NHMRC Public Consultations

This section requires rewriting in active voice.

Comments about MAGICapp

•  Good that the “link” icon is present so able to send the specific link to someone.  However the labelling of the sections is quite confusing and difficult to find between the index on the left and the actual sections.  Suggest putting the numerical section labels into the index on the left. 

• Will it be possible to print a copy of the guidelines in full from the MAGICapp or NHMRC website? 

• When in a heading and the option of “view more details” appears, it is difficult to see where the additional text ends before the next section starts (particularly when the additional text runs over the current screen view).  The very faint box around it perhaps needs to be darker or it clearer that in the next section as quite confusing.

• Suggest headings are numbered in the side bar to align with the heading in the main section and with the links in the text of the document.  E.g. see section 3.3.2.

• Instructions required regarding the decision aid feature.

• Unclear what the Research evidence tab represents.

• Table headings don’t remain fixed - for example 6.2 checklist for SP and 6.4 Type and duration of precautions for specific infections and conditions – lots of scrolling up and down required, not user friendly.

• It’s not possible to do a word search unless the word is contained in a recommendation.

• MAGICapp is not intuitive to use or easy to navigate around.

General comments

•  The current format and content is difficult to use. The content is contradictory and out of date.  It doesn’t reflect the differences on recommendation and legislations.  Over prescriptive in some areas and under prescriptive in other areas.

• Not practical for use when implementing an infection control program. 

• Grade system confuses the intention of the information – use of the terminology ‘weak’ recommendation is misleading as it implies that it is not worthwhile doing.  ‘Weak against’ is a double negative which appears illogical.  There needs to be separation in the text and chapters between what should be done and the rationale for doing so. At the moment, some sections give straightforward advice while others include the rationale for the advice/ recommendations.

• The use of the recommendation system is somewhat confusing – there is a risk that that the practices where there are ‘weak recommendations’ may be interpreted as ‘should not be used’. For example recommendation 8 is a weak recommendation (based on research findings) and you have to go to another section to identify that this is a recommended practice based on other rationale. It would be simpler to recommend wearing protective eyewear based on OH&S principles.

• The language use is a bit vague at times – wording such as ‘it is suggested’ and ‘it is good practice’ and should be performed’ when discussing glove use or hand hygiene makes it appear that these are optional practices.

• The guideline appear to have not been updated in a number of sections such as cleaning and disinfectants.  The old content has been used in the draft document.  Examples provided are not relevant to the risk management steps, are out of date and not reflective of usual situations.

• There are too may bracketed examples – perhaps use full sentences
  

Healthcare associated infections should be referred to consistently throughout the document - in this section it is referred to as both ‘health-care associated’ and ‘healthcare-associated’. Healthcare should also be referred to consistently – in this section it is referred to as ‘health care’ and ‘healthcare’ and ‘health-care’

2.1 Infection prevention and control in the healthcare setting

 Prions are not microorganisms. I would delete ‘prion’ from that sentence.

 ‘other sources of transmission include endogenous flora of patients…’ doesn’t really make sense. The paragraph previously describes humans as sources which could include endogenous flora rather than being a separate point.

 The level of risk relating to the patient should also include their adherence to hand hygiene.

 The level of risk relating to the healthcare worker should also include their adherence to standard and transmission based precautions as well.

 Suggest removing norovirus from the list of illnesses transmitted via contact and droplet routes as this implies some sort of respiratory transmission.

 Highly contagious skin infections/infestations are not infectious agents; this sentence will require rewording.

 Droplet transmission – suggest remove the sentence that reads ‘However, droplets can also be transmitted indirectly to mucosal surfaces (e.g. via hands or contact with fomites’. Indirect droplet transmission does not occur – it becomes indirect contact transmission when the organism has been coughed or sneezed onto a surface and then transmitted to someone else’s mucosal surface via their hands. Droplet transmission as per the second sentence occurs directly between people and this is reflected in the various sections about droplet transmission and droplet precautions.

 Change ‘meningogoccus’ to Neisseria meningitidis; the current droplet transmission sentence doesn’t make sense

Suggest that the following sentence needs rewording “Transmission of infection can also occur via common sources such as…”. For medications, devices or equipment, presumably this is referring to contact transmission? The other examples are faecal-oral route of transmission. The current sentence seems a little odd and needs rewording.

