____________________________________________ #98641 Infection Control: The New York Requirement

COURSE #98641 — 5 CONTACT HOURS/CREDITS Release Date: 04/01/16 Expiration Date: 03/31/19

Infection Control:
The New York Requirement
Mrs. Shenold served as the Continuum of Care Manager
HOW TO RECEIVE CREDIT for Vencor Oklahoma City, coordinating quality review,
• Read the enclosed course. utilization review, Case Management, Infection Control,
and Quality Management. During that time, the hospital
• Complete the questions at the end of the course.
achieved Accreditation with Commendation with the
• Return your completed Evaluation to NetCE by Joint Commission, with a score of 100.
mail or fax, or complete online at www.NetCE.
com. (If you are a physician or Florida nurse, please Mrs. Shenold was previously the Infection Control
return the included Answer Sheet/Evaluation.) Nurse for Deaconess Hospital, a 300-bed acute care facil-
Your postmark or facsimile date will be used as ity in Oklahoma City. She is an active member of the
your completion date. Association for Professionals in Infection Control and
• Receive your Certificate(s) of Completion by mail, Epidemiology (APIC). She worked for the Oklahoma
fax, or email. Foundation for Medical Quality for six years.
Faculty Disclosure
Contributing faculty, Lori L. Alexander, MTPW, ELS,
MWC, has disclosed no relevant financial relationship
Faculty with any product manufacturer or service provider
Lori L. Alexander, MTPW, ELS, MWC, is President mentioned.
of Editorial Rx, Inc., which provides medical writing
and editing services on a wide variety of clinical topics Contributing faculty, Carol Shenold, RN, ICP, has
and in a range of media. A medial writer and editor for disclosed no relevant financial relationship with any
more than 30 years, Ms. Alexander has written for both product manufacturer or service provider mentioned.
professional and lay audiences, with a focus on continu- Division Planners
ing education materials, medical meeting coverage, and John M. Leonard, MD
educational resources for patients. She is the Editor Jane C. Norman, RN, MSN, CNE, PhD
Emeritus of the American Medical Writers Association
(AMWA) Journal, the peer-review journal representing Division Planners Disclosure
the largest association of medical communicators in the The division planners have disclosed no relevant
United States. Ms. Alexander earned a Master’s degree in financial relationship with any product manufacturer
technical and professional writing, with a concentration or service provider mentioned.
in medical writing, at Northeastern University, Boston. Audience
She has also earned certification as a life sciences editor This course is designed for physicians, physician assis-
and as a medical writer. tants, nurses, and other healthcare professionals in New
Carol Shenold, RN, ICP, graduated from St. Paul’s York required to complete education to enhance their
Nursing School, Dallas, Texas, achieving her diploma knowledge of infection control.
in nursing. Over the past 30 years she has worked in Accreditations & Approvals
hospital nursing in various states in the areas of obstet- NetCE is accredited by the Accreditation Council for
rics, orthopedics, intensive care, surgery and general Continuing Medical Education to provide continuing
medicine. medical education for physicians.
NetCE is accredited as a provider of continuing nurs-
ing education by the American Nurses Cre­dentialing
Center’s Commission on Accreditation.

Copyright © 2016 NetCE

A complete Works Cited list begins on page 25. Mention of commercial products does not indicate endorsement.
NetCE • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 1
#98641 Infection Control: The New York Requirement _____________________________________________
Designations of Credit Our contributing faculty members have taken care to
NetCE designates this enduring material for a maximum ensure that the information and recommendations are
of 5 AMA PRA Category 1 Credit(s)™. Physicians should accurate and compatible with the standards generally
claim only the credit commensurate with the extent of accepted at the time of publication. The publisher
their participation in the activity. disclaims any liability, loss or damage incurred as a con-
sequence, directly or indirectly, of the use and applica-
Successful completion of this CME activity, which
tion of any of the contents. Participants are cautioned
includes participation in the evaluation component,
about the potential risk of using limited knowledge when
enables the participant to earn up to 5 MOC points
integrating new techniques into practice.
in the American Board of Internal Medicine’s (ABIM)
Maintenance of Certification (MOC) program. Partic- Disclosure Statement
ipants will earn MOC points equivalent to the amount It is the policy of NetCE not to accept commercial sup-
of CME credits claimed for the activity. It is the CME port. Furthermore, commercial interests are prohibited
activity provider’s responsibility to submit participant from distributing or providing access to this activity to
completion information to ACCME for the purpose learners.
of granting ABIM MOC credit. Completion of this
Course Objective
course constitutes permission to share the completion
The purpose of this course is to provide a review of cur-
data with ACCME.
rent infection control practices and accepted standards,
NetCE designates this continuing education activity for with an emphasis on the application of infection control
5 ANCC contact hours. standards and practices in outpatient and ambulatory
settings.
NetCE designates this continuing education activity for
6 hours for Alabama nurses. Learning Objectives
Upon completion of this course, you should be able to:
NetCE designates this continuing education activity
for 1 pharmacotherapeutic/pharmacology contact hour. 1. Discuss the standards of professional conduct
associated with infection control in the
AACN Synergy CERP Category A. healthcare setting.
Individual State Nursing Approvals 2. Outline the infectious disease process.
In addition to states that accept ANCC, NetCE is 3. Describe various practices that can result
approved as a provider of continuing education in in exposure to bloodborne pathogens.
nursing by: Alabama, Provider #ABNP0353 (valid 4. Identify effective strategies to prevent or
through December 12, 2017); California, BRN Pro- control infection, including precautions,
vider #CEP9784; California, LVN Provider #V10662; isolation techniques, hand hygiene, standards
California, PT Provider #V10842; Florida, Provider #50- for cleaning, and safe injection practices.
2405; Iowa, Provider #295; Kentucky, Provider #7-0054
5. Describe the role of surveillance and reporting
through 12/31/2017.
in an effective infection control program.
Special Approvals 6. Discuss the impact of communicable diseases in
This activity is designed to comply with the require- healthcare professionals, including the necessity
ments of California Assembly Bill 1195, Cultural and for preplacement evaluations, periodic health
Linguistic Competency. assessments, education, and postexposure
This course is approved by the New York State Depart- prophylaxis.
ment of Health to fulfill the requirement for 3 hours of
Infection Control Training as mandated by Chapter 786
of the Laws of 1992. Provider #TP02078. Sections marked with this symbol include
evidence-based practice recommen­dations.
About the Sponsor The level of evidence and/or strength
The purpose of NetCE is to provide challenging cur- of recommendation, as provided by the
ricula to assist healthcare professionals to raise their evidence-based source, are also included
levels of expertise while fulfilling their continuing so you may determine the validity or relevance of the
education requirements, thereby improving the quality information. These sections may be used in conjunc-
of healthcare. tion with the course material for better application to
your daily practice.

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____________________________________________ #98641 Infection Control: The New York Requirement
According to data published in 2014, HAIs
INTRODUCTION develop in an estimated 1 in 25 hospitalized
patients (excluding skilled nursing facilities); this
The development of formal infection control pro-
number varies from year to year and had previously
grams in hospitals and other healthcare facilities
been estimated at a high of 1 in 10 [1; 4; 94; 95].
was spurred by the Joint Commission accreditation
There were an estimated 722,000 HAIs in 648,000
standards for infection control, published in 1976.
adults and children in acute care hospitals in
According to the standards, accredited facilities
2011; more than half of infections (65%) occurred
should have a program for the surveillance, preven-
outside of intensive care units [95]. Additionally,
tion, and control of healthcare-associated infec-
the infections were the cause of approximately
tions (HAIs) [1]. The most important aspect of
75,000 deaths and add approximately $28.4 to
infection control is establishing multidisciplinary
$33.8 billion in direct medical costs annually [4; 5;
programs that promote teamwork and foster an
95]. The most common types of HAIs were pneu-
organizational culture centered on patient safety.
monia (22%), surgical site infections (22%), and
HAIs are one of the leading causes of death and gastrointestinal infections (17%) [95]. Of the 481
increased morbidity for hospitalized patients and reported pathogens, the most common was Clos-
are a significant problem for healthcare providers tridium difficile (12%), followed by Staphylococcus
[2]. Historically, these infections have been known aureus (11%), Klebsiella pneumonia and K. oxytoca
as nosocomial infections or hospital-acquired (10%), and Escherichia coli (9.5%).
infections because they develop during hospital-
As HAIs have become a cause for increasing con-
ization. As health care has increasingly expanded
cern, many national organizations, state depart-
beyond hospitals into outpatient settings, nurs-
ments of health, and professional organizations
ing homes, long-term care facilities, and even
have taken additional steps to prevent or control
home care settings, the more appropriate term
infection in the healthcare environment.
has become healthcare-acquired or healthcare-
associated infection.
Many factors have contributed to an increase in STANDARDS OF
HAIs. Advances in medical treatments have led PROFESSIONAL CONDUCT
to more patients with decreased immune function
or chronic disease. The increase in the number of The increased focus on healthcare quality over the
these patients, coupled with a shift in health care past decade has highlighted the need to prevent
to the outpatient setting, yields a hospital popula- HAIs as part of overall efforts to enhance patient
tion that is both more susceptible to infection and safety. These efforts have been developed by
more vulnerable once infected. In addition, the healthcare quality agencies, professional associa-
increased use of invasive devices and procedures tions, advocacy organizations, healthcare regulat-
has contributed to higher rates of infection [3]. ing bodies, and policymakers [6; 7; 8; 9; 10; 11; 12;
13]. Prevention of HAIs and of methicillin-resis-
tant Staphylococcus aureus (MRSA) infection are
listed among safe healthcare practices established
by the Agency for Healthcare Research and Qual-
ity (AHRQ) and the National Quality Forum, and
prevention of HAIs was noted by the Institute of
Medicine (IOM) to be one of 20 priority areas for

