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Basic Infection Control and Prevention Plan for Outpatient Oncology Settings guideline coverBasic Infection Control and Prevention Plan for Outpatient Oncology Settings

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IV. Standard Precautions

A. Hand Hygiene

Hand hygiene procedures include the use of alcohol-based hand rubs (containing 60-95% alcohol) and handwashing with soap and water. Alcohol-based hand rub is the preferred method for decontaminating hands, except when hands are visibly soiled (e.g., dirt, blood, body fluids), or after caring for patients with known or suspected infectious diarrhea (e.g., Clostridium difficile, norovirus), in which case soap and water should be used. Hand hygiene stations should be strategically placed to ensure easy access.

1.  Sample Procedures for Performing Hand Hygiene

Using Alcohol-based Hand Rub (follow manufacturer’s directions):

  • Dispense the recommended volume of product
  • Apply product to the palm of one hand
  • Rub hands together, covering all surfaces of hands and fingers until they are dry (no rinsing is required)

Handwashing with Soap and Water:

  • Wet hands first with water (avoid using hot water)
  • Apply soap to hands
  • Rub hands vigorously for at least 15 seconds, covering all surfaces of hands and fingers
  • Rinse hands with water and dry thoroughly with paper towel
  • Use paper towel to turn off water faucet

2.  Indications for Hand Hygiene

Always perform hand hygiene in the following situations:

  • Before touching a patient, even if gloves will be worn
  • Before exiting the patient’s care area after touching the patient or the patient’s immediate environment
  • After contact with blood, body fluids or excretions, or wound dressings
  • Prior to performing an aseptic task (e.g., accessing a port, preparing an injection)
  • If hands will be moving from a contaminated-body site to a clean-body site during patient care
  • After glove removal

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B. Personal Protective Equipment

Personal Protective Equipment (PPE) use involves specialized clothing or equipment worn by facility staff for protection against infectious materials. The selection of PPE is based on the nature of the patient interaction and potential for exposure to blood, body fluids or infectious agents. A review of available PPE should be performed periodically (e.g., annually) due to new product developments and improvements. Please note that this section does not address issues related to PPE for the preparation and handling of antineoplastic and hazardous drugs. The recommended PPE for those procedures should be determined in accordance with OSHA and NIOSH.

1.  Use of PPE

Gloves
Wear gloves when there is potential contact with blood (e.g., during phlebotomy), body fluids, mucous membranes, nonintact skin or contaminated equipment.

  • Wear gloves that fit appropriately (select gloves according to hand size)
  • Do not wear the same pair of gloves for the care of more than one patient
  • Do not wash gloves for the purpose of reuse
  • Perform hand hygiene before and immediately after removing gloves

Gowns
Wear a gown to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated.

  • Do not wear the same gown for the care of more than one patient
  • Remove gown and perform hand hygiene before leaving the patient’s environment (e.g., exam room)

Facemasks (Procedure or Surgical Masks)
Wear a facemask:

  • When there is potential contact with respiratory secretions and sprays of blood or body fluids (as defined in Standard Precautions and/or Droplet Precautions)
    • May be used in combination with goggles or face shield to protect the mouth, nose and eyes
  •  When placing a catheter or injecting material into the spinal canal or subdural space (to protect patients from exposure to infectious agents carried in the mouth or nose of healthcare personnel)
    • Wear a facemask to perform intrathecal chemotherapy

Goggles, Face Shields
Wear eye protection for potential splash or spray of blood, respiratory secretions, or other body fluids.

  • Personal eyeglasses and contact lenses are not considered adequate eye protection
  • May use goggles with facemasks, or face shield alone, to protect the mouth, nose and eyes

Respirators
If available, wear N95-or higher respirators for potential exposure to infectious agents transmitted via the airborne route (e.g., tuberculosis).

  • All healthcare personnel that use N95-or higher respirator are fit tested at least annually and according to OSHA requirements

2.  Recommendations for Donning PPE

  • Always perform hand hygiene before donning PPE
  • If wearing a gown, don the gown first and fasten in back accordingly
  • If  wearing a facemask or respirator:
    • Secure ties or elastic band at the back of the head and/or neck
    • Fit flexible band to nose bridge
    • Fit snug to face and below chin
  • If wearing goggles or face shield, put it on face and adjust to fit
  • If wearing gloves in combination with other PPE, don gloves last

3.  Recommendations for Removing PPE

  • Remove PPE before leaving the exam room or patient environment (except respirators which should be removed after exiting the room)
  • Removal of gloves:
    • Grasp outside of glove with opposite gloved hand; peel off
    • Hold removed glove in glove hand
    • Slide ungloved fingers under the remaining glove at the wrist; peel off and discard
  • Removal of gowns:
    • Remove in such a way to prevent contamination of clothing or skin
    • Turn contaminated outside surface toward the inside
    • Roll or fold into a bundle and discard
  • Removal of facemask or respirator
    • Avoid touching the front of the mask or respirator
    • Grasp the bottom and the ties/elastic to remove and discard
  • Removal of goggles or face shield
    • Avoid touching the front of the goggles or face shield
    • Remove by handling the head band or ear pieces and discard
  • Always perform hand hygiene immediately after removing PPE

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C. Respiratory Hygiene and Cough Etiquette

To prevent the transmission of respiratory infections in the facility, the following infection prevention measures are implemented for all potentially infected persons at the point of entry and continuing throughout the duration of the visit. This applies to any person (e.g., patients and accompanying family members, caregivers, and visitors) with signs and symptoms of respiratory illness, including cough, congestion, rhinorrhea, or increased production of respiratory secretions. Additional precautions (e.g., Transmission-Based Precautions) can be found in Section V.