 The introductory sentence ‘TBP may include one or any combination of the following’ sounds a bit odd; the first two points related to accommodation and should be OR…and all the other points are relevant for all TBP except ‘air handling’. Perhaps this needs to be reworded.

The term ‘TGA-registered disinfectant with label claims’ is problematic in its application e.g. sodium hypochlorite could not be used if that is strictly applied. The term should be changed to ‘TGA-listed or registered’.

2.2 Overview of risk management in infection prevention and control

 Case study: measles outbreak. Suggest that there are a number of issues with the example provided for risk management in GP setting. Perhaps another example may be better to demonstrate application of risk management in this setting.

 If this case study is maintained, I provide the following comments:

The ‘treat the risk section’ should include reference to how to manage a person presenting with suspected measles – donning surgical mask, segregating them away from other patients and how their assessment is undertaken – what specimens to take and who to contact…perhaps refer to the SONG

 The risk evaluation matrix for measles I find problematic, particularly for the first 2 points.

•  There is no role for disinfectant spray in the absence of prior cleaning in any setting. The ‘analysis’ statement is not correct. Environmental cleaning should be viewed as an important strategy but the use of disinfectant spray is not appropriate.

• The second point provides an unclear message. Hand hygiene is a critical component of standard precautions. Stating here that it is low impact sends the wrong message. I would delete this example.

• Linen change is part of standard precautions. Again, the way this is stated sends the wrong message.

The monitor and review section would also need rewording:

The number of cases identified should be notified to Public Health as a notifiable condition

Does reporting occurs from the general practice to infection prevention and control or other quality committees; is this relevant here?

2.3.1 Involving patients in their care

 Suggest that ‘how to implement airborne precaution’ is removed as patients families will not be expected to do this –wearing PPE will be what they would be required to do and this is already outlined.

I think that this section should include actions that the patient (and their family/visitors) can do to reduce their risk of acquisition of healthcare pathogens, particularly hand hygiene – with some examples of initiatives that have demonstrated reduction in acquisition of pathogens e.g. VRE, C. difficile – with provision of accessible product prior to eating/after toileting etc.

Suggest revise summary statements. For example…TBP are used when SP alone will not reduce or prevent the risk of transmission of infectious agents

3.1.1 Hand Hygiene

Suggest referencing and linking to HHA for this entire section.  Restrict information to the 5 Moments.

‘had’ instead of ‘hand’ in paragraph below Figure 5

 Recommendation 1.

Hand hygiene should be performed before donning of gloves as well as after the removal of gloves.

Research evidence tab is empty currently

Table 2.

Suggest delete ‘whether own or patient’s’ relating to food/drinks.

We would recommend hand hygiene before touching a patient, after touching a patient and after touching a patient’s surrounding, regardless of whether they are immunocompromised or whether they are in isolation or TBP. It is part of standard precautions regardless of perceived risk.

Before and after a procedure or blood/body fluid risk will need to be added to.

 Recommendation 2.

Suggest that it should be a stronger recommendation than practice statement. There is published literature relating to patient hand hygiene and impact on HAI.

 ABHR not the preferred HH product for patients, particularly for use after the toilet/commode. There should be commentary around this and the preferences.

 Research evidence tab is empty currently

 The practical information tab should be specific to patients. The content largely relates to HCW.

 Recommendation 3.

The recommendation should refer to the different alcohol compounds; ethanol and isopropanol are not equivalent

Research evidence tab is empty currently

Should there be a comment about the role of chlorhexidine within HH product?

 Recommendation 4

Suggest that the recommendation needs to be reworded. ?It is good practice that ABHR used in healthcare meet the requirements of European Standard EN 1500…(and delete the next part of the sentence).

 Recommendation 5

Research evidence tab is empty currently

 Recommendation 6

Suggest that it should be a stronger recommendation than practice statement – we should be doing HH for all patients regardless of pathogen identified – the question is, what HH product should be used.

 Research evidence tab is empty

3.1.2 Personal Protective Equipment

The diagrams only illustrate sequencing when all items of PPE are required. Would be helpful to have diagrams illustrating how to put on and safely remove individual items of PPE as this is how they are usually used.

 Why is there reference to ties and lanyards in the PPE section?

Why is there reference to uniforms in the PPE section?

• Perhaps there is a role for a separate section to address HCW dress etc.

 Donning PPE

• There should be reference to where this is done

• It should specify that it is a surgical mask (for standard precautions)

 Why is there reference to a P2 mask in the standard precaution section?

