NHMRC Public Consultations

Skip Navigation and go to Content
Visit NHMRC website

Draft revised Australian Guidelines for the Prevention and Control of Infection in Healthcare submission

ID: 
7
Personal Details
This submission reflects the views of
Organisation Name: 
IPC research team, Westmead Institute for Medical Research
Specific Questions
2. Basics of infection prevention and control: 

2.3 A patient-centred approach

2.3.1 Involving patients in their care

The collation of advice on how to involve patients in IPC at these two points makes it much easier to quickly find patient centred approaches in the document.

 

In particular, I like the examples of the types of information that should be provided to patients at 2.3.1.

However, I think that a section could be included about information that can be given to patients/visitors about what they can do to prevent transmission & keep themselves safe from infections in everyday healthcare situations - not just during outbreaks.

 

Granted there is a section patient hand hygiene (3.1.1 – practice statement 2)– but research has shown that:

1)  patients know little about what they can and can’t do when they are on transmission based precautions in endemic, non-outbreak settings

2) some patients (isolated or not) interact with other patients and their personal belongings in ways that expose people, unnecessarily, to colonisation/infection risk (e.g. sitting on other patients beds; sharing personal items).

 

Refs:

Wyer, Mary, et al. "Should I stay or should I go? Patient understandings of and responses to source-isolation practices." Patient Experience Journal 2.2 (2015): 60-68.

 

Barratt, Ruth, Ramon Shaban, and Wendy Moyle. "Behind Barriers: Patients' Perceptions of Source Isolation for Methicillin-resistant'Staphylococcus aureus'(MRSA)." Australian Journal of Advanced Nursing, The 28.2 (2010): 53.

3. Standard and transmission-based precautions: 

3.1.1 Hand hygiene

1. It is recommended that routine hand hygiene is performed:

'Hand hygiene must also be performed after the removal of gloves' -  include performing hand hygiene prior to putting on gloves as well if this additional statement relating to gloves will be included. the most common 'missed' moment related to glove use is not performing HH prior putting on non-sterile disposable gloves.

 

3. It is recommended that alcohol-based hand rubs that contain between 60% and 80% v/v ethanol or equivalent should be used for all routine hand hygiene practices. 

Include the words isopropyl alcohol as the current wording indicates that only ABHR with ethanol as an alcohol base are acceptable. Including isopropyl makes it clearer.

 

6. It is good practice to perform hand hygiene in the presence of known or suspected Clostridium difficile and non-enveloped viruses such as norovirus as follows:' - 

This statement is misleading for non-enveloped viruses as the first bullet point refers to spores which are not present for Norovirus ("use soap and water to facilitate the mechanical removal of spores"). The use of ABHR for norovirus cases in which hands are not visibly soiled and gloves have NOT been worn is still indicated in most situations and cases and is a better way to ensure compliance with HH according to the 5 Moments than restricting to hand washing. This section should only refer to 'known or suspected Clostridium difficile'


3.1.2 Personal Protective Equipment

7. It is suggested that clean aprons/gowns should: 

Under the rationale for the above the 3rd bullet point (in bold below) should be removed from the following text:

Wearing of personal protective clothing (gowns and aprons) is an internationally accepted practice when:

  • healthcare workers are in close contact with the patient, materials or equipment that may lead to contamination of skin, uniforms or other clothing with infectious agents
  • there is a risk of contamination with blood, body substances, secretions or excretions (except sweat)
  • entering the room of a patient requiring contact precautions.

There is now more emphasis on taking a risk assessment with gowns (and potentially gloves) for patients in CP for MRO. Removing the requirement to always don a gown for patients in CP for MRO can be economically beneficial for the patient (increased HCW attention and decreased feelings of isolation).

 

8. It is suggested that face and protective eyewear should be worn during procedures that generate splashes or sprays of blood and body substances into the face and eyes.

Under 'Rationale' the acronym for OH&S is incorrect - ".....by WH&S principles and expert opinion."