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#98641 Infection Control: The New York Requirement _____________________________________________
enhancing the quality of health care [6; 7; 12]. In The New York Codes, Rules, and Regulations
2004, the Institute for Healthcare Improvement require that certain healthcare professionals who
(IHI) established the 100,000 Lives Campaign as may influence the control and prevention of
a challenge to save 100,000 patient lives through HAIs complete training or education regarding
six healthcare interventions, three of which were infection control and barrier precautions [15].
related to HAIs: preventing central line infections, New York State has also established professional
surgical site infections, and ventilator-associated standards of conduct to ensure that infection
pneumonia [8]. Building on the success of the prevention and control practices are adhered to.
100,000 Lives Campaign, the IHI established the 5 According to the Rules of the Board of Regents:
Million Lives Campaign in December 2006, adding Part 29, “failing to use scientifically accepted
six more interventions, one of which is to reduce infection prevention techniques appropriate to
MRSA infection [8]. In 2010, the Centers for each profession for the cleaning and sterilization
Medicare & Medicaid Services (CMS) launched or disinfection of instruments, devices, materials
the Partnership for Patients with the goal of reduc- and work surfaces, utilization of protective garb, use
ing all HAIs 40% compared to 2010 and reducing of covers for contamination-prone equipment and
readmissions due to HAIs by 20% by focusing on the handling of sharp instruments” is considered
transitions from one care setting to another [96]. unprofessional conduct [16]. Appropriate infection
control techniques include, but are not limited to,
Regulatory bodies have also focused on HAIs. Goal
wearing appropriate personal protective equip-
7 of the National Patient Safety Goals developed
ment, adhering to recommendations for Universal
by the Joint Commission is to reduce the risk of
and Standard Precautions, following sterilization
HAIs in hospitals as well as ambulatory care/office-
and disinfection standards, and using the correct
based surgery, long-term care, and assisted living
equipment in the correct way [16].
settings [13]. Perhaps the most aggressive campaign
against HAIs has come from CMS, which has Healthcare professionals have the responsibility
suspended reimbursement of hospital costs related to adhere to scientifically accepted principles and
to three categories of HAIs it considers “reason- practices of infection control in all healthcare
ably preventable:” catheter-related urinary tract settings and to oversee and monitor those medical
infection, vascular catheter-associated infection, and ancillary personnel for whom the professional
and various surgical site infections [10; 11; 14]. is responsible [16]. Healthcare professionals are
However, studies have shown that this policy has expected to use scientifically accepted infection
not been a contributor to any decrease in the rate prevention techniques appropriate to each profes-
of HAIs, and a survey indicated that adherence sion for handwashing; aseptic technique; cleaning
to only a few prevention strategies has increased and sterilization or disinfection of instruments,
as a result of the policy [97; 98]. The policy also devices, materials, and work surfaces; use of protec-
has the potential to lead to increased unnecessary tive garb; use of covers for contamination-prone
use of antimicrobials in an effort to prevent infec- equipment; and handling of sharp instruments
tions [99]. [15; 16; 17].

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____________________________________________ #98641 Infection Control: The New York Requirement
CONSEQUENCES OF charges of professional misconduct [45]. The Office
NONCOMPLIANCE WITH GUIDELINES of Professional Medical Conduct may investigate
The results of the Centers for Disease Control and on its own any suspected professional misconduct
Prevention (CDC) Study of Efficacy of Nosocomial and is required to investigate each complaint
Infection Control suggested that 6% of all HAIs received regardless of the source. The charges must
could be prevented by minimal infection control state the substance of the alleged misconduct and
efforts and 32% by “well organized and highly effec- the material facts (but not the evidence). A hear-
tive infection control programs” [18; 19]. A later ing may be called, if warranted. The results of the
review estimated that as many as 65% to 70% of hearing (i.e., findings, conclusions, determinations,
cases of catheter-associated infections and 55% of order) will be made public upon issuance. Any
cases of surgical site infections are preventable [20]. professional found guilty of misconduct shall be
subject to penalties, including [46]:
Evidence-based guidelines are at the heart of strate-
gies to prevent and control HAIs and drug-resistant • Censure and reprimand
infections and address a wide range of issues from • Suspension of license or limitation of
architectural design of hospitals to hand hygiene. license to a specified area or type of practice
These guidelines have been developed primarily • Revocation of license
by the CDC and the World Health Organization
• Annulment of license or registration
(WHO), infection-related organizations, and other
professional societies. Some specialty organizations • Limitation on registration or issuance
and quality improvement groups have summarized of any further license
the guidelines for easier use in practice [2; 17; 21; • A fine not to exceed $10,000 upon each
22; 23; 24; 25; 26; 27; 28; 29; 30; 31; 32; 33; 34; 35; specification of charges of which the
36; 37; 38; 39; 40; 41; 42]. Adherence to individual respondent is determined to be guilty
guidelines varies but, in general, is low. Historically, • A requirement that a licensee pursue a
87% of hospitals have failed to implement all of the course of education or training
recommended guidelines for preventing HAIs [43]. • A requirement that a licensee perform up
Hand hygiene is the most basic and single most to 500 hours of public service in a manner
important preventive measure, yet compliance and at a time and place as directed
rates among healthcare workers have averaged
only 30% to 50% [3; 31; 44; 56; 57; 58]. Decreasing METHODS OF COMPLIANCE
the number of HAIs will require research to better The education and training of healthcare person-
understand the reasons behind lack of compliance nel are prerequisites for ensuring that Standard
with guidelines and to develop strategies that target Precautions are understood and practiced. Educa-
those reasons. tion on the principles and practices for prevent-
In addition, there are professional consequences ing transmission of infectious agents should begin
for New York healthcare professionals who do not during training in the health professions and be
adhere to appropriate infection control efforts. provided to anyone who has an opportunity for
Healthcare professionals who fail to use scientifi- contact with patients or medical equipment. Edu-
cally accepted barrier precautions and state-estab- cation programs for healthcare personnel have
lished infection control practices may be subject to been associated with sustained improvement in
adherence to best practices [17].

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#98641 Infection Control: The New York Requirement _____________________________________________
Adherence to recommended infection control In addition to breaks in the skin, other primary
practices decreases transmission of infectious entry points for micro-organisms are mucosal sur-
agents in healthcare settings; however, several faces, such as the respiratory, gastrointestinal, and
observational studies have shown limited adher- genitourinary tracts [50]. The membranes lining
ence to recommended practices by healthcare these tracts comprise a major internal barrier to
personnel. Improving adherence to infection micro-organisms due to the antimicrobial proper-
control practices requires a multifaceted approach ties of their secretions. The respiratory tract filters
that incorporates continuous assessment of both inhaled micro-organisms, and mucociliary epithe-
the individual and the work environment. It also lium in the tracheobronchial tree moves them out
requires that the organizational leadership make of the lung. In the gastrointestinal tract, gastric
prevention an institutional priority and integrate acid, pancreatic enzymes, bile, and intestinal secre-
infection control practices into the organization’s tions destroy harmful micro-organisms. Nonpatho-
safety culture [17; 47; 48]. genic bacteria (commensal bacteria) make up the
normal flora in the gastrointestinal tract and act as
protectants against invading pathogenic bacteria.
THE INFECTIOUS Commensal bacteria are a source of infection only
DISEASE PROCESS if they are transmitted to another part of the body
or if they are altered by the use of antibiotics [2].
A comprehensive description of the pathogenesis
of infection is beyond the scope of this course. HAIs are commonly caused by bacteria, but can
However, a broad overview of pathogen-host also be caused by viruses, fungi, and parasites.
interaction will aid in the understanding of how These types of infection occur less frequently and
infection develops in the healthcare setting. often do not carry the same risks of morbidity and
mortality as bacterial infections. Viral infections
A healthy human body has several defenses against are more common in children than in adults and
infection: the skin and mucous membranes form carry a high epidemic risk [1]. Fungal infections
natural barriers to infection, and immune responses frequently occur during prolonged treatment with
(nonspecific and specific) are activated to resist antibiotics and in patients who have compromised
micro-organisms that are able to invade. The skin immune systems [2]. Various pathogens have
can effectively protect the body from most micro- different levels of pathogenicity, virulence, and
organisms unless there is physical disruption. For infectivity.
example, the human papillomavirus can invade
the skin, and some parasites can penetrate intact The transmission of infection follows the cycle
skin, but bacteria and fungi cannot [49]. Other (the “cycle of infection”) that has been described
disrupters of the natural barrier are lesions (e.g., for all diseases, and humans are at the center of this
chapped, abraded, affected by dermatitis), injury, cycle [2; 51]. In brief, a micro-organism requires a
or in the healthcare setting, invasive procedures reservoir (a human, soil, air, or water), or a host, in
or devices [84]. which to live. The micro-organism also needs an
environment that supports its survival once it exits
the host and a method of transmission. Inherent
properties allow micro-organisms to remain viable
during transmission from a reservoir to a susceptible
host, another essential factor for transmission of
infection. The primary routes of transmission for
infections are through the air, blood (or body fluid),

