Standard 3: Healthcare Associated Infection

Standard and transmission-based precautions

Action 3.5

The health service organisation has processes to apply standard and transmission-based precautions that are consistent with the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare,and jurisdictional requirements

Intent

The risk of infection to patients, the workforce and visitors is minimised by the routine application of basic infection prevention and control strategies.

Reflective question

How does the health service organisation ensure that its standard and transmission-based precautions are consistent with the Australian Guidelines for the Prevention and Control of Infection in Healthcare1, and with state or territory requirements?

Key tasks

  • Use information from risk management systems to identify strategies to reduce the risks of healthcare-associated infections.
  • Review current policies, procedures and protocols to ensure that they align and comply with the Australian Guidelines for the Prevention and Control of Infection in Healthcare and jurisdictional requirements.
  • Provide access to the equipment, supplies and products required to comply with standard and transmission-based precautions.
  • Use the results of risk assessment processes to set priorities for assessment of workforce compliance with standard and transmission-based precautions.
  • Include the expectations of the workforce regarding infection prevention and control activities, including application of standard and transmission-based precautions, in the organisation’s workforce orientation program.

Strategies for improvement

Hospitals

Ensure that the Australian Guidelines for the Prevention and Control of Infection in Healthcare and relevant state or territory requirements are available and accessible to the workforce when reviewing practice, policy and procedures.

Ensure that policies, procedures and protocols respond to areas in which there is the greatest risk of infection transmission. Work with individuals, services and committees to identify where risks have been identified, and where changes need to occur or improvements can be made to respond to risks.

Ensure that the equipment, supplies and products required by the workforce to work safely and minimise the risk of infection transmission are accessible, located where required and appropriate to the risks identified for that clinical area.

Based on information from the risk management systems, identify and set priorities for when, where and how compliance with standard and transmission-based precautions can be monitored, assessed and reviewed. Activities may include:

  • Auditing hand hygiene
  • Auditing putting on and removal of personal protective equipment
  • Prioritising competency assessment for aseptic technique to members of the workforce who have been identified as high risk
  • Assessing compliance with the requirements of transmission-based precautions when applied to a specific infection risk
  • Reviewing surveillance data on healthcare-associated infections
  • Reviewing incident reports relating to
    • infection prevention and control issues
    • intravascular devices
    • sharps and waste management
    • occupational exposures
    • biological spills and environmental cleaning.

Review or develop workforce education and orientation programs to include key aspects of standard and transmission-based precautions.

Evaluate attendance at, and content of, the orientation or induction programs for the workforce.

Develop or review signage, alert systems, and information/reminder systems and resources to raise awareness of standard and transmission-based precautions, and ensure consistency with the Australian Guidelines for the Prevention and Control of Infection in Healthcare.

Have a management plan that can operate during localised outbreaks or periods when infections may be common (for example, seasonal influenza or local outbreaks of viral gastroenteritis) that:

  • Identifies possible cases
  • Implements other treatment options (for example, rescheduling procedures)
  • Advises about exclusion periods for elective procedures
  • Suggests management options for suspected or confirmed infections that may be transmissible
  • Reduces impacts on treatment and recovery
  • Addresses workforce occupational risk.
Day Procedure Services

Ensure that the Australian Guidelines for the Prevention and Control of Infection in Healthcare and relevant state or territory requirements are available and accessible to the workforce when reviewing practice, policy and procedures.

Ensure that policies, procedures and protocols respond to areas in which there is the greatest risk of infection transmission. Work with individuals, services and committees to identify where risks have been identified, and where changes need to occur or improvements can be made to respond to risks.

Ensure that the equipment, supplies and products required by the workforce to work safely and minimise the risk of infection transmission are accessible, located where required and appropriate to the risks identified for that clinical area.

Based on information from the risk management systems, identify and set priorities for when, where and how compliance with standard and transmission-based precautions can be monitored, assessed and reviewed. Activities may include:

  • Auditing hand hygiene
  • Auditing putting on and removal of personal protective equipment
  • Prioritising competency assessment for aseptic technique to members of the workforce who have been identified as high risk
  • Assessing compliance with the requirements of transmission-based precautions when applied to a specific infection risk
  • Reviewing surveillance data on healthcare-associated infections
  • Reviewing incident reports relating to
    • infection prevention and control issues
    • intravascular devices
    • sharps and waste management
    • occupational exposures
    • environmental cleaning and biological spills.

