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

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1. Introduction: 

General comment Regarding Recommendations and Practice statements

The recommendation language (strong/weak) is inconsistent with common language use, confusing, easily misinterpreted, and diminishes/ weakens the message when taken to management to justify or support requests for investment or resources. Push back language ICP's recieve includes  ‘but that is only a guideline’ (compliance is not mandated), ‘but this is not a standard’ (we do not have to comply). “Is this reference a standard or only a guideline”, ‘is it a standard or only a recommendation”?

Also applies to situations instructing clinician practice.  Offering a ‘weak recommendation’ that ‘suggests’ protective eyewear should be worn; or it is a ‘weak recommendation’ that ‘suggests’ we should decontaminate the site of blood spills does not give a strong base to influence and change practice. Additionally this language does not give a strong position to  attract resource allocation in a tight economic environment using ‘weak recommendations suggesting’.  

Sodium hypochlorite is frequently listed (78 occasions) and appears synonymous with disinfectant. There is a range of TGA listed hospital strength products on the market. Consider changing the language to be generically inclusive of the full range of products with TGA approval for the purpose.

2. Basics of infection prevention and control: 

Section 2

2.3.1 Table Management of outbreak situations: This dot point should be the first dot point rather than last.

In hospitals, staff must respond quickly to an outbreak of an infection to contain the infection and stop it spreading further. Actions may include testing patients to see who may carry the infection, placing patients in single rooms or with other patients who have the infection, and limiting movements of people around the facility.

3. Standard and transmission-based precautions: 

3.1.4 Practice statement 12: Consider including detergent solution/wipe as part of the language otherwise it implies a liquid solution is the only choice. Change to flow to all references to detergent solutions in the guideline.

3.1.4 pdf page83; If a disinfectant is required, particularly during the implementation of transmission-based precautions, a TGA-registered hospital grade disinfectant (or sodium hypochlorite (TGA-listed) if indicated for use as per recommendation 17) must be used. The disinfectant chosen should have label claims against the organism of concern. The language TGA listed and registered need clarification. It has been explained to me that the  standard classification for Hospital Grade Disinfectants is ‘listing’. Listed  disinfectants have passed the TGA's Test with 4 micro-organisms under dirty conditions (E.Coli, Staphlococcus Aureus, Pseudomonas Aeruginosa and Proteus Vulgaris) which means listed disinfectants automatically have these 4 claims whether or not they are written on the label.

3.1.4 at practice statement 16. The section transition from spills to norovirus without any heading.

3.14 Recommendation 20. Reads like UV without sodium hypochlorite is still an option

3.1.4 pdf page 88  under quality of evidence “may not be be” (be is repeated); and .. imprecision and consistency cannnot (3 n’s in cannot)

3.1.6 all reusable medical devices and patient-care equipment used in the clinical environment should be reprocessed according to their intended use and manufacturer’s advice. This is a ‘Shall’ (mandatory) specification in section 5.1.2 of AS/NZS 4187:2014

3.1.6 Table 5 Non critical row

  • Disinfectant terminology – consistency AS4187 and TGO 54 use the term instrument grade with high, intermediate and low level disinfectants. (AS41871.5.33 page 14, TGO54 pare 2 and 20).
  • The non critical row is silent on items (e.g. bowls, bedpans) that can be cleaned/disinfected in Washer Disinfector – this omission implies the standard is manual clean and chemical disinfection AS/NZS 4187:2014 specifies an automated  washing/ disinfection is preferred (section 6.2.3 (ii))
  • The non critical row (in example column) - Non invasive ultrasound probes should also specify not used in contact with non-intact skin or mucous membranes.