 Recommendation 7

Why is this a weak recommendation? The way it looks is that we shouldn’t really be recommending the use of aprons/gowns where contamination with blood/body fluids is likely.

 In the practical information tab, it refers to gowns and aprons used in clinical areas being ‘fluid resistant’. Shouldn’t this be ‘fluid impervious’ due to difference in testing methodology.

 Recommendation 8

Concerned that this is a weak recommendation.

There is much confusion around masks in healthcare and many healthcare settings are just going to access level 3 surgical masks (rather than all 3 types) to minimise confusion. Should there be a comment in relation to this?

 Recommendation 9

Practical Info tab; Gloves are not a part of droplet precautions but contact precautions.

There is a repetition in relation to indications for use of gloves

3.1.3 Use and management of sharps, safety engineered devices and medication vials

Medical vials do not fit in this section.

3.1.4 Routine management of the physical environment

 Future research section is not needed in these guidelines.  Practical information only.

 Referring to sodium hypochlorite as a novel disinfectant is confusing as it has been used for a long time.

 General comments:

• Should there be some discussion about detergents? What they are and what would be an appropriate detergent and that solution is preferred and in what circumstances a detergent wipe may be considered?

• Should there be some discussion about disinfectants and what they are? Should there be some discussion about an appropriate disinfectant and that solution is preferred? Should there be some specific comment about disinfectant wipes and the lack of evidence to support their use currently?

 Recommendation 12

 Significant concerns with the wording of this recommendation.

 “Cleaning frequently touched surfaces with detergent solution at least daily, when visibly soiled and after every known contamination”.

•  What does ‘every known contamination’ mean?

• Is there consideration for after a patient transfer/discharge in an acute setting

 “Cleaning general surfaces and fittings when visibly soiled and immediately after spillage”.

 Does this mean that patient rooms/bathrooms are not cleaned regularly and only cleaned if visibly soiled or after spillage?

 Practical info tab:

 The routine environmental cleaning is missing another grouping of surfaces e.g. horizontal surfaces, bathrooms, toilets

 How is the detergent determined by the nature of the surface and likely degree of contamination? This doesn’t make sense.

 The procedures should also include:

 Orientation and ongoing education/support

• Cleaning products

• Audit and feedback process

 Use of disinfectant section:

•  Not strictly correct to ‘clean with a disinfectant’ – probably better to say “clean with detergent then follow with disinfectant”

• Suggest delete the section ‘…could be used if this process involves mechanical/manual cleaning’

• What does ‘mechanical cleaning’ mean? Delete?

• Perhaps say ‘Initial cleaning with a detergent is critical. Disinfection is not recommended without the use of a detergent’?

 In figure 8, should it be minimally touched surfaces in low risk settings? What about the other surfaces that are neither minimally touched nor frequently touched (as outlined above)? I think that they should be cleaned with detergent and disinfectant too. Care needs to be put into this section as it will be referred to frequently.

The table for ‘choosing cleaning/disinfection products’:

•  Reference should be specific in relation to the TGA and include TGA registered or listed products

 Recommendation 13

 What is an example of an exception? Can’t think of any.

Recommendation 14

 Suggest reword this and make it quite specific to the clinical surfaces (and equipment) that this would refer to. It would not be good practice to use surface barriers generally – it would need to be specific to the circumstance.

 Does it matter if it is a gloved or ungloved hand? Remove ‘gloved?

 Recommendation 16

Should there be reference to other circumstances where sodium hypochlorite should be used specifically? It seems odd here to just refer to norovirus outbreaks.

3.1.5 Novel disinfection methods

 Future research section is not needed in these guidelines.  Practical information only.

 Referring to sodium hypochlorite as a novel disinfectant is confusing as it has been used for a long time.

 Use of disinfectants - reference is made to TGA registered hospital grade disinfectants only as per the previous guidelines. The section on disinfectants should include TGA listed products as well - rationale for this is:

• Disinfectants used for environmental disinfection of healthcare premises are defined as ‘hospital grade disinfectants’ under the ‘Therapeutic Goods Order No. 54 – Standard for Disinfectant and Sterilants’¹, made under Section 10 of the Therapeutic Goods Act 19893 and must comply with this Order.

