial, pleural,

8. Clinical sepsis and blood or CSF isolate obtained from an infant ≤ 72 hours of age.

peritoneal, joint, or vitreous) bone, internal body sites, or other normally

9. Individual cases of “significant unusual illness” are also reportable.

sterile site including muscle. *

10. Community-acquired: infection present on admission to hospital, and person has

Report HAIs according to current CMS pay-for-reporting or pay-for-

no previous hospitalizations or regular contact with the health-care setting.

performance requirements. Detailed instructions on the types of HAIs, facility types

and locations, and methods of reporting are available on the DPH website: www.ct.

gov/dph/HAI.

How to report: The PD-23 is the general disease reporting form and should be used if other specialized forms are not available. The PD-23 can be found on the DPH

website (www.ct.gov/dph/forms). It can also ordered by writing the Department of Public Health, 410 Capitol Ave., MS#11EPI, P.O. Box 340308, Hartford, CT 06134-0308 or

by calling the Epidemiology and Emerging Infections Program (860-509-7994). Specialized reporting forms are available on the DPH website or by calling the following

programs: Epidemiology and Emerging Infections Program (860-509-7994) - Hospitalized and Fatal Cases of Influenza, Healthcare Associated Infections (860-509-7995) -

National Healthcare Safety Network, HIV/AIDS Surveillance (860-509-7900) - Adult HIV Confidential Case Report form, Immunizations Program (860-509-7929) -

Chickenpox Case Report (Varicella) form, Occupational Health Surveillance Program (860-509-7740) - Physician’s Report of Occupational Disease, Sexually Transmitted

Disease Program (860-509-7920), and Tuberculosis Control Program (860-509-7722).

Telephone reports of Category 1 disease should be made to the local Director of Health for the town in which the patient resides, and to the Ep idemiology and

Emerging Infections Program (860-509-7994). Tuberculosis cases should be directly reported to the Tuberculosis Control Program (860-509-7722). For the name, address,

or telephone number of the local Director of Health for a specific town contact the Office of Local Health Administration (860-509-7660).

For public health emergencies on evenings, weekends, and holidays call 860-509-8000.

SECTION 11: Service and Assistance Animals

In compliance with the Americans with Disabilities Act and other applicable state and federal law,

the purpose of this policy is to establish guidance for Yale University employees in a clinical setting.

For the policy statement please refer to the Yale University policy for service and assistance animals.

https://your.yale.edu/policies-procedures/policies/4400-service-and-assistance-animals

11.1 Guidelines for Service Animals Visiting Heath Care Facilities.

1. Require that all patients, visitors and health care workers practice hand hygiene both before

and after each animal contact.

2. Require that animal handlers carry an alcohol based hand rub product with them, and that

they offer the product to anyone who wishes to touch the animal.

3. Require that animal handlers practice personal hand hygiene in accordance with Yale

University policy for employees.

4. Service animals must be harnessed, leashed or tethered unless these devices interfere with

the animal's work or the person's disability prevents using these devices.

5. The handler must carry supplies sufficient to clean up the animal’s excreta (feces, urine,

vomitus). If the animal has an elimination accident, gloves should be worn to remove the

debris and clean up the area and hand hygiene performed after glove removal. Any organic

debris and paper towels should be placed in a plastic bag and discarded in an outdoor trash

receptacle. After the area is cleaned, it must be disinfected with the facility's approved

product, following the label instructions for appropriate concentration and contact time.

6. Patients must make arrangements to take care of the pet if they cannot physically do so.

7. Access cannot be denied to a person with a service animal because of allergies or fear of

dogs. If a person has allergies to dog dander or is afraid of a dog, accommodations should be

made by assigning them to different locations in the room or different rooms in the facility.

11.2 Staff Responsibilities

1. When encountering an individual with a disability, it is acceptable to ask if they need

assistance. If yes, ask how you can best assist them.

2. Allow a service animal to accompany the partner at all times and everywhere on campus

except where service animals are specifically prohibited.

3. A person with a disability cannot be asked to remove his or her service animal from the

premises unless the dog is not housebroken, is out of control, or if the handler/owner does

not take effective action to control the service animal.

4. When encountering an individual with a service animal, treat the individual and the service

animal with respect and do not treat the animal like a pet (e.g. pat the animal or otherwise

distract it from its duties).

5. With regard to those with animals that appear to be service animals, staff may not ask about

the person’s disability; require medical documentation, a special identification card, or

training documentation for the dog; or ask the dog to demonstrate its ability to perform the

work or task. When it is not obvious what task is being performed by a service animal, staff

may ask only two questions:

• Is the dog a service animal required because of a disability?

• What work or task has the dog been trained to perform?

6. Staff is not required to provide care or food for a service animal.

11.3 Permitted and Restricted Areas for Service Animals and Additional Information for Staff

Areas Where Service Animals Are Permitted:

A service animal is permitted in areas of Yale University clinics that are unrestricted to inpatients,

outpatients or visitors, provided the presence of the animal does not compromise patient care subject

to the following:

Areas Where Service Animals Are Not Permitted:

Restricted areas where a service animal generally cannot be permitted include:

1. Areas that employ greater than general infection-control measures

2. Other restricted areas include:

• Food preparation areas

• Central sterile processing

• Operating rooms (and other invasive treatment/procedure rooms)

• Post anesthesia areas

• Heart and vascular procedure rooms

• Intensive care units and/or other locations with immunocompromised patients.

Individualized (case-by-case) assessment should be made to determine whether animal

visitation is appropriate for immunocompromised patients.

• Diagnostic areas

• Family birthing areas

• Nurseries

• Medication rooms

• Pharmacy

• Playrooms

• Oncology transplant unit

• Areas, facilities, or rooms where a patient(s) have

o altered mental status

o had a splenectomy

o open wounds

o behavior or psychiatric disorders

APPENDIX A: Needle Stick Procedure

Standard:

Yale Health will have a policy to define the sequence of events which needs to take place

after a health care worker sustains a needlestick, or other injury involving exposure to

human blood or body fluids. This policy conforms to the requirements set forth by

OSHA.

Policy:

The Yale Health needlestick policy has been developed by the Department of Employee

Health and applies to all health care workers of the facility. Any health care worker

(HCW) who sustains a needlestick or exposure to human blood or body fluids during the

course of his or her job duties must follow the steps outlined in the following procedure.

The policy’s aim is to provide the optimum care to the injured HCW and attempt to

prevent or identify infections caused by blood borne pathogens that the employee might

be exposed to in the course of the injury.

Procedure:

1. Employees or students who sustain a needlestick should Immediately report to

receive medical care at Yale Health (Employee Health Department 432-7978,

Student Health 432-0312, or Acute Care 432-0123). It is important to begin any

recommended treatment within 1 to 2 Hours after exposure.

2. If the exposure occurs at the Yale New Haven Medical Center and the HCW

wishes to be seen on site, he/she should report to the Occupational Health Service

(7:30 a.m. to 4:30 p.m., Monday through Friday) at 203-688-2462 or to Yale New

Haven Hospital Emergency Room (203-688-2222) if the episode occurs outside

of regular daytime working hours.

3. The source patient for the exposure should be immediately approached to give

consent for a baseline HIV, Hepatitis B Surface Ag, Hepatitis B Surface Ab,

Hepatitis B core Ab, and Hepatitis C Ab. Rapid HIV testing on the source patient

should be requested for all needlestick cases. Rapid HIV testing can be done at the

Yale-New Haven Hospital Laboratory. The attending physician for the source

patient should be notified to obtain this testing. The Yale Health or YNHH

Occupational Health providers can assist with this process. If the source patient

has no medical provider to perform testing and consents to testing, the treating

M.D. can order the tests through Yale Health and bill to Employee Health. The

Employee Health provider must be informed of the testing and of a means to

follow up with source patient to communicate the results. If the source patient

does not give consent for testing, the institution's needlestick committee should

convene as soon as possible to take the necessary steps to obtain testing. If the

source is known to be HIV positive or is on antiretroviral therapy, then the

attending physician should be questioned about known HIV resistance patterns.