3.2.1  Environmental cleaning The sentence structure is not clear. “In acute-care areas where the presence of infectious agents requiring transmission-based precautions is suspected or known, surfaces should be physically cleaned with a detergent solution. A TGA-registered hospital-grade disinfectant (or sodium hypochlorite (TGA-listed) if indicated for use as per Recommendation 17) should then be used (e.g. 2-step clean or 2-in-1 clean) as outlined in Section 3.1.4. In office-based practices and non-acute-care areas (e.g. long-term care facilities), the risk of contamination, mode of transmission and risk to others should be used to determine whether disinfectants are required.” Acknowledges 2 step but the information is contradictory regarding the use of 1 step or 2 step processes.

3.2.3  Where clinical need permits/is not compromised, it may be possible in some settings (e.g. interventional radiology) to schedule patients who require droplet precautions to the end of the list…. Not sure why this content has been added? Trying to reduce cleaning? Admitting cleaning is sub standard?

3.3.2 Outbreak investigation and management.  The only recommendation/ practice statement in this section is limited to norovirus. Would prefer a generic outbreak recommendation. Possible content includes:

  • All outbreaks, however minor, should be investigated promptly and thoroughly and the outcomes of the investigations documented.” And “An outbreak management plan should be developed based on local policy and consultation between the infection control professional, healthcare workers, patients, facility management and state/territory health authorities as appropriate” (3.3.2 pdf page 139)
  • “In hospitals, staff must respond quickly to an outbreak of an infection to contain the infection and stop it spreading further. Actions may include testing patients to see who may carry the infection, placing patients in single rooms or with other patients who have the infection, and limiting movements of people around the facility. (2.3.1 pdf page 34) Placement of large numbers of patients: In the event of an outbreak or exposure involving large numbers of patients who require airborne precautions, an infection control professional should be consulted before patient placement. What about other transmission pathways? All outbreaks with large numbers require IPC professional; and airborne precautions will require IPC support for measures which may include (return to the 2 dot points). Alternatively  change the section heading to be airborne specific. For specific control measures for CPE positive patient movement, see Australian Commission on Safety and Quality in Health Care, Recommendations for the control of CPE:…..  Add the hyperlink Practice statement 34 is confusing. It is good practice to consider the use of early bay closures to control norovirus outbreaks rather than ward/ unit closures. Most outbreaks (depending on size and volume of cases) use single room, then cohort rooms or bays of ‘Confirmed’cases of the same organism/illness then ward closure. I am not sure of the value of this content which requires the norovirus to be confirmed (it takes 24-48+ to get lab confirmation). Longer in non metropolitan areas sending specimens to micro labs in major cities. By the time the results are available it would not be considered early in the outbreak

3.4.3 Surgical procedures. It would be helpful to have a statement indicating operating room attire (scrubs) should not be worn outside of the OR suite. We need something to quote that scrubs worn in the wards and café should not be worn back into the OR. table 21 Dressings referenced to appendix to for aseptic technique. Also cross reference to section 3.18

4. Organisational support: 

4.1 Summary The last sentence in the summary indicates this content is acute focus – it should be a one health approach otherwise aged care is neglected and under resources.

4.1.1 – Why is there not any recommendation regarding requirement to have and IPC manager; and a resourced IPC program.

4.1.1 Practice statement 36 is about clinical practice rather than organisational governance.

4.1.2 Consider recommending a qualified IPC professional at health services HSO

4.1.3 This is good content for conversion into a recommendation or practice statement.

4.2.1 TST – difficult to resource and many rural and remote HSO are now using IGRA (quantiferon?) as a matter of convenience because TST resources and people who can perform the TST are not available. (also links to TST comment on pdf page 177).

4.2.1 The risk assessment table is confusing.

  • Parts 1 and 2 are separated in the commentary but scored together in the table (figure 8). Consider combining into one part
  • (figure 8) Parts 2 and 3 move left to right across the table page with increasing risk.
  • Part 4 Is not sequenced L to R in increasing order of risk.
  • There is no instruction/direction in how to use this information once competed and scored. Should there be recommended actions for each risk category?

4.2.1 Practice statement 39 is good. Should there be a corresponding practice statement or recommendation that requires the health facility to offer HCW immunisation services. 