Review or develop workforce education and orientation programs to include key aspects of standard and transmission-based precautions. Evaluate attendance at, and content of, the orientation or induction programs for the workforce.

Develop or review signage, alert systems, and information/reminder systems and resources to raise awareness of standard and transmission-based precautions, and ensure consistency with the Australian Guidelines for the Prevention and Control of Infection in Healthcare.

Have a management plan that can operate during localised outbreaks or periods when infections may be common (for example, seasonal influenza or local outbreaks of viral gastroenteritis) that:

  • Identifies possible cases
  • Implements other treatment options (for example, rescheduling procedures)
  • Advises about exclusion periods for elective procedures
  • Suggests management options for suspected or confirmed infections that may be transmissible
  • Reduces impacts on treatment and recovery
  • Addresses workforce occupational risk.

Examples of evidence

Select only examples currently in use:

  • Policy documents about standard and transmission-based precautions that are consistent with the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare and are available to the workforce
  • Audit results of workforce compliance with standard and transmission-based precautions
  • Training documents about standard and transmission-based precautions
  • Examples of improvement activities that have been implemented and evaluated to improve compliance with, and raise awareness of, standard and transmission-based precautions
  • Committee and meeting records in which compliance with, and incidents relating to, standard and transmission-based precautions were discussed
  • Observation of standardised signage and other information resources consistent with the Australian Guidelines for the Prevention and Control of Infection in Healthcare.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established standard and transmission-based precautions systems.

Small hospitals that are not part of a local health network or private hospital group should:

  • Use information from risk management systems to identify strategies to reduce the risks of healthcare-associated infections
  • Review current policies, procedures and protocols to ensure that they align and comply with the Australian Guidelines for the Prevention and Control of Infection in Healthcare and state or territory requirements
  • Provide access to the equipment, supplies and products required to comply with standard and transmission-based precautions
  • Use the results of risk assessment processes to set priorities for assessment of workforce compliance with standard and transmission-based precautions
  • Include the expectations of the workforce regarding infection prevention and control activities, including application of standard and transmission-based precautions, in the organisation’s workforce orientation program.

Ensure that the Australian Guidelines for the Prevention and Control of Infection in Healthcare and relevant state or territory requirements are available and accessible to the workforce when reviewing practice, policy and procedures.

Based on information from the risk management systems, identify and set priorities for when, where and how compliance with standard and transmission-based precautions can be monitored, assessed and reviewed. Activities may include:

  • Auditing hand hygiene
  • Auditing putting on and removal of personal protective equipment
  • Prioritising competency assessment for aseptic technique to members of the workforce who have been identified as high risk
  • Assessing compliance with the requirements of transmission-based precautions when applied to a specific infection risk
  • Reviewing surveillance data on healthcare-associated infections
  • Reviewing incident reports relating to
    • infection prevention and control issues
    • intravascular devices
    • sharps and waste management
    • occupational exposures
    • environmental cleaning and biological spills.

Develop or review signage, alert systems, and information/reminder systems and resources to raise awareness of standard and transmission-based precautions, and ensure consistency with the Australian Guidelines for the Prevention and Control of Infection in Healthcare.

Have a management plan that can operate during localised outbreaks or periods when infections may be common (for example, seasonal influenza or local outbreaks of viral gastroenteritis) that:

  • Identifies possible cases
  • Implements other treatment options (for example, rescheduling procedures)
  • Advises on exclusion periods for elective procedures
  • Suggests management options for suspected or confirmed infections that may be transmissible
  • Reduces effect on treatment and recovery
  • Addresses workforce occupational risk.

Action 3.6

Clinicians assess infection risks and use transmission-based precautions based on the risk of transmission of infectious agents, and consider:

a. Patients’ risks, which are evaluated at referral, on admission or on presentation for care, and reevaluated when clinically required during care

b. Whether a patient has a communicable disease, or an existing or a pre-existing colonisation or infection with organisms of local or national significance

c. Accommodation needs to manage infection risks

d. The need to control the environment

e. Precautions required when the patient is moved within the facility or to external services

f. The need for additional environmental cleaning or disinfection

g. Equipment requirements

Intent

Exposure of other patients or the workforce to infectious agents that cannot be contained by standard precautions alone is minimised. Risk is assessed at all access opportunities to the health service organisation, and necessary precautions are implemented and maintained for as long as necessary.