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____________________________________________ #98641 Infection Control: The New York Requirement
contact (direct or indirect), fecal-oral route, food, Infection is transmitted in a healthcare environ-
animals, or insects. Once inside a host, micro- ment primarily through exogenous and endogenous
organisms thrive because of adherent properties modes. Exogenous transmission is through patient-
that allow them to survive against mechanisms in to-patient or staff-to-patient contact. Patients who
the body that act to flush them out. Bacteria adhere do not have infection but have bacterial coloniza-
to cell surfaces through hair-like projections, such tion can act as vectors of transmission. Staff mem-
as fibrillae, fimbriae, or pili, as well as by proteins bers can also act as vectors because of colonization
that serve as adhesions [50]. Fimbriae and pili are or contamination. Endogenous infection occurs
found on gram-negative bacteria, whereas other within an individual patient through displacement
types of adhesions are found with both gram- of commensal micro-organisms.
negative and gram-positive bacteria. Receptor Factors specifically related to the healthcare envi-
molecules in the body act as ligands to bind the ronment are not common causes of HAIs [2; 52;
adhesions, enabling bacteria to colonize skin and 53]. However, consideration should be given to
mucous membranes. The virulence of the micro- the prevention of infection with environmental
organism, the integrity of skin and membrane pathogens. The CDC revised guideline related to
barriers, and patient status determine whether environmental factors for infection provides clear
colonization is followed by invasive infection. recommendations for infection control measures
With colonization, there is no damage to local or according to several environment-related catego-
distant tissues and no immune reaction; with infec- ries, including air (normal ventilation and filtra-
tion, bacterial toxins that break down cells and tion, as well as handling during construction or
intracellular matrices are released, causing dam- repair), water (water supply systems, ice machines,
age to local and distant tissues and prompting an hydrotherapy tanks and pools), and environmental
immune response in the host. Bacteria continue to services (laundry, housekeeping) [30].
thrive within a host through strategies that enable
them to acquire iron for nutrition and to defend In general, the spread of infectious disease is pre-
against the immune response. These virulence vented by eliminating the conditions necessary
factors enhance a micro-organism’s potential for for the micro-organism to be transmitted from a
infection by interrupting or avoiding phagocytosis reservoir to a susceptible host. This can be accom-
or living inside phagocytes [50]. plished by:
A healthcare environment increases the risk • Destroying the micro-organism
of infection for two primary reasons. First, it is • Blocking the transmission
likely that normally sterile body sites will become • Protecting individuals from becoming
exposed, allowing pathogens to cause infection vectors of transmission
through contact with mucous membranes, non-
• Decreasing the susceptibility of potential
intact skin, and internal body areas [51]. Second,
hosts
the likelihood of a susceptible host is high due to
the vulnerable health status of patients. Especially
in an era of decreased hospital stays and increased
outpatient treatments, it is the sickest patients
who are hospitalized, increasing the risk not only
for infection to develop in these patients but also
for their infection to be more severe and to be
transmitted to others.

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#98641 Infection Control: The New York Requirement _____________________________________________
Antiseptic techniques and antibiotics will kill PARENTERAL EXPOSURE
micro-organisms, while proper hand hygiene Parenteral exposures (i.e., injection with infectious
will block their transmission. Gloves, gowns, material) may occur during administration of par-
and masks remove healthcare professionals from enteral medications, sharing of blood monitoring
the transmission cycle by protecting them from devices (e.g., glucometers, lancets), or infusion of
contact with micro-organisms. Contact Precau- contaminated blood products or fluids. Generally,
tions and isolation techniques help patients avoid these exposures are the result of poor adherence
being vectors of transmission. Lastly, ensuring that to Standard Precautions and infection control
patients and healthcare professionals are immune guidelines.
or vaccinated can help decrease the availability of
potential hosts. MUCOUS MEMBRANE AND
NONINTACT SKIN EXPOSURE
Mucous membrane and nonintact skin exposures
HIGH-RISK PRACTICES: may occur when blood or body fluids come in
EXPOSURE TO direct contact with the eyes, nose, mouth, or other
BLOODBORNE PATHOGENS mucous membranes via contaminated hands, open
skin lesions, or splashes or sprays of blood or body
Healthcare professionals, emergency response per- fluids (e.g., during irrigation or suctioning). Again,
sonnel, and public safety personnel may be exposed following established infection control guidelines
to a variety of bloodborne pathogens, including greatly reduces the risk of this type of exposure.
human immunodeficiency virus (HIV), hepatitis
B virus (HBV), and hepatitis C virus (HCV).
Exposure may occur percutaneously, parenterally, PRECAUTIONS AND
or through contact with mucous membranes and ISOLATION TECHNIQUES
nonintact skin [54].
The CDC guideline for isolation precautions in
PERCUTANEOUS EXPOSURE hospitals, last updated in 2007, synthesizes a vari-
Percutaneous exposures may occur through the ety of recommendations for precautions based on
handling, disassembly, disposal, or reprocessing the type of infection and the route of transmission
of contaminated needles and other sharp objects. [17]. As defined by the CDC, Standard Precau-
They may also be related to the performance of tions represent measures that should be followed
procedures in which there is poor visualization for all patients in a healthcare facility, regardless
(e.g., blind suturing, placing the nondominant of diagnosis or infection status. Standard Precau-
hand next to or opposing a sharp, or performing tions apply to blood; all body fluids, secretions, and
procedures where bone spicules or metal fragments excretions except sweat, regardless of whether they
are produced). Data from the CDC National Sur- contain visible blood; nonintact skin; and mucous
veillance System for Hospital Health Care Workers membranes [17]. For patients who are known to
(NaSH) have shown that approximately 70% of have or are highly suspected to have coloniza-
percutaneous injuries occur during use of a sharp, tion or infection, Contact Precautions should be
while 15% occur after use and before disposal [55]. followed. This type of precaution is designed to
reduce exogenous transmission of micro-organisms
through direct or indirect contact from healthcare
professionals or other patients. Airborne Precau-
tions are used for patients who have or are highly
suspected of having infection that is spread by
airborne droplet nuclei, such as tuberculosis,

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____________________________________________ #98641 Infection Control: The New York Requirement
measles, or varicella. Droplet Precautions target tissues, and to perform hand hygiene after contact
infections that are transmitted through larger with respiratory secretions. Masks should be offered
droplets generated through talking, sneezing, or to coughing patients and other individuals with
coughing, such as invasive Haemophilus influenzae symptoms, and such persons should be encouraged
type b disease, diphtheria (pharyngeal), pertus- to maintain an ideal distance of at least 3 feet from
sis, group A streptococcal pharyngitis, influenza, others in common waiting areas.
mumps, and rubella [17]. The following descriptions of precautions are
summarized from the 2007 guideline for isolation
The American College of Gastroenterology precautions [17]. The guideline includes recom-
recommends Contact Precautions for mendations found in the CDC guideline on hand
patients with Clostridium difficile should hygiene [31]. Although the 2007 guideline is the
be maintained at a minimum until the
most recent version, guidance regarding Ebola
resolution of diarrhea.
virus precautions and isolation has been updated
(http://www.guideline.gov/content.
aspx?id=45139. Last accessed March 18, 2016.)
and will be discussed briefly [100].
Strength of Recommendation/Level of Evidence: STANDARD PRECAUTIONS
Strong recommendation, high-quality evidence
Hand Hygiene
The guideline includes recommendations found in
The CDC guideline includes descriptions of all the CDC guideline on hand hygiene [31]. Hand
the elements involved in the four types of precau- hygiene guidelines will be discussed in length later
tions, including hand hygiene; the use of personal in this course.
protection equipment (i.e., gloves, gown, face
Gloves
protection); placement of the patient; handling
of patient-care equipment; and environmental Wear gloves (clean, nonsterile gloves are adequate)
services and occupational health. New elements when touching blood, body fluids, secretions,
of Standard Precautions added to the 2007 guide- excretions, and contaminated items. Latex or
line include infection control practices (i.e., use nitrile gloves are preferable for clinical procedures
of masks) for special lumbar puncture procedures, that require manual dexterity and/or will involve
safe injection practices (discussed later in this more than brief patient contact. Put on clean
course), and respiratory hygiene/cough etiquette gloves just before touching mucous membranes
[17]. Recommendations in this area address the and nonintact skin. When worn in combination
importance of educating healthcare profession- with other personal protective equipment, don
als about adherence to measures to control the gloves last.
transmission of respiratory pathogens, especially Change gloves between tasks and procedures
during seasonal outbreaks of viral respiratory on the same patient after contact with mate-
tract infections. In addition, the guideline states rial that may contain a high concentration of
that efforts should be made to contain respiratory micro-organisms. Remove gloves promptly after
secretions in patients and other individuals who use, before touching noncontaminated items
have signs and symptoms of a respiratory infec- and environmental surfaces and before going to
tion, beginning at the point of initial encounter another patient, and wash hands immediately to
in a healthcare setting. Signs should be posted to avoid transfer of micro-organisms to other patients
instruct patients and visitors with symptoms of or environments. Avoid contamination of cloth-
respiratory infection to cover their mouths/noses ing and skin when removing gloves. Do not reuse
when coughing or sneezing, to use and dispose of gloves or wash gloves for subsequent reuse.

