Infection control - standard and transmission-based precautions

Infection prevention and control uses a risk management approach to minimise or prevent the transmission of infection. The two-tiered approach of standard and transmission-based precautions provides a high level of protection to patients, healthcare workers and other people in healthcare settings.

For further information regarding infection prevention and control practices in the healthcare setting see the National Health and Medical Research (NHMRC) Australian guidelines for the prevention and control of infection in healthcare (2010).

The use of standard precautions is also applicable to and essential for many non-health care settings, such as personal care and body art industries. For further information regarding infection prevention and control guidelines for these industries see the department's Health guidelines for personal care and body art industries.

Standard precautions

All people potentially harbour infectious microorganisms. As such, it must be assumed that all blood and body fluids/substances are potentially infectious. Standard precautions are the work practices required to achieve a basic level of infection prevention and control. The use of standard precautions aims to minimise, and where possible, eliminate the risk of transmission of infection, particularly those caused by blood borne viruses.

Standard precautions apply to all patients regardless of their diagnosis or presumed infection status. Standard precautions must be used in the handling of:

• blood (including dried blood)
• all other body fluids/substances (except sweat), regardless of whether they contain visible blood
• non-intact skin
• mucous membranes.

Standard precautions consist of the following practices:

• hand hygiene before and after all patient contact
• the use of personal protective equipment, which may include gloves, impermeable gowns, plastic aprons, masks, face shields and eye protection
• the safe use and disposal of sharps
• the use of aseptic "non-touch" technique for all invasive procedures, including appropriate use of skin disinfectants
• reprocessing of reusable instruments and equipment
• routine environmental cleaning
• waste management
• respiratory hygiene and cough etiquette
• appropriate handling of linen.

Standard precautions are the minimum infection prevention and control practices that must be used at all times for all patients in all situations.

Hand hygiene

Hand hygiene is considered one of the most important infection control measures for reducing the spread of infection. Hand hygiene is a general term that refers to any action of hand cleansing, such as handwashing or handrubbing.

Microorganisms are either present on hands most of the time (resident flora) or acquired during healthcare activities (transient flora). The aim of hand hygiene is to reduce the number of microorganisms on your hands, particularly transient flora which may present the greater risk for infection transmission.

Handwashing: Hands should be washed with soap and water when visibly soiled and after using the toilet.

Handrubbing: Handrubbing with an alcohol-based hand rub (ABHR) is the preferred method for hand cleansing in the healthcare setting when hands are not visibly soiled. ABHRs are more effective against most bacteria and many viruses than either medicated or non-medicated soaps. ABHRs are also less drying on hands than washing hands with soap and water, and consequently cause less irritation to the skin. ABHRs should be applied to dry hands.

The 5 Moments for hand hygiene, or times when hand hygiene should be attended to, was developed by the World Health Organisation (WHO). The 5 moments are:

• before touching a client
• before performing a procedure
• after a procedure or exposure to body fluids/substances
• after touching a client
• after touching the environment around a client.

See Hand Hygiene Australia for more information on hand hygiene and for ‘How to handwash’ and ‘How to handrub’ posters.

Personal protective equipment (PPE)

PPE protects the healthcare worker from exposure to blood and body fluids/substances. PPE that complies with relevant Australian Standards should be readily available and accessible in all health services.

Gloves

• The use of gloves should not be considered an alternative to performing hand hygiene. Hand hygiene is required before putting on gloves and immediately after removal.
• Wear gloves (single-use non-sterile) when there is the potential for contact with blood, body fluids/substances, mucous membranes or non-intact skin.
• Sterile gloves are only required for certain invasive procedures, otherwise non-sterile gloves may be used if a aseptic non-touch technique is used.
• Change gloves between tasks and procedures on the same patient. Gloves should be removed immediately after a procedure and hand hygiene performed so as to avoid contaminating the environment, other
• patients or other sites on the same patient.
• Gloves used for healthcare activities are to be single-use only. ABHR should not be used on gloves to decontaminate them, nor should gloves be washed with soap and water and continued to be used.

Gowns and aprons

• Wear an apron or gown to protect skin and prevent soiling of clothing during procedures and patient care activities that are likely to generate splashing or sprays of blood, body fluids, secretions or excretions, or cause soiling of clothing.
• Select a gown or apron (i.e., long or short sleeves) that is appropriate for the activity and the amount of fluid likely to be encountered. If an apron is used, staff should ensure they are “bare-below-the-elbows”.
• Remove the used gown as promptly as possible and roll it up carefully and discard appropriately.
• Perform hand hygiene immediately after removal.

Masks, eye protection, face shields

• Wear a mask and eye protection, or a face shield to protect mucous membranes of the eyes, nose and mouth during procedures, patient-care activities and cleaning procedures that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions.
• Remove the mask by holding the ties only and dispose of the mask into a waste bin.
• Perform hand hygiene immediately after removal.

Environmental control

• Ensure that the health service has adequate procedures for the routine care, cleaning and disinfection of environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces, and that these procedures are being followed. See also Cleaning and waste disposal for further information.

Transmission-based precautions

Transmission-based precautions (TBPs) are used in addition to standard precautions when standard precautions alone may be insufficient to prevent transmission of infection. TBPs are used for patients known or suspected to be infected or colonised with epidemiologically important or highly transmissible pathogens that can transmit or cause infection.

TBPs are not required for patients with bloodborne viruses, such as HIV, hepatitis B virus or hepatitis C virus.

The type of TBPs applied is based upon the mode of transmission of the pathogen. For diseases that have multiple routes of transmission, more than one TBP category is applied. The following are the routes of transmission.

• airborne transmission, e.g. pulmonary tuberculosis, chickenpox, measles
• droplet transmission, e.g. influenza, pertussis (whooping cough), rubella
• contact transmission (direct or indirect), e.g. viral gastroenteritis, Clostridium difficile, MRSA, scabies

TBPs should be tailored to the particular infectious agent involved and the mode of transmission.
To minimise the exposure time of other people in office-based practices or hospital waiting rooms, people identified as at risk of transmitting droplet or airborne diseases (for example, a child with suspected chickenpox) should be attended to immediately and placed into appropriate transmission-based precautions to prevent further spread of disease.

Table 1 outlines the TBPs to be taken for infections with airborne, droplet or contact transmission.

Table 1: Transmission-based precautions required according to route of transmission

For information on infection prevention and control precautions required for carbapenemase-producing Enterobacteriaceae (CPE) see the Victorian guideline on CPE for health services (2017) or Victorian guideline on CPE for long-term residential care facilities (2017).

For information on infection prevention and control precautions for other multi-resistant organisms see the Patient-centred risk management strategy for multi-resistant organisms (2011).

For more information regarding which other infectious agents require transmission-based precautions, see the NHMRC Australian guidelines for the prevention and control of infection in healthcare (2010).

Signage

Signage should be positioned prominently outside the room of a patient in TBPs. This is to ensure staff and visitors do not enter without appropriate PPE. Note: visitors may not always be required to wear PPE when visiting patients in TBPs. Please consult local health service policies and procedures.

Standardised TBPs signage has been developed by the Australian Commission on Safety and Quality in Health Care and are available in portrait style or landscape style.

If a health service uses their own signage, ensure that signage clearly notes the type of TBPs and PPE required.