1.  Identifying Persons with Potential Respiratory Infection

  • Facility staff remain alert for any persons arriving with symptoms of a respiratory infection
  • Signs are posted at the reception area instructing patients and accompanying persons to:
    • Self-report symptoms of a respiratory infection during registration
    • Practice respiratory hygiene and cough etiquette (technique described below) and wear facemask as needed

2.  Availability of Supplies

The following supplies are provided in the reception area and other common waiting areas:

  • Facemasks, tissues, and no-touch waste receptacles for disposing of used tissues
  • Dispensers of alcohol-based hand rub

3.  Respiratory Hygiene and Cough Etiquette

All persons with signs and symptoms of a respiratory infection (including facility staff) are instructed to:

  • Cover the mouth and nose with a tissue when coughing or sneezing;
  • Dispose of the used tissue in the nearest waste receptacle
  • Perform hand hygiene after contact with respiratory secretions and contaminated objects/materials

4.  Masking and Separation of Persons with Respiratory Symptoms

  • If patient calls ahead:
    • Have patients with symptoms of a respiratory infection come at a time when the facility is less crowded or through a separate entrance, if available
    • If the purpose of the visit is non-urgent, patients are encouraged to reschedule the appointment until symptoms have resolved
    • Upon entry to the facility, patients are to be instructed to don a facemask (e.g., procedure or surgical mask)
    • Alert registration staff ahead of time to place the patient in an exam room with a closed door upon arrival
  • If identified after arrival:
  • Provide facemasks to all persons (including persons accompanying patients) who are coughing and have symptoms of a respiratory infection
  • Place the coughing patient in an exam room with a closed door as soon as possible (if suspicious for airborne transmission, refer to Airborne Precautions in Section V.D.); if an exam room is not available, the patient should sit as far from other patients as possible in the waiting room
  • Accompanying persons who have symptoms of a respiratory infection should not enter patient-care areas and are encouraged to wait outside the facility

5.   Healthcare Personnel Responsibilities

  • Healthcare personnel observe Droplet Precautions (refer to Section V.C.), in addition to Standard Precautions, when examining and caring for patients with signs and symptoms of a respiratory infection (if suspicious for an infectious agent spread by airborne route, refer to Airborne Precautions in Section V.D.)
  • These precautions are maintained until it is determined that the cause of the symptoms is not an infectious agent that requires Droplet or Airborne Precautions
  • All healthcare personnel are aware of facility sick leave policies, including staff who are not directly employed by the facility but provide essential daily services
  • Healthcare personnel with a respiratory infection avoid direct patient contact; if this is not possible, then a facemask should be worn while providing patient care and frequent hand hygiene should be reinforced
  • Healthcare personnel are up-to-date with all recommended vaccinations, including annual influenza vaccine

6.  Staff Communication

  • Designated personnel regularly review information on local respiratory virus activity provided by the health department and CDC to determine if the facility will need to implement enhanced screening for respiratory symptoms as outlined in step 7

7.  During Periods of Increased Community Respiratory Virus Activity (e.g., Influenza Season)

In addition to the aforementioned infection prevention measures, the following enhanced screening measures are implemented:

  • When scheduling and/or confirming appointments:
    • Pre-screen all patients and schedule those with respiratory symptoms to come when the facility might be less crowded, if possible
    • Instruct patients with respiratory symptoms to don a facemask upon entry to the facility
    • If the purpose of the visit is non-urgent, patients with symptoms of respiratory infection are encouraged to schedule an appointment after symptoms have resolved
    • Encourage family members, caregivers, and visitors with symptoms of respiratory infection to not accompany patients during their visits to the facility
    • If possible, prepare in advance for the registration staff a daily list of patients with respiratory symptoms who are scheduled for a visit
  • Upon entry to the facility and during visit:
    • At the time of patient registration, facility staff identify pre-screened patients (from the list) and screen all other patients and accompanying persons for symptoms of respiratory infection
    • Patients identified with respiratory symptoms are placed in a private exam room as soon as possible; if an exam room is not available, patients are provided a facemask and placed in a separate area as far as possible from other patients while awaiting care
    • If patient volume is anticipated to be higher than usual with prolonged wait time at registration:
      1. A separate triage station is established to identify pre-screened patients (from the list) and to screen all other patients and accompanying persons immediately upon their arrival and prior to registration
      2. Patients identified with respiratory symptoms are registered in a separate area, if possible, and placed immediately in a private exam room; if an exam room is not available, patients are  provided a facemask and placed in a separate area as far as possible from other patients while awaiting care
    • If possible, encourage family members, caregivers, and visitors with symptoms of respiratory infection to not enter the facility

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