Reflective questions

How do clinicians decide on the need to apply transmission-based precautions?

How do clinicians assess and manage infection risks when a patient presents for care?

Key tasks

  • Use the results of the organisational risk assessment and gap analysis to identify priority areas for review, action or monitoring.
  • Review and use surveillance data to identify which communicable diseases, emerging risks or infectious agents of local, national or international significance affect the health service organisation, patients and the workforce.
  • If available, use national systems and definitions to collect surveillance data on infectious agents.
  • Identify the systems that are already in place to manage the risk of transmission of these infectious agents.
  • Set up or review the processes for communicating risks and risk management strategies to clinical areas or units, services or facilities (internal and external) that may be involved in the care of the patient.

Strategies for improvement

Hospitals

Review and assess the organisation’s processes that will inform risk management strategies to minimise exposure of patients, the workforce and the organisation to infectious agents. These include:

  • How the risk of infection or communicable disease is assessed on admission, on referral or on presentation for care in the organisation
  • What processes are in place to reassess the risks when clinically indicated during care
  • How infection risks are acted on, if identified
  • What processes are in place to inform the workforce or external services of a risk of an infectious agent or communicable disease
  • How contracts and service performance of any external providers of goods and services are reviewed.

Information sources to help with this assessment may include:

  • Data on waiting times for admission, movement through the emergency department and delays in patient placement because of a lack of appropriate accommodation, resources and equipment
  • Pathology reports on infectious agents of local, national or international significance that require transmission-based precautions
  • Surveillance data and reports from the organisation and other sources (for example, national, or state or territory surveillance reports) that have been gathered using national systems and definitions (if available)
  • Incident reports relating to possible transmission of infectious agents
  • Consumer feedback reports
  • Maintenance or service history and pathology reports to identify appropriate monitoring of air-handling systems, water supply systems and other relevant equipment
  • Data on cleaning and disinfection regimes.

Develop strategies to respond to any risks identified as part of the review, or any risks identified as part of a public health response or pandemic planning.

Include identified risks in the organisation’s quality improvement program so that actions and outcomes are monitored, measured, assessed and reported to leadership, the workforce and consumers. If appropriate, report recommendations to external departments, facilities or services that may be involved in the care of the patient.

If the health service organisation is part of a larger organisation or corporate group, refer to their policies, procedures and protocols for managing and communicating risk of infectious agents of local, national and international significance.

The Australian Guidelines for the Prevention and Control of Infection in Healthcare1 provide detailed information about risk assessment processes for infection prevention and control.

Day Procedure Services

Review and assess the organisation’s processes that will inform risk management strategies to minimise exposure of patients, the workforce and the organisation to infectious agents. These include:

  • How the risk of infection or communicable disease is assessed on admission, on referral or on presentation for care in the organisation
  • What processes are in place to reassess the risks when clinically indicated during care
  • How infection risks are acted on, if identified
  • What processes are in place to inform the workforce or external services of a risk of an infectious agent or communicable disease
  • How contracts and service performance of any external providers of goods and services are reviewed.

Information sources to help with this assessment may include:

  • Data on waiting times for admission, rescheduling of procedures and delays in patient placement because of a lack of appropriate accommodation, resources and equipment
  • Pathology reports on infectious agents of local, national or international significance that require transmission-based precautions
  • Surveillance data and reports from the organisation and other sources (for example, corporate, national, or state and territory surveillance reports) that have been gathered using national systems and definitions (if available)
  • Incident reports relating to possible transmission of infectious agents
  • Consumer feedback reports
  • Maintenance or service history and pathology reports to identify appropriate monitoring of air-handling systems, water supply systems and other relevant equipment
  • Data on cleaning and disinfection regimes.

Develop strategies to respond to any risks identified as part of the review, or any risks identified as part of a public health response or pandemic planning.