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#98641 Infection Control: The New York Requirement _____________________________________________
Mask, Eye Protection, Face Shield Environmental Control
Wear a mask and eye protection or a face shield to Ensure that the hospital has adequate procedures
protect mucous membranes of the eyes, nose, and for the routine care, cleaning, and disinfection of
mouth during procedures and patient-care activi- environmental surfaces, beds, bedrails, bedside
ties that are likely to generate splashes or sprays of equipment, and other frequently touched surfaces,
blood, body fluids, secretions, or excretions. and ensure that these procedures are being fol-
lowed.
Gown
Wear a gown (a clean, nonsterile gown is adequate) Linen
to protect skin and to prevent soiling of clothing Handle, transport, and process used linen soiled
during procedures and patient-care activities that with blood, body fluids, secretions, and excretions
are likely to generate splashes or sprays of blood, in a manner that prevents contamination of air,
body fluids, secretions, or excretions. Select a gown surfaces, and individuals.
that is appropriate for the activity and amount of
fluid likely to be encountered. Remove a soiled Occupational Health
gown as promptly as possible (turning outer “con- and Bloodborne Pathogens
taminated” side of the gown inward), roll gown into Take care to prevent injuries when using needles,
a bundle, and discard appropriately. Wash hands to scalpels, and other sharp instruments or devices;
avoid transfer of micro-organisms to other patients when handling sharp instruments after procedures;
or environments. Do not reuse gowns, even for when cleaning used instruments; and when dispos-
repeated tasks with the same patient. ing of used needles. Never recap used needles, or
otherwise manipulate them using both hands, or
Patient Placement use any other technique that involves directing
Use a private room for a patient who contaminates the point of a needle toward any part of the body.
the environment or who does not (or cannot be Rather, use either a one-handed “scoop” technique
expected to) assist in maintaining appropriate or a mechanical device designed for holding the
hygiene or environmental control. If a private needle sheath. Do not remove used needles from
room is not available, consult with infection con- disposable syringes by hand, and do not bend,
trol professionals regarding patient placement or break, or otherwise manipulate used needles by
other alternatives. hand. Place used disposable syringes and needles,
scalpel blades, and other sharp items in appropriate
Patient-Care Equipment puncture-resistant containers, which are located
Handle used patient-care equipment soiled with as close as practical to the area in which the items
blood, body fluids, secretions, and excretions in a were used, and place reusable syringes and needles
manner that prevents skin and mucous membrane in a puncture-resistant container for transport to
exposures, contamination of clothing, and transfer the reprocessing area.
of micro-organisms to other patients and environ-
Use mouthpieces, resuscitation bags, or other
ments. Ensure that reusable equipment is not used
ventilation devices as an alternative to mouth-to-
for the care of another patient until it has been
mouth resuscitation methods in areas where the
cleaned and reprocessed appropriately. Ensure that
need for resuscitation is predictable.
single-use items are discarded properly.

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____________________________________________ #98641 Infection Control: The New York Requirement
CONTACT PRECAUTIONS Patient Transport
Patient Placement Limit the movement and transport of the patient
from the room to essential purposes only. If the
Place the patient in a private room. When a private
patient is transported out of the room, ensure that
room is not available, place the patient in a room
precautions are maintained to minimize the risk of
with a patient(s) who has active infection with the
transmission of micro-organisms to other patients
same micro-organism but with no other infection
and contamination of environmental surfaces or
(cohorting). When a private room is not available
equipment.
and cohorting is not achievable, consider the epi-
demiology of the micro-organism and the patient Patient-Care Equipment
population when determining patient placement. When possible, dedicate the use of noncritical
Consultation with infection control professionals patient-care equipment to a single patient (or
is advised before patient placement. cohort of patients infected or colonized with the
Gloves and Handwashing pathogen requiring precautions) to avoid sharing
between patients. If use of common equipment or
In addition to wearing gloves as outlined under
items is unavoidable, then adequately clean and
Standard Precautions, wear gloves (clean, nonster-
disinfect them before use for another patient.
ile gloves are adequate) when entering the room.
During the course of providing care for a patient, AIRBORNE PRECAUTIONS
change gloves after having contact with infective All precautions described for airborne pathogens
material that may contain high concentrations of are in addition to Standard Precautions.
micro-organisms (e.g., fecal material, wound drain-
age). Remove gloves before leaving the patient’s Patient Placement
room, and wash hands immediately with an antimi- Place the patient in a private room that has (1)
crobial agent or a waterless antiseptic agent. After monitored negative air pressure in relation to the
glove removal and handwashing, ensure that hands surrounding areas; (2) 6 to 12 air changes per hour;
do not touch potentially contaminated environ- and (3) appropriate discharge of air outdoors or
mental surfaces or items in the patient’s room, to monitored high-efficiency filtration of room air
avoid transfer of micro-organisms to other patients before the air is circulated to other areas in the hos-
or environments. pital. Keep the room door closed and the patient
Gown in the room. When a private room is not available,
place the patient in a room with a patient who has
In addition to wearing a gown as outlined under active infection with the same micro-organism,
Standard Precautions, wear a gown (a clean, non- unless otherwise recommended, but with no other
sterile gown is adequate) when entering the room infection. When a private room is not available
if you anticipate that your clothing will have sub- and cohorting is not desirable, consultation with
stantial contact with the patient, environmental infection control professionals is advised before
surfaces, or items in the patient’s room, or if the patient placement.
patient is incontinent or has diarrhea, an ileostomy,
a colostomy, or wound drainage not contained
by a dressing. Remove the gown before leaving
the patient’s environment. After gown removal,
ensure that clothing does not contact potentially
contaminated environmental surfaces, to avoid
transfer of micro-organisms to other patients or
environments.

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#98641 Infection Control: The New York Requirement _____________________________________________
Respiratory Protection Patient Transport
Wear respiratory protection (N95 respirator) when Limit the movement and transport of the patient
entering the room of a patient with known or sus- from the room to essential purposes only. If trans-
pected infectious pulmonary tuberculosis. Suscep- port or movement is necessary, minimize patient
tible persons should not enter the room of patients dispersal of droplets by placing a surgical mask on
known or suspected to have rubeola (measles) or the patient, if possible.
varicella (chickenpox) if other immune caregiv-
ers are available. If susceptible persons must enter HAND HYGIENE
the room of a patient known or suspected to have Hand hygiene is the most important preventive
rubeola or varicella, they should wear respiratory measure in hospitals, and the Joint Commission
protection (N95 respirator). Persons immune to mandates that hospitals and other healthcare
rubeola or varicella need not wear respiratory facilities comply with the Level I recommenda-
protection. tions in the CDC guideline for hand hygiene [31].
The CDC guideline states the specific indica-
Patient Transport tions for washing hands, the recommended hand
Limit the movement and transport of the patient hygiene techniques, and recommendations about
from the room to essential purposes only. If trans- fingernails and the use of gloves (Table 1) [31].
port or movement is necessary, minimize patient The guideline also provides recommendations for
dispersal of droplet nuclei by placing a surgical surgical hand antisepsis, selection of hand-hygiene
mask on the patient, if possible. agents, skin care, educational and motivational
programs for healthcare professionals, and admin-
DROPLET PRECAUTIONS istrative measures.
All precautions described for droplet pathogens are
Despite the simplicity of the intervention, its
in addition to Standard Precautions.
substantial impact, and wide dissemination of the
Patient Placement guideline, compliance with recommended hand
Place the patient in a private room. When a pri- hygiene has ranged from 16% to 81%, with an aver-
vate room is not available, place the patient in a age of 30% to 50% [3; 31; 43; 56; 57; 58]. Among
room with a patient(s) who has active infection the reasons given for the lack of compliance are
with the same micro-organism but with no other inconvenience, understaffing, and damage to skin
infection. When a private room is not available [1; 31; 56]. The development of effective alcohol-
and cohorting is not achievable, maintain spatial based handrub solutions addresses these concerns,
separation of at least 3 feet between the infected and studies have demonstrated that these solutions
patient and other patients and visitors. Special air have increased compliance [57; 59; 60]. The CDC
handling and ventilation are not necessary, and the guideline recommends the use of such solutions
door may remain open. on the basis of several advantages, including [31]:
• Better efficacy against both gram-negative
Mask
and gram-positive bacteria, mycobacteria,
In addition to wearing a mask as outlined under fungi, and viruses than either soap and water
Standard Precautions, wear a mask when working or antimicrobial soaps (e.g., chlorhexidine)
within 3 feet of the patient. (Logistically, some
• More rapid disinfection than other hand-
hospitals may want to implement a policy of wear-
hygiene techniques
ing a mask to enter the room.)
• Less damaging to skin
• Time savings (18 minutes compared
with 56 minutes per 8-hour shift)