• Any product labelled or sold as a hospital grade disinfectant has to be either ‘registered’ or ‘listed’^{2, 3} on the TGA’s Australian Register of Therapeutic Goods (ARTG)⁴. Disinfectants with specific biocidal claims must be registered while those without specific biocidal claims are listed ^2,3,4.  There are a small number of TGA registered products on the ARTG, while a large number are listed.  Many TGA listed disinfectant contain chemicals that are well established disinfectants with robust evidence for efficacy⁵. (Section 1.1.2 of Appendix 18, DR4).

• There are inconsistencies in the use of terminology of ‘TGA approved’, ‘TGA registered’ and ‘TGA listed’ and their application in the National and various State guidelines. The current 2010 ‘Australian Guidelines for the Prevention and Control of Infection in Healthcare’, recommends the use of a TGA registered disinfectant but also recommends sodium hypochlorite (TGA listed) for blood and body fluid spills and for Clostridium difficile. This has not changed in the revised guidelines (as per section 3.1.5) but we would suggest that this section is reviewed in light of the above comments.  

1.  Australian Government, Federal Register of Legislation, Therapeutic Goods Order No. 54 – Standard for Disinfectant and Sterilants 1996, <https://www.legislation.gov.au/Details/F2009C00327>

2. Australian Government, Department of Health, Therapeutic Goods Administration, Summary of disinfectant regulation, 2012, < https://www.tga.gov.au/summary-disinfectant-regulation>

3.   Australian Government, Department of Health, Therapeutic Goods Administration, The regulation of disinfectants and sterilants , 2012, < https://www.tga.gov.au/regulation-disinfectants-and-sterilants>

4. Australian Government, Department of Health, Therapeutic Goods Administration Australian Register of Therapeutic Goods (ARTG), https://www.tga.gov.au/australian-register-therapeutic-goods

5. Australian Government, Department of Health, Therapeutic Goods Administration, Therapeutic goods regulations – exempt goods, 1997, < https://www.tga.gov.au/sites/default/files/dr4-appendix-08.pdf>

 Disagree with the inclusion of sodium hypochlorite in the novel disinfectant section. These have been used for a long period of time as a disinfectant in healthcare settings. There is published literature supporting their efficacy, both in-vitro and in-vivo. What disinfectants are not novel?

When hydrogen peroxide is discussed, it should be discussed in its’ various forms as they don’t appear to be equivalent. Vapourised hydrogen peroxide e.g. Nocospray vs other delivery methods. There needs to be a balanced summary of the literature in relation to the products, their efficacy and their potential issues.

Are quaternary ammonium compounds going to be discussed? If so, there needs to be a balanced summary of the literature in relation to the products, their efficacy and their potential issues.

Why hasn’t there been a systematic review on steam and microfiber? Why is there not a recommendation about this? This would seem relevant in the Australian setting given that this form of cleaning has been widely disseminated as an effective method of cleaning despite limited evidence. 

Recommendation 17

Should sodium hypochlorite be recommended rather than suggested?? Has terminal clean been defined?

Rationale section: What are MRO spores?

As mentioned above – should there be recommendations in relation to not using QAT and steam and microfiber as well?

3.1.6 Reprocessing of reusable instruments and equipment

Single use and single patient use equipment is not mentioned in the document.  Suggest it could fit in this section

3.1.9 Waste management

The waste management link for Tasmania does not open and crashes/ closes the app. 

3.2.2 Contact precautions

 The example provided for direct transmission is incorrect. This is referring to BBV and these patients do not require contact precautions.

 The layout of the recommendations make it unclear what is being recommended for practice.

 Recommendation 23

 Practical information tab; highly contagious skin infections/infestations are not infectious agents. Perhaps include some specific examples e.g. MRSA

 Single rooms are not routinely recommended for ‘immunocompromised patients’ ?delete

Cohorting – droplet transmission not relevant for contact precautions

3.2.3 Droplet precautions

 The role of eyewear should be commented and discussed within the droplet precaution section. It has been recommended within guidelines for the management of patients with influenza. 

Recommendation 27

 Mixing hand hygiene up with droplet precautions is confusing. Hand hygiene is part of standard precautions and is important for all patient care. This should not be confused in the application of TBP. When discussing surgical masks, there should be discussion about which type is recommended.

 Recommendation 28

Should there be a comment about ‘aerosol generating procedures’ in relation to patients with infections transmitted by the droplet route. Are there additional considerations to be made in relation to these patients – accommodation, PPE? There is reference in the airborne transmission section for the use of a P2 mask in this setting – but this should be in the droplet precaution section. Are AGP defined?