Include identified risks in the organisation’s quality improvement program so that actions and outcomes are monitored, measured, assessed and reported to leadership, the workforce and consumers. If appropriate, report recommendations to other services and clinicians that may be involved in the care of the patient.

If the day procedure service is part of a larger organisation or corporate group, refer to its policies, procedures and protocols for managing and communicating risk of infectious agents of local, national and international significance.

The Australian Guidelines for the Prevention and Control of Infection in Healthcare1 provide detailed information about risk assessment processes for infection prevention and control.

Examples of evidence

Select only examples currently in use:

  • Policy documents about the assessment of infection risks and implementation of transmission-based precautions to manage the risks
  • Patient referral or admission documentation that demonstrates assessment of infection risks and precautions to manage risks
  • Committee and meeting records in which infection risks and precautions to manage them were discussed
  • Audit results of the use of precautions for infection risks
  • Training documents about assessing infection risks and precautions to manage the risks
  • Examples of activities that have been implemented and evaluated to improve assessment and management of infection risks
  • Observation that relevant equipment, including personal protective equipment, is available to the workforce
  • Observation of physical and environmental controls for managing the risk of transmission of infectious agents
  • Cleaning schedules that outline further requirements associated with infection risk
  • List of communicable diseases or infectious agents of local or national significance that affect the health service organisation, patients and the workforce
  • Examples of communication with the workforce and patients about the risk of infectious agents and communicable diseases, and measures that can be used to reduce the risks.
MPS & Small Hospitals

MPSs and small hospitals should:

  • Use the results of the organisational risk assessment and gap analysis to identify priority areas for review, action or monitoring
  • Review and use surveillance data to identify which communicable diseases, emerging risks, or infectious agents of local, national or international significance affect the health service organisation, patients and the workforce
  • If available, use national systems and definitions to collect surveillance data on infectious agents
  • Identify the systems that are already in place to manage the risk of transmission of these infectious agents
  • Set up or review the processes for communicating risks and risk management strategies to clinical areas or units, services or facilities (internal and external) that may be involved in the care of the patient.

Review and assess the organisation’s processes that will inform risk management strategies to minimise exposure of patients, the workforce and the organisation to infectious agents. These include:

  • How the risk of infection or communicable disease is assessed on admission, on referral or on presentation for care in the organisation
  • What processes are in place to reassess the risks when clinically indicated during care
  • How infection risks are acted on, if identified
  • What processes are in place to inform the workforce or external services of the risk of an infectious agent or communicable disease
  • How contracts and service performance of any external providers of goods and services are reviewed.

Information sources to help with this assessment may include:

  • Data on waiting times for admission, movement through clinics or the emergency department, and delays in patient placement because of a lack of appropriate accommodation, resources and equipment
  • Pathology reports on infectious agents of local, national or international significance that require transmission-based precautions
  • Surveillance data and reports from the organisation and other sources (for example, national, state or territory surveillance reports) that have been gathered using national systems and definitions (if available)
  • Incident reports relating to possible transmission of infectious agents
  • Consumer feedback reports
  • Maintenance or service history and pathology reports to identify appropriate monitoring of air-handling systems, water supply systems and other relevant equipment
  • Data on cleaning and disinfection regimes.

The Australian Guidelines for the Prevention and Control of Infection in Healthcare provide detailed information about risk assessment processes for infection prevention and control.

Action 3.7

The health service organisation has processes for communicating relevant details of a patient’s infectious status whenever responsibility for care is transferred between clinicians or health service organisations

Intent

A patient’s known or suspected colonisation or infection risks are communicated to an admitting, transferring or referring facility to minimise exposure of patients, the workforce and visitors to infectious agents.

Reflective question

How does the health service organisation communicate the patient’s infectious status when care is transferred?

Key tasks

  • Develop, review or implement a process to identify relevant pre-existing colonisation, infection or communicable diseases that will affect
    • patient placement while in the health service organisation
    • the risk to the workforce, other patients and consumers
    • transfer of care.
  • Review systems and processes used by managers and the workforce on admission, at entry points or when care is transitioning, including
    • pre-admission information
    • alerts, flags or risk identification processes
    • protocols for clinics, day surgery, emergency departments, community services and clinicians’ rooms on how to assess patients for colonisation, infections or communicable diseases
    • processes for transportating patients within or outside the health service organisation.