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____________________________________________ #98641 Infection Control: The New York Requirement

SUMMARY OF CDC RECOMMENDATIONS FOR HAND HYGIENE

Indications for Hand Hygiene
Wash hands with nonantimicrobial or antimicrobial soap and water when they are visibly dirty, contaminated, or soiled.
If hands are not visibly soiled, use an alcohol-based handrub for routinely decontaminating hands.
Specific Indications
Wash hands before patient contact and before putting on gloves for insertion of invasive devices that do not require
surgery (e.g., urinary catheters, intravascular devices).
Wash hands after:
• Contact with a patient’s skin
• Contact with body fluids or excretions, nonintact skin, or wound dressings
• Removing gloves
Recommended Handrub Technique
Apply to palm of one hand, rub hands together, covering all surfaces until dry.
Recommended Handwashing Technique
• Wet hands with water, apply soap, and rub hands together for at least 15 seconds.
• Rinse and dry with disposable towel.
• Use towel to turn off faucet.
Fingernails and Artificial Nails
Keep tips of natural nails to a length of ¼ inch. Do not wear artificial nails during direct contact with high-risk patients
(e.g., patients in intensive care unit or operating room).
Use of Gloves
Use gloves when there is potential for contact with blood or other potentially infectious materials, mucous membranes,
or nonintact skin. Change gloves after use for each patient.
Source: [31] Table 1

The guideline suggests that healthcare facilities hand-hygiene practices, as no studies have dem-
promote compliance by making the handrub solu- onstrated the superiority of any intervention [61].
tion available in dispensers in convenient locations Single interventions are unlikely to be effective
(e.g., entrance to patients’ room, at the bedside) [61].
and provide individual pocket-sized containers Several single-institution studies have demon-
[31]. The handrub solution may be used in all
strated that appropriate hand hygiene reduces
clinical situations except for when hands are vis- overall rates of HAIs, including those caused by
ibly dirty or are contaminated with blood or body MRSA and vancomycin-resistant enterococci [57;
fluids. In such instances, soap (either antimicrobial 58; 59; 60]. However, rigorous evidence linking
or nonantimicrobial) and water must be used. hand hygiene alone with the prevention of HAIs
However, there are many other reasons for lack of is lacking, making it difficult to evaluate the true
adherence to appropriate hand hygiene, including impact of hand hygiene alone in reducing HAIs
denial about risks, forgetfulness, and belief that [62]. One challenge in evaluating the impact of
gloves provide sufficient protection [1; 31; 56]. hand hygiene is that a variety of methodologies
These reasons demand education for healthcare (e.g., surveys, direct observation, measurement of
professionals to emphasize the importance of hand product use) have been used to assess compliance,
hygiene. Also necessary is research to determine each with its own advantages and disadvantages
which interventions are most likely to improve [63]. Measuring the effect of appropriate hand

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#98641 Infection Control: The New York Requirement _____________________________________________
hygiene alone is also difficult because the inter-
vention is often one aspect of a multicomponent STANDARDS FOR EQUIPMENT
strategy to reduce infection [58]. Lastly, as noted AND ENVIRONMENTAL SERVICES
previously, the development of HAIs is complex,
with many contributing factors [58]. Although The infection control manual should contain
more research is needed to assess the individual details on cleaning and disinfecting equipment
impact of appropriate hand hygiene, this basic and the healthcare environment. The procedures
prevention measure is the essential foundation of should follow those set forth by the CDC in its
an effective infection control strategy and is an guidelines for environmental infection control and
element of every infection control guideline [2; for disinfection and sterilization [26; 30]. These
17; 25; 26; 28; 29; 31; 32; 33; 36; 38]. procedures are related to the routine cleaning,
disinfection, and reprocessing of equipment; the
EBOLA VIRUS cleaning and disinfection of environmental sur-
Care of patients with Ebola requires Standard, faces; the cleaning of spills of blood and other body
Contact, and Airborne Precautions. Duration of fluids; the cleaning and maintenance of laundry
these measures is determined on a case-by-case and bedding, carpeting, and cloth furnishings; and
basis, in conjunction with local, state, and federal the handling of medical waste.
health authorities. A single-patient room with the
CLEANING, DISINFECTING,
door closed is preferred. A log of all people enter-
AND REPROCESSING EQUIPMENT
ing the patient’s room is required. Barrier protec-
tions against blood and body fluids should be used The guideline on disinfection and sterilization
upon entry into room (i.e., gloves, fluid-resistant published by the CDC in 2008 includes updated
or impermeable gown, face/eye protection with evidence-based recommendations on preferred
masks, goggles or face shields). Additional protec- methods for cleaning, disinfecting, and sterilizing
tive wear (i.e., double gloves, leg and shoe cover- medical devices and for cleaning and disinfecting
ings) should be used during the final stages of illness the healthcare environment [26]. The guideline
when hemorrhage may occur. The use of dedicated also addresses several new topics, including inac-
disposable medical equipment is preferred for tivation of antibiotic-resistant bacteria, bioterror-
patient care. All nondedicated, nondisposable ist agents, emerging pathogens, and bloodborne
equipment should be cleaned and disinfected pathogens; disinfection of patient-care equipment
after use. If possible, needles, sharps, and aerosol- used in ambulatory settings and home care; and
generating procedures should be avoided as much new sterilization processes, such as hydrogen per-
as possible, and the number of procedures and tests oxide gas plasma and liquid peracetic acid [26].
should be limited. Public health officials should be Various levels of cleaning and disinfection have
notified immediately if Ebola is suspected. been defined, and decontamination and cleaning
must be carried out before any of the higher level
processes (Table 2) [2; 26; 51]. The cleaning and
disinfection of devices varies according to the
Spaulding classification, which categorizes devices
as critical (i.e., enters normally sterile tissue or the
vascular system), semicritical (i.e., comes into con-
tact with intact mucous membranes and does not
ordinarily penetrate sterile tissue), or noncritical

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____________________________________________ #98641 Infection Control: The New York Requirement

DEFENITIONS OF LEVELS OF CLEANING AND DISINFECTION

Level Definition
Decontamination Use of a 0.5% chlorine solution to reduce the number of pathogenic organisms
on the device
Cleaning Use of soap and water to remove all visible dust, soil, blood, or other body fluids
Low-level disinfection Use of disinfectant to destroy pathogenic organisms (may not eliminate resistant
bacteria or most viruses or fungi)
Intermediate-level disinfection Use of disinfectant to destroy pathogenic organisms (eliminates most bacteria,
viruses, and fungi)
High-level disinfection Use of chemical disinfectants, boiling, or steaming to destroy all micro-organisms
Sterilization Use of high-pressure steam (autoclave), dry heat (oven), chemical sterilants,
or radiation to eliminate all forms of viable micro-organisms
Reprocessing A multistep procedure that consists of meticulous cleaning, high-level
disinfection with a liquid chemical sterilant or disinfectant, and proper drying
Source: [2; 26; 51] Table 2

(i.e., does not ordinarily touch a patient or touches Also, various steps in the procedure have been
only intact skin) [51; 64]. Critical devices require emphasized as being the most critical. For example,
sterilization, and semicritical devices require high- one report notes that meticulous mechanical clean-
level disinfection; noncritical devices may be ing is the most important step because it removes
cleaned with low-level disinfection [2; 37; 51; 64]. the majority of the contaminating bacteria [65].
Another report emphasizes the importance of
Endoscopic instruments present a challenge
drying to avoid waterborne bacteria, such as Pseu-
to proper reprocessing because of the complex
domonas aeruginosa [67].
internal design and long, narrow channels [2].
Reprocessing should be carried out by trained and A report of four patients with infection with P.
accredited personnel according to the manufac- aeruginosa after transrectal ultrasound-guided
turer’s recommendations, and the process should be prostate biopsies raised awareness about the need
monitored regularly for quality control [65]. Guide- for thorough cleaning of equipment. Evaluation
lines and recommendations for reprocessing of of the findings on the four patients demonstrated
gastrointestinal endoscopes have been developed that the infection was caused by contamination of
by several federal agencies, such as the U.S. Food the needle guide as a result of inadequate clean-
and Drug Administration (FDA) and the CDC, ing (with a brush) and improper rinsing (with tap
as well as many professional organizations [2; 37; water) after reprocessing [69]. The report led to
65; 66; 67; 68]. The reprocessing procedure should the FDA issuing a Public Health Notification on
begin immediately after use to prevent secretions proper reprocessing of such devices [70].
from drying [2; 26; 67; 68]. Reprocessing of bronchoscopes has received less
Some inconsistencies across reprocessing guide- attention, perhaps because of the low risk of infec-
lines and manufacturer recommendations have tion, but general recommendations, similar to
been found, primarily with regard to drying [67]. those for gastrointestinal endoscopes, are available
[21; 71].