4.2.2 “They should not penalise healthcare workers with loss of wages, benefits, or job status”. This is an Industrial issue not IPC.

4.2.2 Gastro – only 24 hour exclusion.  The reference for this content has numerous references to 48 hour exclusion periods (p16, 18, 19, 82, 95, 99, 105, 140, 149, 153 and 157. As well as Outbreak guidelines specify 48 hours (Vic, NSW, WA, & DoHA aged care outbreak). Section of this doc indicates 2 days.

4.2.2 Varicella ……..personnel must be (what?) until all blisters have dried.

4.2.2 Question – Should c diff be added to this chart?

4.2.2 Practice statement 40– is limited to norovirus – should the statement generically refer to all conditions on the table rather than only 1 condition.

4.2.5 Joint replacement is listed as a podiatry procedure

4.3 Practice statement 41. Agree that ICP need ongoing commitment and engagement with professional development. Should there also be a requirement for health facilities to employ an ICP with a minimum qualification or credential?

4.4 “All staff involved in surveillance should be appropriately trained in data collection techniques” supports need to recommend facilities have qualified ICP

5. Appendix 1: 

No comments submitted

6. Appendix 2: 

6.1 Cleaning frequency tables

6.1 risk rating table: Outbreak is listed associated with a high risk area. Outbreaks are bad news in all risk areas. Can the category be called Outbreak?

6.1 Carpet has lost table formatting and the information does not line up

6.1 Curtains and blinds has lost table formatting and information does not line up

6.1 Fridges. 3x frequency in Significant risk only – for food safety the frequency of fridge 6.1 cleaning should be standard regardless of setting

6.1 Glazing – low risk inconsistent (spot clean)

6.1. Locker – specify ‘bedside’ to differentiate from staff lockers. Why 2x day clean in outbreak. This is inconsistent with frequently touched ‘like’ equipment (e.g. IV stands, light switch, door handles) which have not been amplified.

6.1 Manual handling (hoists) is missing the cleaning method

6.1 Mattress: clean weekly while occupied by the same person?? Same for pillow.

6.1 Medical equipment: Not connected to the patient -clean daily does this mean while the  equipment is in storage

6.1 Microwave: 3x cleaning assumes outbreak is gastro. Inconsistent win clinical areas Food safety is food safety and the risk does not change with the ward setting.

6.1 Pillow: see mattress above.

6.1 Hand basin: Does not get cleaned after each use – suggest add ‘spot clean’

6.1 Surfaces (ledges) Daily and after use window ledges are not a frequently touched surface

6.1 Telephone – why is the phone amplified cleaning x2 daily for outbreak?.

6.1 Toilet (raised seat) – if left insitu it should assume the same frequency as the toilet

6.1 Wash bowl  – non environmental item. Should be processed in the washer disinfector.

6.2 Checklist 6.2 table header. Why are gloves and sterile gloves (a sub set of gloves) in sperate columns? Suggest the table would be simpler by putting gloves in one column and use text to indicate if unsterile or sterile are required. Or change gloves to ‘unsterile gloves)

6.4 table of diseases, precautions and duration

6.4 General: Precautions – standard precautions is not listed for all diseases (omitted when other precautions are listed). S should be included for all.

6.4 Inconsistent positioning of which column not transmitted person to person is in across the chart

6.4 Bronchiolitis contact and droplet transmission listed – only contact precautions listed? Why is the following different for Chicken pox Susceptible healthcare workers must not attend the patient. This is different to the detail in the listed reference (page 112. “Susceptible HCWs should not enter room if immune caregivers are available; no recommendation for face protection of immune HCWs; no recommendation for type of protection, i.e., surgical mask or respirator for susceptible HCWs.”) Is there another reference for ‘must not’   NB:  measles and polio  indicate “Non-immune staff should not care for patient”

6.4 Conjunctivitis acute Bacterial  transmission route and precautions is blank

6.4 Guillian Barre – type of infection and transmission route is blank – needs an indicator to show n/a or not an infectious condition (Rheumatic fever)

6.4 Haemophilus pneumonia adults – transmission is blank

6.4 Haemophilus pneumonia children – transmission is blank

6.4 Hep B comments indicate to immunise HCW’s - should this statement also be made for all vaccine preventable diseases with HCW recommendations?