This should be considered when prescribing anti-viral treatment. Do not delay

treatment pending the information however.

4. Consider requesting expert Infectious Disease Consult for exposures to known

HIV source cases that are currently receiving treatment for HIV. The CDC Post

Exposure Prophylaxis Hotline at 1-888-448-4911 is available for consultation 24

hours a day.

5. The exposed employee/student should immediately be tested for a baseline HIV,

Hepatitis B Surface Ab, Hepatitis C Ab following the institution's established

testing guidelines.

6. Post Exposure Prophylaxis ( PEP) should be offered to any health care provider

who has been exposed to blood or body fluids from an HIV positive source, or

from a source with reasonable suspicion of HIV infection. PEP is not justified for

situations where there is negligible risk of transmission. Expert consultation

should be sought if needed to determine the need for PEP.

7. Any health care provider who is prescribed PEP should receive a 3 drug regimen.

The preferred regimen is:

Truvada once daily plus Raltegrvir (Isentress) 400 mg bid for 4

weeks.

This should be started as soon as possible, using the starter packets

available in the Pharmacy or Pyxis in Acute Care. If treatment has been

delayed but the exposure is subsequently found to be high risk, it may be

started up to 72 hours later (this could change the effectiveness).

8. If the source patient is subsequently found to be HIV negative, any PEP that was

prescribed should be discontinued and no further follow up is indicated.

9. Workers who receive antiviral prophylaxis should also have baseline CBC, renal

and hepatic function tests drawn.

10. If antiviral prophylaxis for HIV is indicated, the HCW should be given a 96 hour

packet of prophylactic medication, which is available at each institution in the

Pharmacy or Pyxis in Acute Care.

11. The health care worker should then be instructed to follow up with the appropriate

department (either Employee Health at 432-7978 or Student Health 432-0312) on

the next business day by phone to receive further instructions within 72 hours.

12. All HCWs taking antiviral prophylaxis should be reevaluated at 2 weeks for a

CBC, LFT's and renal functions to check for any symptoms of drug toxicity,

which may necessitate a reduction of dosage or change in medication. Expert

consultation with an infectious disease specialist should be obtained for situations

which might require a change in the protocol or for cases where the source HIV

strain is known to be resistant to one or more drugs.

13. If the health care worker follow up testing is done using a 4th generation HIV p24

Ag/HIVAb test, they should receive follow up testing at 6 weeks and 4 months,

after which follow up can be considered complete. (Testing should be extended to

6 months if a standard HIV Ab test is used).

14. See Appendix 1 for situations where expert consultation for PEP is recommended.

15. The exposed worker should be advised to use precautions (e.g., use of barrier

contraception and avoidance of blood or tissue donations, pregnancy, and, if

possible, breast-feeding) to prevent secondary transmission, especially during the

first 6–12 weeks after exposure. They should be counseled about symptoms of

acute retroviral syndrome, possible drug interactions, the need to adhere to the

PEP regimen and possible drug toxicities and rashes.

16. Appropriate prophylaxis for Hepatitis B exposure should be included in all

evaluations where indicated. (See Table 3)

17. The employee should be evaluated for exposure to Hepatitis C if the source

patient is infected with Hepatitis C or has risk factors for infection. Testing for

Hep C should include a viral RNA for Hep C and Hep C AB at 4-6 weeks, and a

Hep C Antibody at 3-4 months, and 6 months.

18. All employees/students who sustain a potential exposure to blood or bodily fluids

should make certain an incident report is filed within 24 hours (at Yale-New

Haven Hospital or Yale Medical School, this is done at the Medical-Legal Affairs

Office, 203 Clinic Building). Employees should also make certain a Yale

University Report of Injury is filed.

19. All record of testing and treatment of HCW should follow established

confidentiality guidelines and should be forwarded to the physician who will be

following the patient (either in Employee Health or Student Health).

20. Employees who refuse to get initial HIV testing may choose to have their initial

serum drawn and stored in the laboratory. They must be informed that their

refusal to submit to HIV testing within 72 hours post accident will make it

impossible to order testing of the source patient without consent.

21. Please see Table A1 for alternative PEP regimens and Table B1 for side effects

information.

Reference: “JSTOR: Infection Control and Hospital Epidemiology, Vol. 34, No. 9 (September 2013)

Needle Stick Procedure Appendix 1

Situations for Which Expert Consultation for Human Immunodeficiency Virus (HIV)

Post exposure Prophylaxis (PEP) Is Recommended

Delayed (i.e., later than 72 hours) exposure report

• Interval after which benefits from PEP are undefined

Unknown source (e.g., needle in sharps disposal container or laundry)

• Use of PEP to be decided on a case-by-case basis

• Consider severity of exposure and epidemiologic likelihood of HIV exposure

• Do not test needles or other sharp instruments for HIV

Known or suspected pregnancy in the exposed person

• Provision of PEP should not be delayed while awaiting expert consultation

Breast-feeding in the exposed person

• Provision of PEP should not be delayed while awaiting expert consultation

Known or suspected resistance of the source virus to antiretroviral agents

• If source person’s virus is known or suspected to be resistant to 1 or more of the

drugs considered for PEP, selection of drugs to which the source person’s virus is

unlikely to be resistant is recommended

• Do not delay initiation of PEP while awaiting any results of resistance testing of

the source person’s virus

Toxicity of the initial PEP regimen

• Symptoms (e.g., gastrointestinal symptoms and others) are often manageable

without changing PEP regimen by prescribing antimotility or antiemetic agents

• Counseling and support for management of side effects is very important, as

symptoms are often exacerbated by anxiety

Serious medical illness in the exposed person

• Significant underlying illness (e.g., renal disease) or an exposed provider already

taking multiple medications may increase the risk of drug toxicity and drug-drug

interactions

Expert consultation can be made with local experts or by calling the National Clinicians’

Post-Exposure Prophylaxis Hotline (PEPline) at .

Needle Stick Procedure Appendix 2

Counseling of Healthcare Personnel (HCP) Exposed to Known or Suspected Human

Immunodeficiency Virus (HIV)–Positive Sources

Counseling (at the time of exposure and at follow-up appointments). Exposed HCP

should be advised to use precautions (e.g., use of barrier contraception and avoidance of

blood or tissue donations, pregnancy, and, if possible, breast-feeding) to prevent

secondary transmission, especially during the first 6–12 weeks after exposure.

For exposures for which post exposure prophylaxis (PEP) is prescribed, HCP should be

informed regarding the following:

• Possible drug toxicities (e.g., rash and hypersensitivity reactions that could imitate

acute HIV seroconversion and the need for monitoring)

• Possible drug interactions

• The need for adherence to PEP regimens

TABLE 3. Postexposure management of health-care personnel after occupational

percutaneous and mucosal exposure to blood and body fluids, by health-care personnel

HepB vaccination and response status

Postexposure testing

Postexposure prophylaxis

Source patient

(HBsAg)

HCP testing

(anti-HBs)

HBIG*

Vaccination

Documented

responder

after complete

series (≥3 doses)

No action needed

Positive/unknown

—**

HBIG x2

separated

by 1 month

—

Negative

No action needed

Positive/unknown

<10mIU/mL

HBIG x1

Negative

<10mIU/mL

None

Any result

≥10mIU/mL

No action needed

Positive/unknown

—**

HBIG x1

Complete

vaccination

Yes

Negative

—

None

Complete

vaccination

Yes

Abbreviations: HCP = health-care personnel; HBsAg = hepatitis B surface antigen; anti-HBs = antibody to hepatitis B surface

antigen; HBIG = hepatitis B immune globulin.

* HBIG should be administered intramuscularly as soon as possible after exposure when indicated. The effectiveness of HBIG when

administered >7 days after percutaneous, mucosal, or nonintact skin exposures is unknown. HBIG dosage is 0.06 mL/kg.