Strategies for improvement

Hospitals

Review or develop processes to communicate relevant information relating to a patient’s infection status whenever responsibility for care is transferred. This includes:

  • Between members of the workforce
    • on admission
    • at every clinical handover
    • at any transition or transfer of care, including to other departments in the health service organisation (for example, radiology, operating theatre, rehabilitation)
    • during clinical review or consultation
    • during transport both within and outside the health service organisation
  • To other relevant clinicians or care providers, including
    • general practitioners
    • community nurse services
    • allied health clinicians
    • carers and family on discharge
  • To other heath service organisations, including rehabilitation and aged care services.

Develop or use relevant information systems and materials to inform clinicians about infection risks and the requirements to minimise the risks. Infection prevention and control risks should be included on:

  • Requests for admission
  • Referral documentation
  • Transport requests
  • Clinical handover reports
  • Discharge or transfer summaries
  • Notification, alert or flag systems for infection status, and precautions required for current and future care and treatment.

Develop or use resources to inform the workforce, patients and visitors of relevant infection risks, and infection prevention and control strategies to minimise risk to patients, visitors and the workforce.

Day Procedure Services

Review or develop processes to communicate relevant information relating to a patient’s infection status whenever responsibility for care is transferred. This includes:

  • Between members of the workforce
    • on admission
    • at every clinical handover
    • at any transition or transfer of care (for example, admission, radiology, operating theatre, recovery)
    • during clinical review or consultation
    • during transport both within and outside the day procedure service
  • To other relevant clinicians or care providers, including
    • general practitioners
    • community nurse services
    • allied health providers
    • family and carers on discharge
  • To other heath service organisations, including rehabilitation and aged care services.

Develop or use relevant information systems and materials to inform clinicians about infection risks and the requirements to minimise the risks. Infection prevention and control risks should be included on:

  • Requests for admission
  • Referral documentation
  • Clinical handover reports
  • Discharge or transfer summaries
  • Notification, alert or flag systems for infection status, and precautions required for current and future care and treatment.

Develop or use resources to inform the workforce, patients and visitors of relevant infection risks, and infection prevention and control strategies to minimise risk to patients, visitors and the workforce.

Examples of evidence

Select only examples currently in use:

  • Policy documents about communicating relevant information about any risks associated with a patient’s infectious status when care is transferred between clinicians or health service organisations
  • Clinical communication processes that include actions to communicate a patient’s infectious status to clinicians
  • Examples of clinical communication that highlights infectious status, such as handover sheets, discharge forms or electronic communication
  • Audit results of compliance with the processes for communicating infectious status, such as reviewing clinical communication documents or related incident reports
  • Resources for patients and visitors about infection risks, and infection prevention and control strategies.

 

MPS & Small Hospitals

MPSs and small hospitals should:

  • Develop, review or implement a process to identify relevant pre-existing colonisation, infection or communicable diseases that will affect
    • patient placement while in the health service organisation
    • the risk to the workforce, other patients and consumers
    • transfer of care
  • Review systems and processes used by managers and the workforce on admission, at entry points or when care is transitioning, including
    • pre-admission information
    • alerts, flags and risk identification processes
    • protocols for clinics, day surgery, emergency departments, community services and clinicians’ rooms on how to assess patients for colonisation, infections or communicable diseases
    • processes for transporting patients within or outside the health service organisation
  • Develop or use relevant information systems and materials to inform clinicians about infection risks and the requirements to minimise the risks. Infection prevention and control risks should be included on
    • requests for admission
    • referral documentation
    • transport requests
    • clinical handover reports
    • discharge or transfer summaries
    • notification, alert or flag systems for infection status, and precautions required for current and future care
  • Develop or use resources to inform the workforce, patients and visitors of relevant infection risks, and infection prevention and control strategies to minimise risk to patients, visitors and the workforce.
Last updated 2nd July, 2018 at 10:46pm
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References

National Health and Medical Research Council. Australian guidelines for the prevention and control of infection in healthcare. Canberra: NHMRC; 2010 (accessed Sep 2017).