 It should be specified what type of masks that patients will be donning if outside their room.

3.3.1 Multi-Resistant Organisms

 Carbapenemase is not spelt correctly.

 Decolonisation – make it clear that this is only for MRSA. Suggest not include specific systemic antibiotics.

 The flow of this section seems a little odd and repetitive. Targeted screening is within the organism-specific approach and then there is a separate section titled screening. This probably needs reworking.

 Suggested MRSA screening approach;

 Suggest deleting ‘chronic wounds’ and ‘a number of comorbidities’

 Suggested MRGN (including CPE) screening approach;

•  Ensure that this is consistent with the agreed Australian CPE Guideline

• Suggest deleting ‘chronic disease and impaired functional status’ (?how do we define that)

• Suggest deleting ‘hospitalised for a long time, diabetes mellitus… this should be consistent with the agreed screening criteria

Recommendation 32

Separation of standard from TBP should be clear

Should there be a level of priority of isolation according to organism e.g. CPE should all be managed in single rooms with ensuites without exception but for other organisms, cohorting may be considered after consultation with the IC unit.

MRSA – tracheostomy not tracheotomy

Is there going to be any further guidance in relation to decolonisation? Inclusion or exclusion criteria?? 

CPE should also have an alert placed.

What about VRE?? This has been missed.

 Recommendation 33

 Should there be a mention here about:

•  SAB surveillance (including MRSA vs MSSA)

• Notifiable diseases in some jurisdictions (e.g. VRE and CPE in Tasmania)

• CARAlert system

3.4 Applying standard and transmission-based precautions during procedures

 Should this section remove reference to TBP?

Predominantly this should be relating to standard precautions. TBP is only relevant if there is suspected or proven infection with an organism that requires TBP. The content does not really assist with these decisions though.

3.4.1 Taking a risk-management approach to procedures

Appropriate use of devices – this information is lost in this section.  It could be moved to 3.4.2 and fleshed out to include the single use symbol.

3.4.2 Therapeutic devices

Should therapeutic devices be referred to as invasive medical devices?

3.4.3.1 Preventing Surgical Site Infections (SSIs)

 Reword (or remove) the sentence in relation to ‘combined use of antibiotics and mechanical cleaning in adult patients undergoing colorectal procedures….’ This is not what we would be recommending currently for colorectal surgery.

In relation to laminar airflow ventilation – there should be more information in relation to this statement.  

Reword (or remove) the sentence that relates to cefotaxime into wounds prior to closure. This is not the only antimicrobial that is administered into wounds. It should be a general statement recommending against the use of antimicrobials until there is robust evidence to support this practice. It is not going to be recommended within the TG: Antibiotic.

Are we going to be recommending antimicrobial suture routinely?? There needs to be further information here – if it is going to be recommended, what is the evidence and in what situation should be it be considered??

 There seems to be a contraindication in the wound management section – in one point it states that there is no robust evidence to support the use of dressing in the immediate…. But the final point, recommends the use of a dressing. This information should be combined to be more coherent – currently, it looks disjointed.

The statement ‘use sterile saline for wound cleansing up to 2 days after surgery’ almost looks like it is being recommended for all wounds. Reword?

In relation to showering, the statement ‘may shower safely 2 days after surgery’ seems a little odd. For the majority of surgical procedures, it would be safe to shower immediately after surgery – should it not depend on what surgery has been done? Does there need to be a context around this?

 In relation to surgical site infection, recommend referring to the Therapeutic Guidelines Antibiotic for recommendations in relation to appropriate antimicrobial choice if indicated. The current paragraph is contradictory in that the first line says ‘give the patient an antibiotic’ and the second point states ‘not all SSIs require antibiotic treatment’…. This section requires rewording.

  

4.1.4 Risk Management

It seems odd that recommendation 37 and 38 are within this section. These recommendations related to chlorhexidine. Suggest that recommendation 37 would be strengthened by listing the situations where chlorhexidine would be recommended for use linked with the appropriate references. Recommendation 38 seems a little odd to just refer to chlorhexidine here – shouldn’t there be generic recommendations for chemicals to be included in a register and not just specifically be mentioning chlorhexidine here? The management of potential adverse reactions associated with chlorhexidine should be a separate section – there are risks in relation to inappropriately labelling an individual with a chlorhexidine allergy as well – similar to antibiotic allergy labelling. There should be options recommended for different circumstances where chlorhexidine wouldn’t be able to be used.