†

Should be performed 1–2 months after the last dose of the HepB vaccine series (and 4–6 months after administration of HBIG to avoid

detection of passively administered anti-HBs) using a quantitative method that allows detection of the protective concentration of anti-HBs (≥10

mIU/mL).

A responder is defined as a person with anti-HBs ≥10 mIU/mL after ≥3 doses of HepB vaccine.

A nonresponder is defined as a person with anti-HBs <10 mIU/mL after ≥6 doses of HepB vaccine.

** HCP who have anti-HBs <10mIU/mL, or who are unvaccinated or incompletely vaccinated, and sustain an exposure to a source patient who

is HBsAg-positive or has unknown HBsAg status, should undergo baseline testing for HBV infection as soon as possible after exposure, and

follow-up testing approximately 6 months later. Initial baseline tests consist of total anti-HBc; testing at approximately 6 months consists of

HBsAg and total anti-HBc.

APPENDIX B: HIV Counseling Guidelines

Risks

The risk of HIV infection after percutaneous exposure to human blood and body fluids is estimated to be 0.3%

on average. The risk is estimated to be higher in cases where the exposure involves a deep injury with a hollow

bore instrument from a patient that has end stage AIDS or an early retro viral syndrome. The risks of a mucous

membrane or skin exposure to HIV infected material is estimated to be lower.

Symptoms

Patients who are exposed to material that is potentially infected with HIV should be counseled about the

symptoms of the acute retroviral syndrome. Symptoms include



fever



sore throat



nausea



headache



enlarged lymph nodes



rash

The symptoms will generally appear within six weeks after an exposure to HIV. The symptoms may be similar

to a viral illness due to other agents, so that patients should be told not to assume the worst if they experience

symptoms after an exposure. Patients should be encouraged to report any suspicious symptoms to their primary

care provider in order to have them evaluated.

Precautions to prevent infection

All patients who have had a potential exposure to HIV should take precautions to avoid possible secondary

transmission. These precautions are the following:



use a condom when engaging in sexual activities



refrain from open mouth kissing



avoid sharing shaving instruments



refrain from donating blood, organs, or other tissues



avoid breast-feeding or becoming pregnant.

Patients should be encouraged to come back for follow up testing at 6 weeks, 3 months, and 6 months. Patients

should continue these precautions until testing at 6 months post exposure confirms lack of seroconversion.

Antiviral Drugs

Patients should be prescribed anti viral drugs based on the needlestick protocol guidelines and risk categories.

Patients should be instructed to begin taking the drugs immediately since the greatest potential benefit results

when the drugs are taken within the first one to two hours post exposure. Patients may be given an initial 72-

hour supply of anti-HIV medications at the time of evaluation. They must contact their clinician and arrange

for further medication without interruption, for a total treatment course of four weeks.

APPENDIX Yale Health 1: Quality Control of Single and Multi-dose Vials/Sterile Solutions

Subject:

Quality control of single dose and multidose vials, non-preservative irrigation solutions,

dated and undated items and topicals

Standard:

Sterility of multidose medication vials/containers will be maintained.

Quality control of multidose medication vials, single use vials, non-preservative irrigation

solutions, non-dated items (alcohol, H

, and green soap), dated items (Betadine), and

topicals will be documented.

Policy

All single and multidose vials/medications will be discarded after single patient use.

•

Medications will be ordered and stocked as single dose vials when possible.

•

Medications only available as multidose vials will still only be used for single patient

administration.

•

Injectable medication administered in the department are basic medical treatment. There

is no charge to the patient.

•

Medications supplied in the department include but are not limited to:

▪

Anesthetics (i.e. Lidocaine 1%, 2% with and without Epinephrine, Benzocaine,

Sodium Bicarbonate).

▪

Steroids (i.e. Kenalog, Celestone, Depo-Medrol, etc.)

Non-preservation irrigation solutions must be discarded at the end of single patient procedure or at

the end of each clinic day. (Normal Saline Irrigation or Sterile Water Irrigation).

Opened solutions i.e., alcohol, peroxide, green soap, betadine will have an expiration sticker

applied when opened. The expiration date will reflect the 1st day of the next month. (Example:

Betadine opened August 15th will have expiration date September 1) All open solutions must be

discarded on the first clinic day of each month.

•

Solutions will be ordered and stocked in the smallest volume when possible.

Expensive allergy extract (single patient use) and multidose vials for vaccines unavailable in

single-dose vial/syringe will expire per manufacturer's expiration date (i.e., meningococcal

vaccine and certain insulin solutions). Exceptions are: "Vial Open Expires..." stickers are

available through the Purchasing Department and should be used to document date opened and

expiration date. Lot number and manufacturers expiration date must not be occluded by sticker.

Exceptions are outlined in the compliance with the Connecticut DPH recommendations.

Manufacturer recommendation must be followed for the storage of multidose vials/containers.

Any exceptions must be approved by the Yale Health Center's Pharmacy and Therapeutic

Committee and Infection Control.

Control testing solutions for CLIA waived tests (HCG, Strep A , glucose, ISTAT, Bianox, A1C,

etc.) are exempt from the monthly discard policy. The solutions are of known consistency and

deliver an expected result. Abnormal results result in removal from service of the testing

device/cartridges/strips. The solutions are not used in direct patient care but rather in calibration of

direct patient care devices. In all cases the manufacturer's instructions for use, retention and

discarding of testing solutions will be followed.

Aseptic technique must be maintained when accessing multidose vials/containers.

Sterile products must be accessed and prepared in areas functionally separate from general work

area.

10.

Eating and drinking must not be allowed in the prep area.

11.

Multidose vials/containers must be inspected for defects, manufacturers expiration date and

product integrity before use. If the product is defective or has expired, it MUST NOT BE USED.

Defective products should be promptly reported to Yale Health Center's Pharmacy.

12.

The rubber stopper of the container must be wiped with 70% alcohol before entry.

13.

Personnel should avoid touch contamination of sterile supplies.

Procedure:

Identify patient, use 2 identifiers (name, DOB).

Assess for allergies.

Medication is verified against physician or PA order.

Expiration date is checked.

Medication is prepared and administered as per MD or PA order by the MD/PA/APRN/RN using

aseptic technique. (See Policy: Intra Articular Injections )

All medication is discarded after single patient use.

APPENDIX Yale Health 2: Laundry

Standard:

Appropriate laundry procedures are followed to minimize potential nosocomial and

occupations risks associated with soiled linen.

Policy & Procedure:

Collection

Soiled linen will be collected in a manner that minimizes agitation to prevent

contamination of the environment and personnel and will be bagged at the site of

use.

Linens are placed in white plastic bags. Linens are double bagged when leakage

onto the environment or contamination of transporting personnel is expected.

All linen is transported to a collection area via linen carts located in the dirty

utility room. Laundry bags will not be overfilled to prevent mechanical

obstruction.

In situations in which laundry is heavily soiled with blood or body fluids,

standard precautions will be followed.

Transportation

Soiled linen will be picked up daily in the morning, Monday, Wednesday and

Friday by Unitex Corporation.

Clean linen is pressed, folded, and delivered to the fifth floor, Inpatient Care

Facility Monday, Wednesday and Friday. it is covered and wrapped for

protection. The laundry staff places laundry on the shelves of the linen closet, the

housekeeping staff assist in keeping the linen neat and monitor the cleanliness of

the closet.

Linen Supply

The Director of Nursing and/or the purchasing department, with the assistance of

the housekeeping department will maintain sufficient levels of linens for three (3)

times the licensed capacity of the facility.

Infection Control

Standard isolation procedures will be followed.

The Infection Control Committee will monitor laundry procedures for

compliance with this policy.

APPENDIX Yale Health 3: Clean Up Spills

Standard:

Clean-up of Spills with Potential for Staff and Patient Exposure to Bloodborne Pathogens.