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#98641 Infection Control: The New York Requirement _____________________________________________
CLEANING THE ENVIRONMENT Written policies should specify how frequently each
Every healthcare facility should have a written area should be cleaned and should note the clean-
housekeeping schedule for the routine cleaning ing agents used for various surfaces and items such
of the environment. Routine cleaning removes as beds, curtains, screens, fixtures, and furniture. In
so-called visible dirt, which can harbor micro- general, all surfaces in the environment (e.g., walls,
organisms. Soap and water can be used to remove doors, floors) must be cleaned daily to remove
visible dirt from most surfaces, such as walls, doors, soil. Sinks, toilets, and baths should be scrubbed
ceilings, and floors. A disinfectant should be used daily, or more often if needed, with a disinfectant
when there are signs of contamination. The level cleaning solution using a separate mop, brush, or
of asepsis in cleaning depends on the likelihood cloth. Patient rooms should also be cleaned daily
of contamination. WHO suggests classifying areas and after each patient is discharged. Surfaces and
within a healthcare facility into four zones [2]: countertops in procedure rooms, examination
rooms, and the laboratory must be cleaned with a
• Zone A: No patient contact disinfectant solution after any activity.
• Zone B: Care of patients who are not
infected and are not highly susceptible
The Association of periOperative
• Zone C: Infected patients (isolation units) Registered Nurses recommends that
• Zone D: Highly susceptible patients procedures for environmental cleaning
(protective isolation) or protected areas and disinfection should be established for
circumstances that may require special
such as operating suites, delivery rooms,
cleaning procedures (i.e., multidrug-
intensive care units, neonatal intensive resistant organisms, Clostridium difficile, prion diseases,
care, transplant units, oncology units, construction, environmental contamination).
and hemodialysis units (http://www.guideline.gov/content.aspx?id=47823.
Last accessed March 18, 2016.)
Cleaning according to this classification should be
as follows [2]: Strength of Recommendation: Expert Opinion/
Consensus Statement
• Zone A: Normal cleaning
• Zone B: Cleaning procedures that do
not raise dust. (Dry sweeping or vacuum Spills of blood or other body fluid should be
cleaners are not recommended.) Use a removed and cleaned immediately. The area should
detergent solution and disinfect any areas first be cleaned with a 0.5% chlorine solution and
with visible contamination with blood then washed clean with a disinfectant solution.
or body fluids before cleaning. Gloves should be worn while cleaning.
• Zone C: Cleaning with a detergent/ MANAGING WASTE
disinfectant solution, with separate Management of waste is a concern in healthcare
cleaning equipment for each room facilities, but 75% to 90% of waste poses no risk
• Zone D: Cleaning with a detergent/ of infection. The following types of waste are con-
disinfectant solution and separate sidered to be hazardous [2]:
cleaning equipment
• Infection-associated waste (from isolation
units, laboratory cultures, tissue swabs)
• Pathologic waste (blood, body fluids,
human tissue)
• Sharps (needles, scalpels, blades, knives)

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____________________________________________ #98641 Infection Control: The New York Requirement
• Pharmaceutical waste (expired Needles, cannulae, and syringes are sterile,
pharmaceutical agents) single-use items; they should not be reused
• Chemical waste (laboratory reagents, for multiple patients.
solvents) • Use fluid infusion and administration sets
• Heavy metal waste (broken blood (e.g., intravenous bags, tubing, connectors)
pressure gauges, batteries) for one patient only, and dispose appropri-
ately after use.
• Radioactive waste
• Use single-dose vials for parenteral
As with cleaning, written policies should document medications whenever possible.
the appropriate handling, storage, and transporta-
• If multidose vials must be used, both the
tion of all types of waste.
needle or cannula and syringe used to
access the multidose vial must be sterile.
SAFE INJECTION PRACTICES • Do not keep multidose vials in the
immediate patient treatment area, and
Infection prevention also includes safe injection store in accordance with the manufacturer’s
practices intended to prevent or reduce the risk recommendations. Discard if sterility is
of transmission of infectious diseases between one compromised or questionable.
patient and another or between a patient and
• Do not use bags or bottles of intravenous
healthcare provider. A safe injection does not harm
solution as a common source of supply for
the recipient, does not expose the provider to any
multiple patients.
avoidable risks, and does not result in waste that
is dangerous for the community [72].
Unsafe injection practices put patients and health- SURVEILLANCE
care providers at unnecessary risk. A wide variety
Surveillance is an essential component of an infec-
of procedures, such as the administration of anes-
tion control program. The infection control team
thetics for outpatient procedures, the administra-
has traditionally conducted surveillance through
tion of other IV medications, flushing IV lines or
open communication with the nursing staff and
catheters, and the administration of IM vaccines,
physicians and meticulous review of patient records
have been associated with unsafe injection [72].
and microbiology results. The advent of electronic
Outbreaks related to these practices indicate that
health systems has enabled some infection control
some healthcare personnel do not adhere to basic
programs to create algorithm-driven surveillance
principles of infection control and aseptic tech-
[1]. In addition, newer technology is adding to
nique. A survey of U.S. healthcare professionals
changes in the way surveillance is conducted.
who provide medication through injection found
An electronic, laboratory-based marker has been
that 1% to 3% reused the same needle and/or
developed and compared with traditional medical
syringe on multiple patients [17].
record review and hospital-wide detection methods
The following guidelines should be considered with (Study on the Efficacy of Nosocomial Infection
regards to injection practices [17]: Control chart review and intensive care unit
• Use aseptic technique to avoid contam­ detection by NNIS techniques). Analysis with the
ination of sterile injection equipment. marker was significantly better than the hospital-
wide detection methods and had sensitivity com-
• Never administer medications from a
parable to medical record review [73].
syringe to multiple patients, even if the
needle or cannula on the syringe is changed.

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#98641 Infection Control: The New York Requirement _____________________________________________
The infections most commonly targeted for surveil- • A certificate of immunization against rubella
lance are those difficult to treat and those associ- and measles (or professionally certified
ated with substantial costs in terms of morbidity, medical exemption from immunization)
mortality, or economics [1]. In addition, infections • A purified protein derivative (PPD)
with a predilection for epidemics are a focus. The (Mantoux) skin test for tuberculosis prior
data gathered should be evaluated in relation to to employment, and no less than every
regional and national norms, and temporal trends year thereafter for negative findings.
should also be noted. Continuing analysis of the Positive findings require appropriate
data allows the infection control team to evaluate clinical follow-up but no repeat test.
the efficacy of programs designed to enhance com- • An annual (or more frequent, if needed)
pliance with hospital-wide strategies to prevent health status assessment to ensure freedom
HAIs. from any health impairment that might pose
EXPOSURE INCIDENTS a risk for other workers, patients, or visitors
If an occupational exposure to a bloodborne • Documentation of pre-employment and
pathogen or infectious material occurs, employers annual vaccination against influenza
should follow all federal (including the Occupa- Screening tests are available to determine suscep-
tional Safety and Health Administration) and tibility to vaccine-preventable diseases, such as
state requirements for recording and reporting. measles, mumps, rubella, and varicella. The results
The circumstances surrounding the exposure and of these tests should be included in personnel
postexposure management strategies should be immunization records to ensure that susceptible
recorded in the exposed person’s confidential medi- personnel are promptly identified and appropri-
cal record and should include [74]: ately vaccinated. All healthcare settings should
• Date and time of exposure conduct initial and ongoing risk assessments for the
transmission of tuberculosis to determine the types
• Details of the procedure performed
of administrative, environmental, and respiratory-
• Details of the exposure protection controls needed. Part of the assessment
• Details about the exposure source should include risk classification to determine the
• Details about the exposed person and need for a screening program and the frequency
any need for counseling, postexposure of screening. All healthcare professionals with
management, or follow-up suspected or confirmed tuberculosis disease who
have duties that involve face-to-face contact with
patients should be included in a screening program
COMMUNICABLE DISEASE [76].
EXPOSURES IN HEALTHCARE All healthcare professionals experiencing fever,
PROFESSIONALS cough, rash, vesicular lesions, draining wounds,
vomiting, or diarrhea require immediate evalua-
PREPLACEMENT EVALUATIONS tion by a licensed medical professional and possible
AND PERIODIC HEALTH ASSESSMENTS restriction from patient care activities and return to
Medical evaluations before placement may reduce work clearance [75]. The CDC recommends that
the undue risk of infection to employees, patients, all healthcare personal obtain annual influenza
and visitors. A health inventory for all new health- vaccination to reduce infection of staff, patients,
care professionals who have direct patient/family and family members and to decrease absenteeism
contact must be documented prior to the beginning [101]. Immunization against hepatitis B and per-
of patient/family contact. The inventory should tussis (Tdap), in addition to all core vaccines, is
include [15; 75]:

