1. Leadership Support

References and resources: 1-12

1. Ensure that the governing body of the healthcare facility or organization is accountable for the success of infection prevention activities.
2. Allocate sufficient human and material resources to infection prevention to ensure consistent and prompt action to remove or mitigate infection risks and stop transmission of infections. Ensure that staffing and resources do not prevent nurses, environmental staff, et. al., from consistently adhering to infection prevention and control practices.
3. Assign one or more qualified individuals with training in infection prevention and control to manage the facility’s infection prevention program.
4. Empower and support the authority of those managing the infection prevention program to ensure effectiveness of the program.

To be successful, infection prevention programs require visible and tangible support from all levels of the healthcare facility’s leadership. 2. Education and Training of Healthcare Personnel on Infection Prevention

References and resources: 1-4, 6-8, 10-13

1. Provide job-specific, infection prevention education and training to all healthcare personnel for all tasks.
   1. Require training before individuals are allowed to perform their duties and at least annually as a refresher.
   2. Provide additional training in response to recognized lapses in adherence and to address newly recognized infection transmission threats (e.g., introduction of new equipment or procedures).
2. Develop processes to ensure that all healthcare personnel understand and are competent to adhere to infection prevention requirements as they perform their roles and responsibilities.
3. Provide written infection prevention policies and procedures that are available, current, and based on evidence-based guidelines (e.g., CDC/ HICPAC, etc.).

Training should be adapted to reflect the diversity of the workforce and the type of facility, and tailored to meet the needs of each category of healthcare personnel being trained. 3. Patient, Family and Caregiver Education

References and resources: 2-5, 7-8, 10-11

1. Provide appropriate infection prevention education to patients, family members, visitors, and others included in the caregiving network.

Include information about how infections are spread, how they can be prevented, and what signs or symptoms should prompt reevaluation and notification of the patient’s healthcare provider. Instructional materials and delivery should address varied levels of education, language comprehension, and cultural diversity 4. Performance Monitoring and Feedback

References and resources: 1-14

1. Identify and monitor adherence to infection prevention practices and infection control requirements.
2. Provide prompt, regular feedback on adherence and related outcomes to healthcare personnel and facility leadership.
3. Train performance monitoring personnel and use standardized tools and definitions.
4. Monitor the incidence of infections that may be related to care provided at the facility and act on the data and use information collected through surveillance to detect transmission of infectious agents in the facility.

Performance measures should be tailored to the care activities and the population served. 5. Standard Precautions Use Standard Precautions to care for all patients in all settings. Standard Precautions include:
5a. Hand hygiene
5b. Environmental cleaning and disinfection
5c. Injection and medication safety
5d. Risk assessment with use of appropriate personal protective equipment (e.g., gloves, gowns, face masks) based on activities being performed
5e. Minimizing Potential Exposures (e.g. respiratory hygiene and cough etiquette)
5f. Reprocessing of reusable medical equipment between each patient or when soiled Standard Precautions are the basic practices that apply to all patient care, regardless of the patient’s suspected or confirmed infectious state, and apply to all settings where care is delivered. These practices protect healthcare personnel and prevent healthcare personnel or the environment from transmitting infections to other patients. 5a. Hand Hygiene

References and resources: 3, 7, 11

1. Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations.
2. Use an alcohol-based hand rub or wash with soap and water for the following clinical indications:
   1. Immediately before touching a patient
   2. Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices
   3. Before moving from work on a soiled body site to a clean body site on the same patient
   4. After touching a patient or the patient’s immediate environment
   5. After contact with blood, body fluids or contaminated surfaces
   6. Immediately after glove removal
3. Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled.
4. Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered.

Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink.

Refer to “CDC Guideline for Hand Hygiene in Health-Care Settings” or “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007” for additional details.

5b. Environmental Cleaning and Disinfection

References and resources: 4, 7, 10, 11, 13, 21

1. Require routine and targeted cleaning of environmental surfaces as indicated by the level of patient contact and degree of soiling.
   1. Clean and disinfect surfaces in close proximity to the patient and frequently touched surfaces in the patient care environment on a more frequent schedule compared to other surfaces.
   2. Promptly clean and decontaminate spills of blood or other potentially infectious materials.
2. Select EPA-registered disinfectants that have microbiocidal activity against the pathogens most likely to contaminate the patient-care environment.
3. Follow manufacturers’ instructions for proper use of cleaning and disinfecting products (e.g., dilution, contact time, material compatibility, storage, shelf-life, safe use and disposal).