Policy:

Provide a safe and clean environment for staff and patients while minimizing the risk of

exposure to bloodborne pathogens: for staff members assigned to decontaminate and clean

spills, and for patients and staff by the timely decontamination and clean-up of spills

posing a risk of exposure to bloodborne pathogens.

Procedure:

Person discovering or receiving report of a spill must, immediately cover spill with

"Red Z", spray with Cavicide and cover spill utilizing supplies and directions located

in all spill kits (available through Building Services, Monday - Friday, 8:30a.m. -

5:00p.m.). Managers or persons responsible for ordering supplies should be sure

enough spill kits are readily available in their department.

Clean-up of spills occurring in a clinic area are the responsibility of the personnel of

that specific clinic, utilizing the supplies and step-by-step directions located in the

spill kit.

Contact Yale Health Building Services Emergency phone at 2-0276 to have the day

housekeeping staff continue the disinfecting process. Yale Health Day Housekeeping

Staff is available: Monday through Friday 7:30 a.m. to 5:00p.m., Saturday at 8:30 a.m.

and Sunday 8:30 a.m. to 5:00 p.m.

Report Incident into the Report Tracker system.

Spills occurring at any time in elevator interiors will be reported to the main desk.

The main desk personnel will shut down the elevator and notify the building Services

Manger of the spill.

Cleaning up of spills occurring in a non-clinical area will be the responsibility of the

following departments for their respective floors, utilizing the supplies and step-by-

step directions located in the spill kit.

Non-Clinical Area

Responsible Department

Lower Level

Building Services

First Floor

Acute Care

Second Floor

Surgical Specialties

Third Floor

Pediatrics

Fourth Floor

Inpatient Care

Elevator Interiors

Building Services

During weeknights 5:00p.m.to 12:00a.m., and weekend hours, Acute Care will be

responsible for any spills ocurring on the First floor and Inpatient Care will be

responsible for spills occurring on the Fourth floor. If a spill occurs on any other floor

during weeknights, 5:00p.m. to 8:30a.m. or weekends due to after hours clinic,

seminars, classes, or special arrangements to see a patient in a clinci area, the person

responsible for the clinic, seminar, class or provider seeing a patient is responsible for

the clean-up of any spill related to persons attending these sessions or patient seen after

hours. These spills must be decontaminated and cleaned up immediately, not left for

housekeeping upon their return to duty.

Spill kits are available through Building Services and include all supplies and the

written protocol to be used in the clean-up of any spill with potential for exposure to

bloodborne pathogens. Be sure enough spill kits are available in your department

since Building Services is not accessible after 5:00p.m. on weekdays and is closed on

weekends/holidays.

Assure that all members of your staff, including per diem, casual and off-hours staff,

with risk for exposure to bloodborne pathogens receive their annual bloodborne

Pathogens Training when yearly sessions are scheduled. These training sessions are

mandated by OSHA and address the issues required to afford staff members the

information they need to maintain a safe environment for both patients and employees

and proper handling of materials with potential for risk of exposure to bloodborne

pathogens. Training sessions are given throughout the year for all new Yale Health

employees.

10.

Assure that all staff members are instructed in the location and use of the spill kits and

spill protocol including all per diem, casual and off-hour staff.

APPENDIX Yale Health 4: Infection Control Protocol

Section II. Infection Control/Quality Assurance Rounds

Protocol and Procedure:

Primary function is to measure compliance of each individual Yale Health Department to

the procedures and protocols outlined in the Yale Health Infection Control Manual and

Standards of Care.

During unannounced walking rounds by the Infection Control Practitioner and

surveillance team, use a check list and document non-compliance.

A form will be utilized to communicate any recommendations by the infection

control practitioner and surveillance team to the responsible Department

Manager/Chief to correct or improve department compliance.

A form will be utilized by the responsible departmental staff to communicate to

the Infection Control Practitioner the action taken to improve or correct

compliance with set criteria.

II.

Surveillance Information is used as a teaching tool and guideline for responsible

departmental staff to meet and maintain compliance.

III.

The responsible departmental manager/chief will be sent a copy of the surveillance

information with the Infection Control Practitioner's recommended action for correction

of non-compliance, when appropriate, or comments. The responsible departmental

manager/chief will receive the completed report after the inspection is completed.

IV.

The responsible departmental manager/chief will respond in writing when cited for non-

compliance with set criteria. Infection Control Practitioner /Surveillance Team must

receive this response within two (2) weeks of date of report. The response must include

the department action taken to improve or correct the area of non-compliance cited. The

copy of the report sent by the Infection Control Practitioner /Surveillance Team includes

a column for department action. The responsible departmental manager/chief will utilize

this system for the department response.

The surveillance team will re-visit a department cited for non-compliance following the

initial visit to assess action taken.

Non-compliance with the potential for serious risk of injury or safety to patients or staff

members will require immediate action and reassessment.

APPENDIX Yale Health 5: TB Exposures at Yale Health

Standard:

Yale Health will follow up on any potential exposure to infectious TB in our facility.

Procedure:

The following steps are to be taken if a case of active TB is diagnosed in the Yale Health patient

population.

The clinician who diagnoses or who is first notified of the diagnosis of active TB in one

of their Yale Health patients must immediately notify the Infection Control practitioner

for the facility with the name of the patient, dates that patient was seen in the facility for

the evaluation of potential TB and names of any other clinicians or staff members known

to have contact with the patient during the visit.

The Infection Control Practitioner will obtain the medical record of the index patient,

verify the diagnosis of active TB and begin a list of staff members that had contact with

the patient during the visits where the patient was symptomatic and/or diagnosed with

TB. The managers of any department involved in the care of the patient may need to be

consulted in order to identify additional exposed staff members. The chart will also be

reviewed to determine whether the appropriate infection control practices were used in

caring for the patient once the diagnosis of active TB was suspected. This review of the

infection control practices will be reported at the Infection Control committee. The

Infection control practitioner will report the index TB case to the State of Connecticut if

the diagnosis was made by a Yale Health clinician as per the Reportable Disease policy.

The Infection Control Practitioner, in conjunction with the Chief of Employee Health will

inform all staff members who had contact with the index case that they need to have a

baseline ppd now (unless one has been placed within the past 3 months) and a follow up

ppd in 3 months time to identify any potential secondary cases. Any staff member who is

determined to have evidence of new TB infection as a result of this testing will be

evaluated as per the facility TB control plan. Any exposed staff who have a previous

history of a past positive ppd will notified to be alert and report any signs or symptoms

consistent with TB disease to employee health.

The Infection Control practitioner will check the computerized department clinic

schedules for the days that the index patient was seen in the facility in the respective

department and begin a list of patients who were likely to have been in the waiting room

in close proximity to the index patient along with their primary providers.

The Infection control staff and/or employee health staff will forward a notice to the

patients who may have been exposed to the index case to alert them of this fact and

recommend that they contact their primary physician for a ppd or evaluation. The primary

physicians will also be notified so that they will be aware of the case. If any exposed

patient subsequently is discovered to be infected with TB by way of a skin test

conversion, their primary physician will notify the Infection control and employee health

staff.

At the end of the follow up period, the employee health chief will report to the Infection

Control committee about the outcome of the monitoring period including any evidence of

secondary spread of TB from the index case by identification of new ppd conversions.

The Infection Control Committee will review the entire infection control practices

surrounding the case as well as the outcome from the monitoring period to document

adherence to the facility TB control plan and to make any recommendations for future

cases.

APPENDIX Yale Health 6: Universal Respiratory Etiquette

Standard:

Many respiratory pathogens are transmitted in health care settings (examples: influenza,

mycoplasma, coronaviruses, adenoviruses). Respiratory etiquette practices can decrease the rate

of transmission of these pathogens to patients, visitors, and staff.

Policy:

Yale Health will implement Universal Respiratory Etiquette practices in the clinical areas of the

facility.