4.2.1 Health status screening and immunisation

 Tuberculin skin test should not be performed routinely on all HCW. Suggest delete ‘routine’

 Table 22 is referenced from NSW documents. This issues is currently being discussed within the Tasmanian Health Service and the current categories within Tasmania have been proposed as follows:

 

Category	Risk	Example
A	Direct contact with patients/clients, deceased persons, pathology specimens or blood or body fluids	Dental practitioners and assistants Medical practitioners Nurses Midwives Allied health practitioners Ambulance and paramedic officers Laboratory staff Environmental cleaners Hospital aides Orderly staff/ward attendants
B	None of the above criteria met	Office clerical staff, kitchen staff and gardening staff with no anticipated direct contact with patients/clients, deceased persons, pathology specimens or blood or body fluids.

The argument was that catering staff and ward clerks etc. should also be vaccinated for HBV (which is the main difference on the proposed risk categories within the draft IC guidelines).

Question whether the category C staff require MMR (as per the IC guidelines).

Not all category A staff should have a TST. 

Table 22/23 and table 24 contradict each other. These need to be consistent.

In relation to practical implementation and usefulness, figures 8-10 are not helpful ?delete.

4.2.2 Exclusion periods for healthcare workers with acute infections

The gastroenteritis section probably needs clarification. The majority of viral gastroenteritis will be norovirus infection and the majority will not have an identifiable pathogen – unless part of a healthcare facility outbreak. This probably needs to be clarified within this section i.e. majority of situations will require 48 hours prior to returning to work. HCW with Giardiasis probably don’t need to be excluded from work.

The influenza exclusion needs to be modified and more closely aligned with the influenza SONG. “Healthcare workers with influenza should stay off work for 5 days after symptom onset, or until they are symptom-free, whichever is longer” 

 The pertussis exclusion also need to be modified to align with the pertussis SONG. “21 days after the onset of any cough, or

 14 days after onset of paroxysmal cough (if the onset is known), or when they have completed 5 days of a course of an appropriate antibiotic.”

 Viral rashes section. This section to be reworded – currently it looks like the HCW can only return to work when they have serology consistent with immunity. The chickenpox section does not seem complete – the last sentence is incomplete. Should herpes zoster be in the ‘viral rash section’?

 Recommendation 40. Suggest this should be a recommendation rather than a ‘practice statement”.

4.2.3 Managing exposures to occupational hazards

 “it should be tested” – is this relating to testing blood from a discarded syringe? Are we recommending this? And testing blood in discarded syringes is not a reliable method of assessing infectivity of the syringe contents.

 PEP does not just relate to HIV – it relates to hepatitis B too. “PEP” does not include first aid, counselling, testing – PEP just relates to the therapy that you may provide to reduce the risk of seroconversion. This needs to be reworded.

Non-immune patients to HBV may require HBIG as well as vaccine. I would recommend reference to the Australian Immunisation Handbook (AIH).

4.2.4 Healthcare workers with specific circumstances

What differences are to be recommended for pregnant HCW and immunocompromised HCW? Currently the guidelines are just referring to the AIH.

4.4.6 Notifiable diseases

 This section needs to be rewritten to reflect the Listed Human Diseases (LHD) (rather than ‘quarantinable diseases’) under the Biosecurity Act 2015.  The 1908 Quarantine Act has been repealed.

 See the following links

 https://www.legislation.gov.au/Details/C2017C00303

 https://www.legislation.gov.au/Details/F2018L00450 https://www.legislation.gov.au/Details/F2016L01027

 http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-quarantine.htm

 http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-biosec-list-diseases.htm

It is important to emphasise the different state and territory requirements perhaps initially – as the requirements are different depending on where you are. Maybe move the ‘state and territory’ section first.

4.5.1 Antimicrobial resistance in Australia

Provide linkage here to the AURA internet site.

4.5.2 Antimicrobial Stewardship Programs

Provide linkage here to the new ACSQHC 2018 AMS book. The key requirements now look different.

4.5.3 Antimicrobial Stewardship Surveillance Methods

Consider deletion of this section. This is well covered within the new AMS book.

4.6 Influence of facility design on healthcare-associated infection

Is there a recommendation for the use of positive pressure rooms and LAF for immunocompromised patients? If so, this is controversial and further specific detail should be provided here with appropriate references.