6.4 Kawasaki syndrome – type of infection and transmission route is blank and looks like an error –  and needs an indicator to show it is N/A.  See Rheumatic fever page 241 indicates not an infectious condition in the type of infection column

6.4 Lice – head has contact precautions?

6.4 Parvovirus B19 (Erythema infectiosum) noted to be droplet transmission. Only standard precautions listed?

6.4 Plague Yersinia pestis. Precautions are not listed

6.4 RSV – noted to be transmitted by droplet. Only contact precautions are listed.

6.4 Rhinovirus noted as droplet and contact transmission. Only droplet precautions are listed. The reference doc has Add Contact Precautions if copious moist secretions and close contact likely to occur in the comments column.

6.4 Rubella Comment column specifies non immune pregnant staff should not attend but leaves other non immune staff ambiguous.

6.4 Rubella lists contact and droplet transmission but only droplet precautions – does this need explanation in the comment column?

6.4 Staphylococcal infection x5 The type of infection and transmission route are not listed.

6.4 Streptococcal infection x7 The type of infection and transmission route are not listed.

6.4 Tuberculosis x5 The type of infection and transmission route are not listed.

6.4 Viral haemorrhagic fevers inconsistent with ebola guidelines.

6.7 Cross linking macromolecules – is alkylating yje aminoe a typo error?

7. Appendix 3 : 

No comment submitted

8. Glossary / Abbreviations and Acronyms: 

8 Glossary: Disinfectant (NB: sodium hypochlorite is an example disinfectant chemical– not a definition). Suggest use the definition from AS4187 or TGO 54

  • AS 4187 A substance that is recommended by its manufacturer for application to an inanimate object to kill a range of microorganisms. section 1.5.19 page 12
  • TGO 54 Disinfectant means a substance:
  • (a) that is recommended by its manufacturer for application to an inanimate object to kill a range of micro-organisms; and
  • (b) that is not represented by the manufacturer to be suitable for internal use. page 3

8 Glossary: Disinfection definition: There is a better definition on page 99 of these guidelines or use AS4187 1.5.20 page 12  Reduction of the number of viable microorganisms on a product to a level previously specified as appropriate for its intended further handling or use.

8 Glossary: HEPA usually all capitals

8 Glossary: Hospital grade disinfectant definition: hospital grade disinfectant means a disinfectant that is suitable for general purpose disinfection of building and fitting surfaces, and purposes not involving instruments or surfaces likely to come into contact with broken skin. TGO 54 page 4

8 Glossary: Hypochlorite – is a chemical rather than a definition of a disinfectant.  Suggest deleting the term

  1. Glossary: Instrument grade disinfectant: instrument grade disinfectant means;

  • a disinfectant which is used to reprocess reusable therapeutic devices; and
  • when associated with the words “low”, “intermediate” or “high” means “low”, “intermediate” or “high” level disinfectant respectively. AS 4187 1.5.33 page 14 and is the same is in TGO 54 page 4

8 Glossary: Low level disinfection – is an adjunct to cleaning. It is not an alternative to cleaning. Always clean first.

8 Glossary: Negative pressure room – Include ventilation detail - The air handling system operates at a lower pressure with respect to adjacent areas such as the anteroom and corridor and is exhausted to the outside. From AUS HFG

8 Glossary: Single use definition ü Do we also need a definition for single patient use? Is there one?

8 Glossary: Sterilization definition – A Validated process used to render a product free from viable microorganisms. AS4187 1.5.83 page 19

8 Glossary – consider adding definitions for TGA listed and TGA registered disinfectant

Page reviewed: 24 September, 2019