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____________________________________________ #98641 Infection Control: The New York Requirement
also recommended [86]. Vaccination of healthcare trol education program on MRSA that included
personnel is considered an essential component of discussion of hospital-specific MRSA data and
a patient safety program [101]. case-based practice [81].
Management Strategies It is important that all education campaigns,
whether they target healthcare professionals, facil-
Prompt diagnosis and management of job-related
ity staff (e.g., janitorial staff), or the patient popula-
illnesses, appropriate postexposure prophylaxis,
tions, take into consideration the special needs of
and implementation of measures to prevent fur-
the intended audience. Compounding this issue is
ther infection transmission are important aspects
the high rate of individuals with limited English
of an effective infection control program. Exclu-
proficiency. According to the U.S. Census Bureau
sion of personnel from work or patient contact,
data from 2013, more than 60 million Americans
depending on the mode of transmission and the
(or 21%) speak a language other than English at
pathogenesis of the disease, may also be necessary.
home, and approximately 42% of these individuals
In these cases, personnel should avoid contact with
speak English less than “very well” [82]. Even those
susceptible persons and should be encouraged to
who do speak English well may prefer to receive
report illnesses or exposures, including any that
education in another language.
occur outside the healthcare setting. Notification
of emergency response personnel possibly exposed POSTEXPOSURE EVALUATION
to selected infectious diseases is mandatory [75]. AND MANAGEMENT
Education on best practices is a crucial aspect of When a healthcare provider has been exposed to
preventing HAIs and is a recommendation in all particular infectious agents, it is important that
infection control guidelines [2; 9; 17; 25; 26; 28; recommended postexposure management guide-
29; 31; 32; 33; 36; 38]. Education should highlight lines are followed. This should reduce the risk
the effect of prevention measures on the rates of of infection and of transmitting the infection to
HAIs, enhance knowledge about currently avail- others [75].
able guidelines, and provide instruction on carry-
ing out guideline recommendations. Research has Bloodborne Pathogens
also suggested that education about prevention Transmission of bloodborne pathogens due to
strategies may be more effective if patterns of care occupational exposure of healthcare professionals
and levels of risk are incorporated into recom- has occurred in needlestick accidents (0.3% risk)
mendations [77]. Numerous studies have shown and blood splashes to the mucous membranes
that knowledge and practices related to HAIs (0.09% risk) [84]. Needlestick is the most com-
and guidelines are improved after educational mon route,but the risk of infection even through
programs. The combination of a self-study module this route is low, and most exposures do not result
(with pretest and post-test), in-service lectures, in infection [83; 84]. The risk for transmission
posters, and fact sheets on the prevention of intra- increases based on the source patient’s viral load
vascular device-related bloodstream infections and and the quantity of blood transferred (e.g., a needle
appropriate practices led to substantial reductions visibly contaminated with blood; a large-gauge
in the prevalence of such infections [78; 79]. A hollow-bore needle; a procedure that involved the
small study showed that intensive care nurses’ needle entering directly into the patient’s artery
knowledge and practices were enhanced by edu- or vein; a deep puncture from a contaminated
cation on the prevention of ventilator-associated needle). In order to decrease the risks associated
pneumonia [80]. A Canadian study demonstrated with bloodborne pathogen exposures, postexposure
that rates of nosocomial MRSA infection signifi- prophylaxis should be initiated as soon as possible
cantly decreased after a mandatory infection con- after the incident.

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#98641 Infection Control: The New York Requirement _____________________________________________
Hepatitis Viruses The following recommendations apply to situ-
Recommendations for HBV postexposure manage- ations where healthcare professionals have had
ment include initiation of the hepatitis B vaccine exposure to a source person with HIV or where
series to any susceptible, unvaccinated person information suggests that there is likelihood that
who sustains an occupational blood or body fluid the source person is HIV-infected. Because most
exposure. Postexposure prophylaxis with hepatitis occupational HIV exposures do not result in the
B immune globulin (HBIG) and/or hepatitis B vac- transmission of HIV, potential toxicity should be
cine series should be considered for occupational carefully considered when prescribing postexposure
exposures after evaluation of the hepatitis B surface prophylaxis. The 2013 update focused on toler-
antigen status of the source as well as the vaccina- ability, side effects, toxicity, safety in pregnancy
tion and vaccine-response status of the exposed and lactation, pill burden, and frequency of dos-
person [74]. ing to maximize adherence to a postexposure
prophylaxis (PEP) regimen [84]. When possible,
Immune globulin and antiviral agents (e.g., inter- these recommendations should be implemented
feron with or without ribavirin) are not recom- in consultation with persons having expertise in
mended for postexposure prophylaxis of HCV. antiretroviral therapy and HIV transmission, due to
In this instance, the HCV status of the source the complexity of selecting appropriate treatment.
and the exposed person should be determined.
For healthcare professionals exposed to an HCV- The preferred regimen for PEP provided in the U.S.
positive source, follow-up HCV testing should be Public Health Service Guidelines for management
performed to determine if infection develops [74]. of healthcare professionals’ exposures to HIV is a
basic regimen that should be appropriate for most
Healthcare professionals exposed to hepatitis HIV exposures: emtricitabine and tenofovir dis-
viruses should refrain from donating blood, plasma, pensed together as Truvada, a fixed-dose combina-
organs, tissue, or semen [74]. When based only on tion tablet, 1 mg once daily, plus raltegravir, 400
exposure to HBV- or HCV-positive blood, modi- mg twice daily [84]. This preparation is available
fications to an exposed healthcare professional’s as a starter packet that should be stocked at every
patient-care responsibilities are not necessary. healthcare facility where exposure to HIV is pos-
Acutely infected healthcare professionals should be sible. As discussed, the regimen has been selected
evaluated according to current guidelines; health- for its tolerability and safety profile. There are
care professionals chronically infected with HBV several alternative regimens that may be selected
or HCV should follow all recommended infection due to individual patient concerns. For example,
control practices [74]. tenofovir is associated with renal toxicity, and
HIV an alternative nucleoside/nucleotide reverse-
transcriptase inhibitor pair, such as zidovudine
This section is from the Updated U.S. Public Health
plus lamivudine (available as Combivir) would be
Service Guidelines for the Management of Occupa-
selected for patients with renal disease [84].
tional Exposures to HIV and Recommendations for
Postexposure Prophylaxis as published by the CDC on
September 25, 2013 in Infection Control and Hospital
Epidemiology [84].

20 NetCE • May 6, 2016 www.NetCE.com

____________________________________________ #98641 Infection Control: The New York Requirement
Healthcare professionals with occupational expo- be obtained to exclude tuberculosis [85]. If either
sure to HIV should receive follow-up counseling, the symptom screen or the BAMT result is posi-
postexposure testing, and medical evaluation tive, the exposed healthcare professional should be
regardless of whether they receive PEP. The 2013 promptly evaluated for tuberculosis. If tuberculosis
guideline highlights the importance of follow- is excluded, additional medical and diagnostic eval-
up within 72 hours to allow the initial shock to uations for latent tuberculosis infection, including
fade and to provide greater opportunity for full an assessment of the extent of exposure, should be
understanding of the risks and benefits of PEP; obtained [76; 85]. Healthcare professionals with
confirmation testing to ensure the necessity of PEP; active tuberculosis should be excluded from duty
increase adherence to PEP; monitoring for adverse until proved noninfectious [75].
reactions and side effects; and treating comorbidi-
ties and altering the regimen [84]. This window Measles
provides an opportunity to discuss the importance According to the CDC and Hospital Infec-
of preventing secondary transmission of HIV in tion Control Practices Advisory Committee
the 6 to 12 weeks following initial infection. HIV- (HICPAC), postexposure measles vaccine should
antibody testing should be performed for at least six be administered to measles-susceptible personnel
months postexposure (e.g., at 6 weeks, 12 weeks, who have had contact with persons with measles
and 6 months). It is unclear whether an extended within 72 hours postexposure [75]. Furthermore,
follow-up period (e.g., 12 months) is indicated for adherence to Airborne Precautions (for suspected
individuals not coinfected with HCV and HIV. If and proven cases) is also necessary. Healthcare pro-
PEP is used, drug-toxicity monitoring should be fessionals without evidence of immunity who are
performed at baseline and again two weeks after not vaccinated after exposure should be removed
starting PEP. Clinical judgment, based on medical from all patient contact and furloughed from day
conditions that may exist in pre-exposure and/or 5 after first exposure through day 21 after last
as a result of the regimen, should determine the exposure [86].
scope of testing. If the source patient is found to
Mumps
be HIV negative, PEP should be discontinued
immediately [84]. The CDC and HICPAC have also established
postexposure protocols for mumps. The mumps
Airborne/Droplet Pathogens vaccine should be administered to all personnel
Tuberculosis without documented evidence of mumps immu-
nity, unless otherwise contraindicated [75; 86].
Healthcare professionals with known or presumed Routine serologic screening is not necessary unless
exposure to Mycobacterium tuberculosis should be the healthcare professional considers screening
asked whether they have experienced any signs or cost-effective or requests it. Susceptible personnel
symptoms of tuberculosis (i.e., coughing for more who are exposed to mumps should not work from
than three weeks, loss of appetite, unexplained the 12th day after first exposure through the 25th
weight loss, night sweats, bloody sputum, hoarse- day after last exposure or, if symptoms develop,
ness, fever, fatigue, or chest pain). Because a blood until five days after onset of parotitis [86].
assay for M. tuberculosis (BAMT) conversion likely
indicates recent infection, a BAMT result should