4.6.2 Mechanisms for influencing healthcare-associated infection through environmental design

 If HEPA-filtered rooms are to be recommended – there needs to be more specific detail included.

 Information on LAF and recommendations need to be clear. This area is controversial. The SSI section states ‘there is low quality evidence to suggest against the use of LAF ventilation systems for patients undergoing total arthroplasty surgery’. The information needs to be consistent and reflect literature.

 Upholstered furniture should not be recommended for use in areas housing any patients – not just immunocompromised patients.

 Should there be commentary around the use of disposable curtains and their management within acute healthcare?

5.2 Risk-management: Case study for glove use and hand hygiene in an office-based practice

 Suggest this is changed to perhaps an audit of practices during influenza season that identifies poor glove use rather than identifying ‘a higher than usual rate of influenza cross-transmission in her practice’ as not sure that such surveillance activities are possible or done (auditing is though).

 Consideration of the following measures to be included:

 waiting room practice – segregation of patients whilst waiting

vaccination – staff vaccination and patient vaccination process and coverage

5.4 Risk-management: Case study for the prevention of stick injury during surgery at a tertiary referral hospital

Should be ‘needlestick injury’.

5.7 Risk-management: Case study for Klebsiella pneumoniae sepsis in a neonatal unit

 Suggest that this scenario is updated (the original is from a 1999 paper) and changed to something relevant to the Australian setting. Perhaps get an examples from a NICU that has had transmission issues.

Current example - Environmental source/s would need to be excluded as ongoing source for transmission – focus on the environmental management would also be important here.

5.9 Risk-management: Case study for M. tuberculosis among immunocompromised patients attending outpatient services

Suggest this scenario is updated to reflect the reality of most healthcare TB exposure situations in Australia where a person is unexpectedly identified as having MTB while an inpatient in a general ward and had been on the ward for a few days with the potential for many contacts (and you should define the amount of time constitutes as contact (smear positive VS smear neg, culture positive). Or maybe use a scenario such as measles or VZV exposure in an ED instead of TB if you want to illustrate how to manage an airborne transmitted disease.

5.10 Examples of how to perform aseptic technique

 Suggest split the table into two with ‘Action’ and ‘Rationale’ rather than the current combination of the two.

Suggest using diagrams with the different scenarios i.e. peripheral and central VAD, wound care – the words need to be simple and provide consistent information. It is difficult to read through the current example.

5.11 Risk management: Case study for norovirus outbreak in a long-term care facility

 Suggest this is updated (original is from a 2004 paper) to a more realistic scenario – norovirus outbreak in a LTCF or an acute hospital ward (rather than a couple of cases in an independent living facility).

 Using ‘droplet precautions’ implies that norovirus is transmitted via respiratory droplets rather than ingestion of virus. The droplet route is contradicted by the statement ‘One source of the risk is the lack of appropriate hand hygiene practices by some residents’. Suggest state using standard and contact precautions as SP includes the use of masks if anticipating contact with blood or body fluids. 

Directly refer and link to the National Guidelines.

5.12 Risk-management: Case study for management of confirmed case of CPE

 Directly refer and link to the National Guidelines.

5.13 Risk Management: Case study for a VRE outbreak in a large tertiary-care referral hospital

Suggest update this as it is based on a 2004 paper when VRE was relatively rare in Australia. Maybe look at horizontal VS vertical precautions for endemic VRE. Suggest changing this to vanA VRE.

5.14 Risk-management: Case study for infection prevention during renovation of emergency department

This should refer to the risk matrix that is used when determining risk of construction/renovation activities.

6.1 Recommended routine cleaning frequencies

Overall, these are very prescriptive. There is a risk that they will be used as a ‘must do’ cleaning frequency irrespective of the setting and resources. Suggest this table is reviewed and summarised – for example, all patient equipment should be cleaned after each patient use;  specifying every item is not necessarily helpful as some may interpret it literally and point out that ‘their’ particular item is not on the list

 There is minimal difference between cleaning frequencies for very high, high and significant risk areas – suggest these are put into one category – acute care and outbreaks. 

 In addition, outbreaks occur in general wards and ‘low risk’ settings and constitute a high risk of microbial transmission – this should be reflected in some way in the settings section which would occur if the ‘acute care and outbreak’ were used as a setting. 

 Suggest ‘bidet’ is removed as this is not commonly used in Australian healthcare.