Procedure:

Patients and visitors with fever, cough or other respiratory symptoms will be offered a

surgical mask to wear while waiting for their health care appointments.

Patients who have the above respiratory symptoms and cannot wear a surgical mask will be

advised to use a tissue to cover their nose or mouth while coughing or sneezing.

Hand hygiene materials will be available in clinical waiting areas. Patients with respiratory

symptoms will be encouraged to perform frequent hand washing using these products.

Clinical staff will be educated about respiratory hygiene and encouraged to wear surgical

masks when assessing patients who have respiratory symptoms. Clinical staff will perform

frequent hand washing when caring for patients with respiratory symptoms.

Clinical managers will be responsible for ensuring that their respective departments keep the

supplies on hand in order to implement this respiratory etiquette policy.

APPENDIX Yale Health 7: Clinical Guidelines for Severe Acute Respiratory Syndrome -

Corona Virus (SARS CoV) Infection

The following guidelines should be used as clinical guidance for evaluating patients with

community-acquired illness for possible SARS-CoV Disease.

In the absence of SARS-CoV transmission anywhere in the world, the diagnosis of SARS-

CoV disease should be considered only in patients who require hospitalization for

radiographically confirmed pneumonia and who have an epidemiologic history that raises the

suspicion of SARS-CoV disease. The suspicion for SARS-CoV disease is raised if, within 10

days of symptom onset, the patient:

▪

Has a history of recent travel to mainland China, Hong Kong, or Taiwan (see Figure 1,

footnote 3) or close contact with ill persons with a history of recent travel to such areas,

▪

Is employed in an occupation at particular risk for SARS-CoV exposure, including a

healthcare worker with direct patient contact or a worker in a laboratory that contains live

SARS-CoV, or

▪

Is part of a cluster of cases of atypical pneumonia without an alternative diagnosis

Persons with such a clinical and exposure history should be evaluated for possible SARS CoV

disease as per CDC guidelines.

Once SARS-CoV transmission has been documented in the world, the diagnosis should still

be considered in patients who require hospitalization for pneumonia and who have the

epidemiologic history described above. In addition, all patients with fever or respiratory

symptoms should be questioned about whether within 10 days of symptom onset they have had:

▪

Close contact with someone suspected of having SARS-CoV disease, OR

▪

A history of foreign travel (or close contact with an ill person with a history of travel) to a

location with documented or suspected SARS-CoV, OR

▪

Exposure to a domestic location with documented or suspected SARS-CoV (including a

laboratory that contains live SARS-CoV), or close contact with an ill person with such an

exposure history.

Persons with such an exposure history should be evaluated for SARS-CoV disease according to

established CDC guidelines ( See CDC web site for most current guidelines)

See attached matrix for CDC recommendations for Outpatient Facilities.

Matrix 1: Recommendations for Inpatient Facilities and Emergency Departments

Level of SARS

activity

Suggested actions

No cases of SARS

in the facility

Triage activities/facility access controls

Notify the SARS coordinator or designee of any transfers from facilities that have SARS

cases.

In accordance with recommendations for respiratory hygiene/cough etiquette, instruct all

patients with respiratory illnesses to perform hand hygiene and cover the nose/mouth

when coughing or sneezing. Manage these patients with Droplet Precautions until

determined that they are not needed.

In the presence of person-to person SARS-CoV transmission in the world but no

known transmission in the area around the facility:

Place signs at all entry points detailing symptoms of and current epidemiologic risk

factors for SARS and directing persons meeting these criteria to an appropriate area for

evaluation.

Initiate screening of patients on entry to the emergency department for symptoms and

epidemiologic links suggesting SARS. Patients with fever or lower respiratory

symptoms and SARS risk factors should perform hand hygiene, wear a surgical mask (if

possible), and be isolated in accordance with the recommendations in Supplement I. If

airborne isolation is not possible, consider cohorting, with all patients wearing surgical

masks. Evaluate patients according to the algorithm (Figure 2) in Clinical Guidance on

the Identification and Evaluation of Possible SARS-CoV Disease among Persons

Presenting with Community-Acquired Illness

(www.cdc.gov/ncidod/sars/clinicalguidance.htm).

If a patient’s risk of exposure to SARS-CoV is high (e.g., close contact with a

laboratory-confirmed case of SARS-CoV disease), the clinical criteria should be

expanded to include other early symptoms of SARS-CoV disease.

In the presence of SARS-CoV transmission in the area around the facility:

All persons should perform hand hygiene on entry.

Actively screen all persons entering the facility for fever and lower respiratory

symptoms. All patients presenting with fever or lower respiratory symptoms should

perform hand hygiene, wear a surgical mask (if possible), and be isolated for SARS in

accordance with the recommendations in Supplement I. If airborne isolation is not

possible, consider cohorting, with all patients wearing surgical masks. Evaluate patients

according to the algorithm (Figure 2) in Clinical Guidance on the Identification and

Evaluation of Possible SARS-CoV Disease among Persons Presenting with Community-

Acquired Illness (www.cdc.gov/ncidod/sars/clinicalguidance.htm).

If a patient’s risk of exposure to SARS-CoV is high (e.g., close contact with a

laboratory-confirmed case of SARS-CoV disease), the clinical criteria should be

expanded to include other early symptoms of SARS-CoV disease.

Intake/triage staff should follow SARS infection control and PPE guidance, as specified

in Supplement I.

Limit visitors (e.g., one per patient per day).

Screen all visitors for SARS risk factors and symptoms.

Limit elective admissions and procedures.

Consider designating an area as a “SARS evaluation center” and sending all patients

presenting with fever or respiratory symptoms to the center for evaluation.

Matrix 1: Recommendations for Inpatient Facilities and Emergency Departments

(continued)

Level of SARS

activity

Suggested actions

No cases of SARS

in the facility

(continued)

Patient placement

In the presence of person-to-person SARS-CoV transmission in the world but NO

known transmission in the area around the facility:

Patients presenting with fever or lower respiratory symptoms and epidemiologic risk

factors for SARS should perform hand hygiene, wear a surgical mask (if possible), and

be isolated for SARS in accordance with the recommendations in Supplement I. If

airborne precautions are not possible, consider cohorting, with all patients wearing

surgical masks. Evaluate patients according to the algorithm (Figure 2) in Clinical

Guidance on the Identification and Evaluation of Possible SARS-CoV Disease among

Persons Presenting with Community-Acquired Illness

(www.cdc.gov/ncidod/sars/clinicalguidance.htm).

If a patient’s risk of exposure is high (e.g., close contact with a laboratory-confirmed

case of SARS-CoV disease), the clinical criteria should be expanded to include, in

addition to fever or lower respiratory symptoms, the other early symptoms of SARS-

CoV disease.

In the presence of person-to-person SARS-CoV transmission in the world but NO

known transmission in the area around the facility:

Patients presenting with fever or lower respiratory symptoms should perform hand

hygiene, wear a surgical mask (if possible), and be isolated in accordance with the

recommendations in Supplement I. If airborne isolation is not possible, consider

cohorting, with all patients wearing surgical masks. Evaluate patients according to the

algorithm (Figure 2) in Clinical Guidance on the Identification and Evaluation of

Possible SARS-CoV Disease among Persons Presenting with Community-Acquired

Illness (www.cdc.gov/ncidod/sars/clinicalguidance.htm).

If a patient’s risk of exposure is high (e.g., close contact with a laboratory-confirmed

case of SARS-CoV disease), the clinical criteria should be expanded to include, in

addition to fever or lower respiratory symptoms, the other early symptoms of SARS-

CoV disease.

Designated personnel

Assign only selected, trained, and fit-tested emergency department staff to evaluate

possible SARS cases. Staff should follow SARS infection control and PPE guidance, as

specified in Supplement I.

Surveillance

Depending on directives from local/state health departments, consider reporting of

patients requiring hospitalization for unexplained pneumonia who have risk factors for

SARS, as specified in Supplement B.