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#98641 Infection Control: The New York Requirement _____________________________________________
Pertussis Serologic screening is indicated for exposed per-
The CDC and HICPAC guideline indicates that sonnel who have not had varicella or are unvac-
antimicrobial prophylaxis against pertussis should cinated; screening for immunity to varicella may
be immediately offered to personnel who have had be considered for exposed, vaccinated personnel
unprotected, intensive contact with a patient who whose antibody status is not known [75; 86]. If the
has clinical syndrome that suggests pertussis and initial test result is negative, retest five to six days
whose cultures are pending [75; 86]. Other health- postexposure to determine whether an immune
care personnel should either receive postexposure response occurred.
antimicrobial prophylaxis or be monitored daily All exposed susceptible personnel should receive
for 21 days after exposure and treated at the onset postexposure prophylaxis [86]. If VZIG is given,
of signs and symptoms [86]. Prophylaxis may be exclude personnel from duty from the 8th day
discontinued if results of cultures or other tests after first exposure through the 28th day after last
are negative for pertussis and the clinical course exposure.
suggests an alternate diagnosis.
Norovirus
Rubella
Although the most frequent routes of transmis-
Susceptible personnel who are exposed to rubella sion of noroviruses are direct contact and food
should be excluded from duty from the 7th day and waterborne routes, several reports suggest that
after first exposure through the 23rd day after noroviruses may be transmitted through infectious
last exposure [75; 86]. Those who acquire rubella small-particle aerosols (e.g., vomitus, fecal mate-
should not work until seven days after the begin- rial) over distances further than 3 feet, typically
ning of the rash. within a defined airspace (e.g., a patient’s room)
Varicella [87; 88; 89; 90]. It is hypothesized that the aerosol-
ized particles are inhaled and subsequently swal-
The Advisory Committee on Immunization Prac-
lowed. Because of its propensity for transmission
tices (ACIP) recommends postexposure prophy-
within healthcare facilities, and its ability to have a
laxis (with vaccination or varicella-zoster immuno-
disruptive impact in healthcare facilities, norovirus
globulin [VZIG], depending on immune status) of
is an “epidemiologically important organism” [17].
exposed healthcare personnel without evidence of
immunity [86]. Healthcare professionals who have The average incubation period for gastroenteritis
onset of varicella should be furloughed until all caused by noroviruses is 12 to 48 hours, with a
lesions have dried and crusted. Personnel exposed clinical course lasting 12 to 60 hours. There are
to varicella who are not known to be immune (by no recommendations for postexposure prophylaxis
history or serology) should be excused from work for healthcare personnel with norovirus infection.
beginning on the 8th day after first exposure until However, recommendations for healthcare person-
the 21st day after last exposure. nel who have symptoms consistent with norovirus
infection include exemption from work for a mini-
Immunocompetent personnel with localized zoster
mum of 48 hours after the resolution of symptoms
should refrain from the care of high-risk patients
and exclusion of nonessential staff from areas in
until lesions are crusted. They may continue to
which outbreaks of norovirus gastroenteritis have
care for other patients with lesions covered [75].
occurred [17; 91].
Susceptible personnel exposed to zoster should
not engage in patient contact from the 8th day
after first exposure through the 21st day after last
exposure (or 28th day if VZIG was given) [75; 86].

22 NetCE • May 6, 2016 www.NetCE.com

____________________________________________ #98641 Infection Control: The New York Requirement

NEW YORK DEPARTMENT OF HEALTH POLICY FOR

TESTING POSSIBLE HIV SOURCES IN THE HEALTHCARE SETTING
Postexposure prophylaxis (PEP) is recommended for healthcare professionals following exposure to blood or visibly
bloody fluid or other potentially infectious material associated with potential HIV transmission.
If HIV serostatus of the source is unknown, voluntary HIV testing of the source should be sought. In New York State,
specific informed consent for HIV testing is required.
Rapid testing with an approved fourth-generation antigen/antibody combination assay is strongly recommended
for the source patient and for those organizations subject to OSHA regulations; rapid testing (versus standard testing)
is mandated for occupational exposures. Rules regarding confidentiality and consent for testing are identical to those
for other HIV tests. Plasma HIV RNA testing is recommended in certain instances.
If the rapid test result is positive, the result should be given to the source patient. To establish a diagnosis of HIV
infection, the test must be confirmed by an antibody-differentiation assay, which should be performed as soon as possible.
If the result from testing the source patient is not immediately available or a complete evaluation of the exposure
is unable to be made within two hours of the exposure, PEP should be initiated while source testing and further
evaluation are underway.
Source: [27] Table 3

Cohorting of affected patients to separate airspaces major life activities, has a record of such impair-
and toilet facilities may help interrupt transmission ment, or is regarded as having such impairment
during outbreaks. Contact Precautions should be [93]. Persons with HIV disease, both symptomatic
used for diapered or incontinent persons for the and asymptomatic, have physical impairments that
duration of illness or to control outbreaks. Con- substantially limit one or more major life activities
sistent environmental cleaning and disinfection and are, therefore, protected by the law. Persons
is important, with focus on restrooms even when who are discriminated against because they are
apparently unsoiled. Persons who clean heavily regarded as being HIV-positive are also protected.
contaminated areas may benefit from wearing In 2010, the Society for Healthcare Epidemiology
masks, as the virus can be aerosolized [17]. of America (SHEA) updated its guidelines for the
HEALTHCARE PROFESSIONALS management of healthcare professionals who are
INFECTED WITH BLOODBORNE infected with bloodborne pathogens [92]. Accord-
PATHOGENS ing to these guidelines, healthcare providers with
HBV, HCV, and/or HIV with greater viral loads
Routine voluntary, confidential testing has been
(≥104 genome equivalents/mL for hepatitis viruses,
recommended for all healthcare providers, particu-
≥5 x 102 genome equivalents/mL for HIV) should
larly for those whose clinical practice places them
be restricted from performing activities associated
at higher risk for exposure and transmission [92].
with a definite risk for provider-to-patient trans-
The New York Department of Health has devel-
mission of bloodborne pathogens, such as most
oped a policy regarding HIV testing of healthcare
surgeries, organ transplantation, and interactions
professionals (Table 3) [27]. It is important to note
with patients prone to biting [92]. These provid-
that New York State Public Health Law protects
ers may engage in procedures for which the risk of
the confidentiality and privacy of anyone who has
transmission is insignificant (e.g., history taking,
been tested for, exposed to, or treated for HIV [27].
regular dental preventive procedures, minor surface
In addition, according to the Americans with Dis-
suturing) or unlikely (e.g., locally anesthetized
abilities Act, an individual is considered to have
ophthalmologic surgery, percutaneous cardiac pro-
a disability if he or she has a physical or mental
cedures, breast augmentation, minor oral surgery).
impairment that substantially limits one or more
Routine double gloving is also recommended [92].

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#98641 Infection Control: The New York Requirement _____________________________________________
Infected healthcare professionals with lower viral
burdens (<104 genome equivalents/mL of hepatitis CONCLUSION
viruses, <5 x 102 genome equivalents/mL for HIV)
An effective infection control team is critical to
may engage in all clinical activities [92]. However,
reducing the incidence of HAIs in a healthcare
all healthcare providers with a bloodborne patho-
facility. All departments within a healthcare facil-
gen must obtain advice from an expert review
ity should be represented on this team to ensure
panel about continued practice, undergo follow-up
widespread adherence to prevention measures.
routinely by an appropriate public health official,
The responsibilities of an infection control team
receive follow-up by a personal physician who has
are to conduct surveillance of infections; ensure
expertise in the management of the infection, and
compliance with infection control guidelines,
adhere to strict infection control procedures [92].
including those for management of drug-resistant
Those with low viral burdens should undergo test-
organisms; and establish response and control plans
ing twice per year to demonstrate maintenance of
for outbreaks and epidemics. Most important is
viral level.
the development of an organizational culture that
fosters a focus on patient safety and that empha-
According to the CDC, healthcare sizes education on HAIs and infection control for
providers with active hepatitis B infection healthcare professionals and patients and their
(i.e., those who are HBsAg-positive) who
families.
do not perform exposure-prone procedures
but who practice non- or minimally
invasive procedures should not be subject
to any restrictions of their activities or study. They
do not need to achieve low or undetectable levels of
circulating HBV DNA, hepatitis e-antigen negativity,
or have review and oversight by an expert review panel,
as recommended for those performing exposure-prone
procedures.
(http://www.guidelines.gov/content.aspx?id=37873.
Last accessed March 18, 2016.)
Strength of Recommendation: Expert Opinion/
Consensus Statement

24 NetCE • May 6, 2016 www.NetCE.com

____________________________________________ #98641 Infection Control: The New York Requirement
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