 ABHR dispenser is to be ‘cleaned daily and after every patient use’. These items are generally used by staff not patients so not sure when they should be cleaned.

 Suggest that the minimum frequency cleaning and its structure be reviewed.

 There is no differentiation between patient areas and administration/office areas nor between daily and discharge/transfer situations.

 Is there differentiation between cloth curtains and disposable curtains?

 Are fans recommended within acute healthcare?

6.2 Checklist of standard precautions for procedures

 This table does not add any extra information over and above - use SP for all patients. Plus this is a table of when to use PPE and Hand Hygiene rather than a table of SP

 An IV cannula insertion is an intravascular access device but there are 2 separate recommendations. This needs to be reviewed.

The recommendations will differ between VAD so this does need to be reflected within this table.

6.3 Application of standard and transmission-based precautions

 Suggest use the wording ‘Use of…’ rather than ‘Application of…’

 Suggest that ‘as per standard precautions’ is used in the following sections  (rather than a star) - mask and eye wear for CP; gloves, apron/gown, eye wear from DP; gloves, gown/apron, eye wear and mask for AP – as these are the precautions that should be used in those precautions.

Is the intent to remove the routine use of gloves from contact precautions? Is this appropriate for all MROs? Is this appropriate for enteric pathogens as well? If so, this is a big shift in practice. What would this mean for norovirus and C. difficile, particularly in relation to our HH recommendations?

 Is the intent to not consider eye protection routinely for droplet transmission organisms including influenza?

 For influenza, the current influenza SONG recommends contact and droplet precautions (i.e. gown, gloves and mask) and in addition, P2 mask and protective eyewear for AGP. In this guideline, we are just recommending a mask – is that the intention?

 For chicken pox, current practice is the use of contact and airborne precautions (i.e. gown, gloves and P2 mask) given that both contact and airborne transmission is important. This is consistent with the revised CDC Guideline. Is the intent to just have a P2 mask now?

 We require all our staff and visitors to wear PPE for patients under precautions. Where is the onus for evidence of immunity? I would advise against this approach.

6.4 Type and duration of precautions for specific infections and conditions

Perhaps have a syndromic table instead of a disease table. The table is a confused mix of conditions that are not transmitted between people, specific infectious diseases, signs (ie cellulitis) and named micro-organisms (S. aureus in every combination). Or have a table of common infections that will be seen within Australian healthcare as well as syndromes (vomiting, diarrhoea of unknown cause, cough of unknown cause etc).

 This table needs quite a bit of work. Examples include:

 Abscess – the need for a single room and contact precautions would be controversial

• Bronchiolitis – consider droplet and contact precautions here, particularly as these are undifferentiated illnesses

• Campylobacter enteritis – the need for a single room and contact precautions would be controversial

• Chickenpox and shingles – this is inconsistent with 6.3 currently – Agree with contact and airborne for chickenpox and disseminated zoster but not for localised zoster (contact only)

• Many other examples that require review…

This will be a table commonly referred to so needs to be correct and internally consistent.

6.5 Collection of pathology specimens

 Suggest NPAACS is the only reference used here as this is Australia wide while the WA Health guideline is only relevant to WA.

Suggest give some examples here of some procedures and what the PPE recommended is.

6.6 Allowing animals into healthcare facilities

Reference 369 requires a reference next to it rather than ‘journal website’

6.7 Mechanisms of antibacterial action of antiseptics and disinfectants

 The statement - ‘Both antiseptics and disinfectants eliminate disease-causing micro-organisms…..’  is not strictly true. They do not eliminate micro-organisms but reduce the number of microbes, not just the disease causing ones.  Suggest this is reworded to ‘reduce the number of micro-organisms’.

 Suggest table is reorganized with the name of the disinfectant or antiseptic in the first column – this would make it easier to look up the active ingredient to find out how it works rather than having to have an idea of what the mode of action is. 

Suggest reformat this table into those disinfectants recommended for use and those not recommended for use, their relevant modes of action.

6.8 Summary table of relevant infection prevention and control guidelines

Suggest using and including AS4187 for reprocessing; ASID/ACIPC position statement of CDI; update the CDNA HCW with a BBV reference to the latest document; the Department of Health Influ Info and Gastro Info kits for Aged Care; the CDNA guidelines for management of gastroenteritis outbreaks and the influenza outbreaks; the various CDNA SoNGS