Healthcare worker restrictions

Healthcare workers should notify the SARS coordinator at each facility where they work

and have at least daily symptom checks if:

They are caring for a SARS patient in another facility.

They are also working in another facility that has reported nosocomial SARS-CoV

transmission.

They have close contact with SARS patients outside the hospital.

Matrix 1: Recommendations for Inpatient Facilities and Emergency Departments

(continued)

Level of SARS

activity

Suggested actions

A few cases in the

facility, but all

cases are imported

(NO nosocomial

transmission)

Triage activities/facility access controls

Same as for “No cases of SARS in the facility.” Add:

No visitors to SARS patients unless necessary (e.g., parents, translators); visitors must

receive infection control training.

Designate specific SARS patient-flow routes (e.g., emergency department to designated

elevator to AIIR; AIIR to radiology).

Clean rooms housing SARS patients in accordance with current recommendations (see

Supplement I).

Patient placement

Same as for “No cases of SARS in the facility.” Add:

Place admitted known or potential SARS patients in AIIRs if available.

Consider cohorting admitted patients in private rooms on designated SARS units,

depending on personnel and availability of AIIRs. Modify designated floors/rooms as

possible.

Designated personnel

Same as for “No cases of SARS in the facility.” Add:

Assign only selected, trained, and fit-tested staff to SARS patient care (includes

designated ancillary personnel).

Assign a selected, trained, and fit-tested team with access to appropriate respiratory

protection (see Supplement I) for emergency resuscitation or respiratory procedures in

known or potential SARS patients.

Surveillance

Conduct active surveillance targeted to healthcare workers providing care to SARS

patients (e.g., symptom monitoring).

Healthcare worker restrictions

Same as for “No cases of SARS in the facility.” Add:

No eating or drinking in SARS patient-care areas.

Furlough healthcare workers with unprotected exposures to SARS patients during high-

risk procedures, and institute checks to evaluate possible symptoms.

Healthcare workers with other (non-high-risk) unprotected exposures to a SARS patient

should undergo checks for possible symptoms. Furlough of these workers could be

considered.

Matrix 1: Recommendations for Inpatient Facilities and Emergency Departments

(continued)

Level of SARS

activity

Suggested actions

A larger number of

SARS cases in the

facility OR

nosocomial

transmission with

all cases linked to a

clearly identified

source

Triage activities/access controls

Same as for “A few cases in the facility but all cases are imported.” Add:

Regardless of the level of SARS activity in the community around the facility:

Limit visitors (e.g., one per patient per day).

Maintain a log of all visitors to SARS patients to aid in contact tracing.

Limit elective admissions/procedures.

All healthcare workers and visitors should have a fever check and perform hand

hygiene on entry.

Patient placement

Same as for “A few cases in the facility but all cases are imported.” Add:

Designated personnel

Same as for “A few cases in the facility but all cases are imported.”

Surveillance

Implement active healthcare worker surveillance (symptom monitoring) throughout the

facility.

Monitor all healthcare worker absenteeism and illnesses (e.g., through the occupational

medicine clinic); evaluate for links to known SARS cases.

Monitor for and evaluate all new fevers and lower respiratory illnesses among patients.

Place any patient with unexplained fever or lower respiratory symptoms on SARS

precautions, and evaluate in accordance with the algorithm (Figure 2) in Clinical

Guidance on the Identification and Evaluation of Possible SARS-CoV Disease among

Persons Presenting with Community-Acquired Illness

(www.cdc.gov/ncidod/sars/clinicalguidance.htm).

If a patient’s risk of exposure is high (e.g., close contact with a laboratory-confirmed

case of SARS-CoV disease), the clinical criteria should be expanded to include, in

addition to fever or lower respiratory symptoms, the other early symptoms of SARS-

CoV disease.

Healthcare worker restrictions

Same as for “A few cases in the facility but all cases are imported.”

100

Matrix 1: Recommendations for Inpatient Facilities and Emergency Departments

(continued)

Level of SARS

activity

Suggested actions

Cases attributed to

nosocomial

transmission with

NO clearly

identified source

Triage activities/access controls

Same as for “A larger number of cases or linked transmission.” Add:

No visitors allowed in hospital unless necessary (e.g., parents, translators); visitors

must receive infection control training.

Close emergency department and facility to admissions and transfers.

Patient placement

Same as for “A larger number of cases or linked transmission.” Add:

Consider cohorting patients and staff to care for patients in the following categories:

Afebrile patients with no close SARS contact -- discharge as soon as medically

indicated

Afebrile patients with close SARS contact -- discharge as soon as medically indicated,

with contact restrictions and health department follow-up per recommendations in

Supplement D

Febrile or symptomatic patients not meeting case definition

Patients meeting case definition

Designated personnel

Same as for “A larger number of cases or linked transmission.” Add:

All persons in the facility should wear a surgical mask when not providing patient care

(this is not meant to serve as SARS PPE but to limit potential SARS-CoV transmission

from someone who develops SARS). When in contact with SARS patients, all persons

should continue to follow SARS infection control guidance and PPE as specified in

Supplement I.

Surveillance

Same as for “A larger number of cases or linked transmission.” Add:

Place any patient with new fever or lower respiratory illness (not just unexplained) on

SARS precautions and evaluate in accordance with the SARS clinical algorithm.

If a patient’s risk of exposure is high (e.g., close contact with a laboratory-confirmed

case of SARS-CoV disease), the clinical criteria should be expanded to include, in

addition to fever or lower respiratory symptoms, the other early symptoms of SARS-

CoV disease.

Healthcare worker restrictions

Same as for “A larger number of cases or linked transmission.” Add:

Depending on staffing issues, either:

Implement home/work restrictions for all healthcare workers in the facility, or

Restrict movement to work and home for all healthcare workers who worked in an

area of the facility where nosocomial transmission may have occurred.

101

Matrix 2: Recommendations for Outpatient Facilities/Areas

Level of SARS

activity

Suggested actions

No person-to-

person SARS

transmission

reported anywhere

in the world

Patient screening and precautions

In accordance with recommendations for respiratory hygiene/cough etiquette, instruct

all patients with symptoms of a respiratory infection to perform hand hygiene and

cover the nose/mouth. Manage these patients with Droplet Precautions until it is

determined that they are not needed. If there are likely to be delays in moving patients

out of the waiting area, consider dividing the area so that patients with respiratory

illnesses do not sit near others.

Healthcare worker precautions

Healthcare workers seeing patients with respiratory illness should use Droplet

Precautions.

During respiratory illness season, intake/triage staff should practice frequent hand

hygiene and could be given the option of wearing surgical masks.

Infrastructure issues

The facility will need a supply of waterless hand-hygiene products, surgical masks,

and other applicable PPE and will need to consider the logistics of implementing a

respiratory hygiene/cough etiquette strategy.

102

Matrix 2: Recommendations for Outpatient Facilities/Areas (continued)

Level of SARS

activity

Suggested actions

Presence of

person-to-person

SARS

transmission

worldwide but no

known

transmission in the

area around the

facility

Patient screening and precautions

Same as for “No person-to-person SARS transmission in the world.” Add:

Screen all patients and visitors with fever or lower respiratory symptoms for SARS

epidemiologic links (e.g., travel to endemic areas or contact with known cases).

Instruct anyone with fever or lower respiratory symptoms and epidemiologic risks for

SARS to wear a surgical mask (if tolerated) and to perform hand hygiene. Place these

patients immediately in a private room. Transfer these patients as soon as possible to a

facility where they can be isolated appropriately during the evaluation. Notify receiving

facilities that the patient is being sent for evaluation of SARS.

If a patient’s risk of exposure is high (e.g., close contact with a laboratory-confirmed

case of SARS-CoV disease), the clinical criteria should be expanded to include, in

addition to fever or lower respiratory symptoms, the other early symptoms of SARS-

CoV disease.