3.1.8 Aseptic technique

22. It is good practice that sterile gloves be used for aseptic procedures and contact with sterile sites.

A differentiation should be made between non-touch aseptic technique (ANTT) and aseptic procedures in this section as ANTT does not require sterile gloves. As it stands currently the practice statement is misleading for those who currently practice ANTT without sterile gloves. Needs a better explanation.

 

3.2.3 Droplet precautions

 

26. It is suggested that droplet precautions are implemented for patients known or suspected to be infected with agents transmitted by respiratory droplets that are generated by a patient when coughing, sneezing or talking.

Under the section 'Practical info' the following sentence:

 "Infectious agents for which droplet precautions are indicated include respiratory syncytial virus (RSV) and meningococcus." incudes RSV as an example of a droplet spread disease. In the healthcare setting this is a poor example as contact is a more common mode of transmission for this disease and also it is rarely diagnosed outside of the paediatric or aged care settings. it would be better to use Influenza as this is very commonly encountered disease spread by Droplet mode.


3.2.4 Airborne precautions

29. It is recommended that airborne precautions, in addition to standard precautions, are implemented in the presence of known or suspected infectious agents that are transmitted person-to-person by the airborne route.

Under the 'Key info' section / quality of evidence, the sentence ending "...transmitted person-to-person by airborne route, such as tuberculosis" should be amended to make it clear what type of tuberculosis is spread via the airborne route e.g. infectious pulmonary tuberculosis.

In the 'Practical info' section the bullet list of Individual actions for reducing risk includes bullet points related to general transmission-based precautions and use of contact and droplet precautions. These bullet points should not be included here as this is specific section for Airborne Precautions. This is not an appropriate section for this general information on TBPs.


30. It is good practice to wear a correctly fitted P2 respirator when entering the patient-care area when an airborne-transmissible infectious agent is known or suspected to be present.

The 'Practical info' should also include pictures and information relating to safe doffing - not just safe donning

"Reconsider the requirement for Fit Testing. The standard is very old and there is no recent evidence that a fit checking programme protects the wearer more than fit checking each time the mask is donned. A fit checking programme is extremely resource demanding and any benefits do not outweigh the cons.


3.3.1 Multi-Resistant Organisms

32. It is suggested that contact precautions be considered for all patients colonised or infected with an MRO, including:

  • performing hand hygiene and putting on gloves and gowns before entering the patient-care area

As commented in above section, a risk assessment should be promoted for gown and glove use for MRO patients due to many isolated for previous colonisation.

In the 'Practical info' the following paragraph:

"There is emerging evidence from the United States which suggests that there are a range of possible negative patient outcomes associated with the use of contact precautions for patients infected or colonised with an MRO which need to be considered.” 

should be amended to not restrict the evidence to emerging or the USA as many countries globally have contributed to the evidence for this for at least 15 years.

Under 'Management of specific MROs - MRSA' strongly disagree with the following statement:

"There is increasing evidence to support the use of a surgical mask when caring for an MRSA positive patient who has respiratory symptoms or a tracheotomy."

This is where standard precautions should be applied - a mask has always been indicated for the examples given as part of Standard Precautions. The disadvantages of routine wearing of a mask by a HCW in the examples stated far outweigh any nebulous benefits.

Under 'Emerging evidence on contact precautions' there are other negative psychological effects for patients not listed which are also signifcant e.g. depression

3.3.2 Outbreak investigation and management

The list of 'Outbreaks commonly identified in healthcare facilities include:' should be revised to group the MROs and reword the MRO bullet 'aminoglycoside or multi-resistant Enterobacteriaceae or pseudomonads' as this is too much a microbiology focused descriptor. Either use the common acronyms or reword using the word 'carbapenemase' or MRGN to be consistent with section 3.3.

The list should include Scabies as common in long term care facilities.

Page reviewed: 24 September, 2019