Manage outpatients in accordance with Clinical Guidance on the Identification and

Evaluation of Possible SARS-CoV Disease among Persons Presenting with Community-

Acquired Illness (www.cdc.gov/ncidod/sars/clinicalguidance.htm).

Healthcare worker precautions

Same as for “No person-to-person SARS transmission in the world.” Add:

Healthcare workers who are in direct contact with patients who might have SARS should

wear full SARS PPE (see Supplement I).

Infrastructure issues

Same as for “No person-to-person SARS transmission in the world.” Add:

The facility will need a supply of PPE (e.g., gowns, gloves, eye protection, respirators

[N-95 or higher level]).

Known

transmission in

the area around

the facility

1) Patient screening and precautions

Screen all patients and visitors for fever and lower respiratory symptoms both

when appointments are made and when they arrive at the clinic. Refer persons

with these symptoms to a facility where they can be isolated appropriately during

evaluation. Warn receiving facilities that the patient is being sent for evaluation

of SARS.

If a patient’s risk of exposure is high (e.g., close contact with a laboratory-

confirmed case of SARS-CoV disease), the clinical criteria should be expanded

to include, in addition to fever or respiratory symptoms, the other early

symptoms of SARS-CoV disease.

Healthcare worker precautions

Same as for “Person-to-person SARS transmission worldwide but no known

transmission in the area around the facility.”

Infrastructure issues

Same as for “Person-to-person SARS transmission worldwide but no known

transmission in the area around the facility.”

103

Matrix 3: Recommendations for Long-Term Care Facilities

Level of SARS

activity

Suggested actions

No person-to-

person SARS

transmission

reported anywhere

in the world

Patient precautions

In accordance with recommendations for respiratory hygiene/cough etiquette, patients

who develop symptoms of a respiratory infection should be placed on Droplet

Precautions until determined that they are not needed.

Healthcare worker precautions

Healthcare workers seeing patients with respiratory illness should use Droplet

Precautions and practice frequent hand hygiene.

Infrastructure issues

The facility will need supplies for Droplet Precautions (masks, gloves and gowns) and

hand hygiene.

Presence of

person-to-person

SARS

transmission

worldwide, but

no known

transmission in

the area around

the facility

Patient precautions

Same as for “No person-to-person SARS transmission reported anywhere in the

world.” Add:

Screen all potential admissions for symptoms and epidemiologic links to SARS.

Healthcare worker precautions

Same as for “No person-to-person SARS transmission reported anywhere in the

world.”

Infrastructure issues

Same as for “No person-to-person SARS transmission reported anywhere in the

world.”

Access controls

Visitors should be screened for symptoms and epidemiologic links to SARS

cases. Visitors with symptoms and epidemiologic links should not be allowed

into the facility.

Known

transmission in

the area around

the facility

Patient precautions

Same as for “No person-to-person SARS transmission reported anywhere in the world.”

All new admissions should be evaluated at an acute-care facility (no direct admissions).

Patients with fever or lower respiratory symptoms should be evaluated according to the

algorithm (Figure 2) in Clinical Guidance on the Identification and Evaluation of

Possible SARS-CoV Disease among Persons Presenting with Community-Acquired

Illness (www.cdc.gov/ncidod/sars/clinicalguidance.htm) before being admitted. Patients

who are asymptomatic but had exposures should be observed for 10 days for the

development of symptoms before they are admitted.

If there is significant transmission in the community around the facility, initiate

surveillance for nosocomial lower respiratory illness, and transfer all patients who

develop such illness to an acute-care facility for evaluation. Acute-care facilities should

be notified that the patients are being transferred for evaluation of SARS.

Healthcare worker precautions

Same as for “No person-to-person SARS transmission reported anywhere in the world.”

Healthcare workers should undergo symptom monitoring. Symptomatic healthcare

workers should be furloughed and evaluated according to the algorithm (Figure 2) in

Clinical Guidance on the Identification and Evaluation of Possible SARS-CoV Disease

among Persons Presenting with Community-Acquired Illness

(www.cdc.gov/ncidod/sars/clinicalguidance.htm).

Infrastructure issues

Same as for “No person-to-person SARS transmission reported anywhere in the world.”

Access controls

Visitors should be actively screened for symptoms.

Visitors with symptoms should not be allowed into the facility.

104

APPENDIX Yale Health 8: Varicella Exposure at Yale Health

Standard:

Yale Health Center will prevent the spread of Varicella when it is diagnosed in a patient or staff

member.

Policy:

Yale Health Center staff will identify, report and use appropriate transmissions based precautions

and personal protective measures to prevent further transmission when a patient is diagnosed with

varicella in our facility.

Procedure:

Patients who call with symptoms of fever and a pruritic vesicular rash should be referred to a

nurse or a CLINICIAN for phone triage. Obtain the name and telephone number of the

patient. Before advising them to come into the facility, Varicella should be considered as a

diagnosis. Please note that varicella requires airborne isolation.

Patients with possible varicella who are severely ill or at risk for complications

(immunocompromised patients, pregnant women) should be referred to Yale-New

Haven Hospital (YNHH) for further evaluation and treatment. The ED at YNHH

should be notified so that the patient can be evaluated with the appropriate airborne

precautions.

Patients who are not severely ill or at risk for complications should speak with a

clinician to make arrangements to have the patient come to the facility wearing a

surgical mask at a specific time or be given a surgical mask at the door. The

ambulance enters should be used. The patient should be immediately escorted into the

airborne isolation room in the Inpatient Care. The patient should only be cared for by

immune staff. If an advance notice is possible, please notify the charge nurse in the

Inpatient Care to confirm availability of the isolation room.

If the patient is well enough to be discharged to home, they must be informed that they

are infectious until all lesions are crusted over (generally about 7 days) and that they

must stay out of work or school and avoid contact with anyone who is not immune to

Varicella.

e. If an undergraduate who lives in the dormitory is diagnosed with varicella, they may

not be sent back to the dormitory and should be offered admission to the isolation room

in the Inpatient Care if available. The policy Managing Students

With VaricellaChickenpox Or Other Potentially Serious Communicable

Diseases will be followed.

g. Any exam room used for a Varicella patient can be cleaned according to the regular

room cleaning procedure.

The clinician who makes the diagnosis of varicella will notify the Infection Control

Practitioner, who will then report it to the State of Connecticut as per the Reportable Disease

policy. The Infection Control practitioner will review the infection control practices used in

caring for the index patient and report on this to the Infection Control committee. In off-

105

hours cases, the clinician of record for the case is responsible for instituting appropriate

Infection Control precautions.

The Infection control practitioner will identify any staff members who were directly

exposed to the index patient and either contact each of them or consult the employee health

clinician to determine the staff members’ varicella immunity status.

Any staff member who is determined not to have an immunity to varicella will be required to

get a varicella titer immediately under the direction of the employee health clinician. A staff

member with a history of the varicella vaccination only (not natural immunity) will also be

required to get a varicella titer.

Any staff member whose varicella titer is negative will be placed on mandatory furlough or

removed from patient care from day 10 to 21(the incubation period) post exposure to the index

case to prevent possible varicella transmission to immunocompromised patients. At this time,

the staff member can be offered the varicella vaccination (up to 72 hrs post exposure) if not

previously vaccinated, which might help prevent a severe infection should they develop

varicella. If they develop varicella during this incubation period, they must report it to the

employee health department as well as notifying their primary provider to seek treatment. If

they do not develop varicella beyond the incubation period, they are unlikely to become ill

.Upon their return to duty, staff members who were not previously vaccinated should be

encouraged to receive the vaccine.

Any exposed non –immune staff member who is immunocompromised or pregnant should

be evaluated for possible administration of varicella-zoster immune globulin by a clinician

with expertise in this area.

The Infection Control practitioner will also determine a list of potential patient contacts who

may have shared the waiting room with the index case. The records of these patients will be

reviewed if available to determine if any of them were immunocompromised or currently

pregnant. All potentially exposed patients will be notified either by phone or letter if

unavailable, that they may have been exposed to varicella. The patients will be advised that if

they had a history of chicken pox, a positive varicella titer, or the varicella vaccine, they are

unlikely to become ill. They will be advised to contact their own doctor immediately if they

do not have a history of immunity, or if they are pregnant or immunocompromised. The

primary physicians of any identified immunocompromised or pregnant patient will also be

notified.

An asymptomatic patient who worries about exposure can be seen to have a baseline

Varicella titer drawn and be offered the Varicella vaccine (if clinically appropriate).

At the end of the incubation period (post day 21), the Infection control committee will

review the exposure history, along with any evidence of secondary transmission and review

the infection control practices to make any recommendations for handling of future cases.

106

APPENDIX Yale Health 9: PnP for Visitors to Inpatient Care

Standard:

Yale Health’s visitor policy balances the needs of patients and their families with heightened

awareness of infectious disease control.

Policy:

It is important to have a policy for visitors to the IC that both protects visitors from infectious

risks from patients and protects patients from infections that might be brought into the facility by

visitors.

Procedure:

All visitors to patients in IC must check in at the nursing station before entering the patient’s

room. Visitors are encouraged to speak with the charge nurse for any questions or concerns.

Visitors who are suffering from cold or flu symptoms or other illness that may be contagious

such as chicken pox, diarrhea, fever, cough, draining uncontained skin wounds, should refrain

from visiting patients in the IC so as not to transmit a potentially contagious illness to patients

who are already ill with other conditions. You should be free of any symptoms for 48 hours

before coming to IC.

Visitors must observe all procedures related to transmission based precautions that pertain to

the patients with whom they are visiting. The nursing staff will instruct visitors on the steps to

observe the proper precautions including items such as the use of gowns, gloves, or masks, as

well as proper hand washing and respiratory etiquette.

For patients on enhanced precautions, do not sit on the bed or use the patients’ toilets, share

patient toiletries, tissues, etc. or handle items of hospital equipment such as intravenous

tubing or drains.

The nursing staff on duty and the administrators of Yale Health reserve the right to deny

visitors permission to visit if it is determined that the visitors pose a potential increased threat

of communicable disease, or if the visitors are unable or unwilling to follow the transmission

based precautions.

Visitors may be asked to leave at any time if a patient’s condition is judged to be

deteriorating, if the patient is becoming fatigued or a clinical intervention is necessary.

107

APPENDIX Yale Health 10: PnP for Negative Pressure Rooms Inpatient Care and Use

Standard:

To provide a negative air pressure environment to safely care for persons requiring respiratory

isolation.

Policy:

Patients admitted to Inpatient Care who require respiratory isolation will be placed in one of the

two negative pressure rooms. Negative pressure will be maintained and monitored at all times.

Procedure:

The Inpatient Care charge nurse is alerted to the admission of a patient requiring

respiratory isolation.

The room, either 10 or 11, is checked for all appropriate furniture and equipment

required. Any unnecessary equipment is removed from the room.

The door to the room is shut and appropriate the signage is placed on the door.

The nurse will set the room to negative pressure by turning the key to the control switch

at the nurse's station.

The monitoring box outside the room is checked by the nurse to assure negative pressure

is attained.

After negative pressure is attained, the door is opened to test that the alarm sounds when

the pressure is no longer negative.

The door is closed again and the nurse verifies that the pressure monitor goes back to the

negative and the alarm stops.

Staff entering the room will open the door after donning PPE and will close the door

immediately after entering the room.

Traffic in and out of the room will be held to a minimum.

No visitors will be allowed unless they have been authorized by the attending

clinician, have been fit tested for a respirator, and have been instructed by staff

on the proper use of personal protective equipment (PPE).

PPE will be removed by staff immediately after exiting the room and disposed of in the

designated waste container outside of the room. Staff will take care to avoid

contaminating themselves while removing the personal protective equipment and will

wash hands immediately upon completion of this step.

10.

When negative pressure rooms are in use, the pressure monitor outside the room will be

checked by the nurse hourly.

108

11.

If the negative pressure cannot be maintained, the patient will don an molded surgical

mask and will be transported to the hospital via AMR as soon as possible.

. The receiving facility as well as the ambulance services will be informed of the need to

use respiratory protection while caring for this patient.

12.

The patient will remain in the room for the duration of their inpatient stay. Only transport

within the building that is absolutely necessary for procedures will be authorized

and the patient will wear a molded surgical mask during any required transport.

The attending clinician can discontinue respiratory protection procedures after a

diagnosis is established that does not require these procedures or once the patient is

deemed noninfectious. Consultation with the Infection Control Staff or Medical Director

is encouraged if there is any doubt about continuation of respiratory isolation.

13.

Internal and external appointments for patients who are on isolation must be approved by

the attending clinician.

Attached: Negative Pressure Weekly Monitoring Log

109

APPENDIX Yale Health 11: Guidelines for the Infection Control management and Prevention

of Norovirus outbreaks

Noroviruses are the most common cause of epidemic gastroenteritis. These viruses are of

particular importance in gastroenteritis outbreaks in long term care and other health care settings

as well as the food service industry.

Noroviruses can cause gastroenteritis in patients of all ages. The incubation period is 12-48 hours

and symptoms are characterized by acute onset of diarrhea (usually nonbloody), vomiting, nausea

and abdominal cramps as well as occasional low grade fever and myalgias. Most cases resolve

without treatment in 1-3 days. The virus is shed in the stool and vomitus and peak shedding is for

2-5 days, although the virus can be detected for up to 4 weeks. Norovirus is extremely contagious

and is generally transmitted by person to person transmission, foodborne or waterborne

transmission. Indirect exposure by contaminated fomites has also been implicated.

The following guidelines from the CDC are recommended as a response to suspected norovirus

outbreaks and as prevention for the spread of the virus:

Report suspected norovirus outbreaks (defined as an unusually large number of cases in a

patient population who either live or work in close proximity to each other) promptly to

Infection Control in order that an investigation can be started to attempt to identify the

source and prevent further transmission.

Enforce good hand hygiene by washing hands with soap and running water for at least 20

seconds. Note that alcohol-based hand sanitizers may not be as effective in the setting of

norovirus outbreaks.

Institute contact precautions for any patients admitted to the infirmary or when caring for

patients that might be incontinent or wearing diapers. In settings with widespread illness,

consider assigning exposed staff members only to care for patients admitted with

norovirus symptoms and re-assign non exposed staff to other patient areas.

During times of widespread illness, visitors to the infirmary will be screened for

symptoms of gastrointestinal illness and not be admitted to the unit if they have

symptoms. Visitors to patients with norovirus symptoms will be kept to the minimal

number necessary for patient comfort and must adhere to strict contact precautions.

Employees or students who are ill with a norovirus like illness will remain home for 48-

72 hours after symptom resolution.

Environmental surfaces will be first cleaned to remove any soiled material and then

disinfected with either a 1:10 solution of bleach or the institutionally approved

disinfectant for norovirus.

Attempt to collect specimens for testing from at least 5 acutely ill patients to test for

norovirus. (whole stool specimens can be sent for PCR testing)

Report all suspected norovirus outbreaks to the local and state health departments using

our standard reportable disease policy and procedure.

110

APPENDIX Yale Health 12: Yale Health Procedure for Discontinuation of Airborne

Isolation for rule out Tuberculosis patients

All suspected or known patients with tuberculosis who are admitted to the ICF must be

admitted to the airborne isolation room according to airborne transmission based

precautions outlined in the Infection Control manual.

Airborne precautions may be discontinued when infectious TB disease is considered

unlikely and either 1) another diagnosis is made that explains the clinical syndrome or 2)

the patient has three consecutive, negative AFB sputum smear results. Each of the three

sputum specimens should be collected in 8–24-hour intervals, and at least one specimen

should be an early morning specimen.

Yale Health Infection Control Committee