When information from manufacturers is limited regarding selection and use of agents for specific microorganisms, environmental surfaces or equipment, facility policies regarding cleaning and disinfecting should be guided by the best available evidence and careful consideration of the risks and benefits of the available options.

Refer to “CDC Guidelines for Environmental Infection Control in Health-Care Facilities” and “CDC Guideline for Disinfection and Sterilization in Healthcare Facilities” for details.

5c. Injection and Medication Safety

References and resources: 7, 11, 16-20

1. Prepare medications in a designated clean medication preparation area that is separated from potential sources of contamination, including sinks or other water sources.
2. Use aseptic technique when preparing and administering medications
3. Disinfect the access diaphragms of medication vials before inserting a device into the vial
4. Use needles and syringes for one patient only (this includes manufactured prefilled syringes and cartridge devices such as insulin pens).
5. Enter medication containers with a new needle and a new syringe, even when obtaining additional doses for the same patient.
6. Ensure single-dose or single-use vials, ampules, and bags or bottles of parenteral solution are used for one patient only.
7. Use fluid infusion or administration sets (e.g., intravenous tubing) for one patient only
8. Dedicate multidose vials to a single patient whenever possible. If multidose vials are used for more than one patient, restrict the medication vials to a centralized medication area and do not bring them into the immediate patient treatment area (e.g., operating room, patient room/cubicle)
9. Wear a facemask when placing a catheter or injecting material into the epidural or subdural space (e.g., during myelogram, epidural or spinal anesthesia)

Refer to “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007” for details. 5d. Risk Assessment with Appropriate Use of Personal Protective Equipment

References and resources: 7, 11, 19, 20

1. Ensure proper selection and use of personal protective equipment (PPE) based on the nature of the patient interaction and potential for exposure to blood, body fluids and/or infectious material:
   1. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur.
   2. Wear a gown that is appropriate to the task to protect skin and prevent soiling of clothing during procedures and activities that could cause contact with blood, body fluids, secretions, or excretions.
   3. Use protective eyewear and a mask, or a face shield, to protect the mucous membranes of the eyes, nose and mouth during procedures and activities that could generate splashes or sprays of blood, body fluids, secretions and excretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed.
   4. Remove and discard PPE, other than respirators, upon completing a task before leaving the patient’s room or care area. If a respirator is used, it should be removed and discarded (or reprocessed if reusable) after leaving the patient room or care area and closing the door.
   5. Do not use the same gown or pair of gloves for care of more than one patient. Remove and discard disposable gloves upon completion of a task or when soiled during the process of care.
   6. Do not wash gloves for the purpose of reuse.
2. Ensure that healthcare personnel have immediate access to and are trained and able to select, put on, remove, and dispose of PPE in a manner that protects themselves, the patient, and others

PPE, e.g., gloves, gowns, face masks, respirators, goggles and face shields, can be effective barriers to transmission of infections but are secondary to the more effective measures such as administrative and engineering controls.

Refer to “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007” as well as Occupational Safety and Health Administration (OSHA) requirements for details.

5e. Minimizing Potential Exposures

References and resources: 1, 7, 11, 21, 22

1. Develop and implement systems for early detection and management (e.g., use of appropriate infection control measures, including isolation precautions, PPE) of potentially infectious persons at initial points of patient encounter in outpatient settings (e.g., triage areas, emergency departments, outpatient clinics, physician offices) and at the time of admission to hospitals and long-term care facilities (LTCF).
2. Use respiratory hygiene and cough etiquette to reduce the transmission of respiratory infections within the facility.
3. Prompt patients and visitors with symptoms of respiratory infection to contain their respiratory secretions and perform hand hygiene after contact with respiratory secretions by providing tissues, masks, hand hygiene supplies and instructional signage or handouts at points of entry and throughout the facility
4. When space permits, separate patients with respiratory symptoms from others as soon as possible (e.g., during triage or upon entry into the facility).

Refer to “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007” for details.

During periods of higher levels of community respiratory virus transmission*, facilities should consider having everyone mask upon entry to the facility to ensure better adherence to respiratory hygiene and cough etiquette for those who might be infectious. Such an approach could be implemented facility-wide or targeted toward higher risk areas (e.g., emergency departments, urgent care, units experiencing an outbreak) based on a facility risk assessment.

*Examples of potential metrics include, but are not limited to, increase in outbreaks of healthcare-onset respiratory infections, increase in emergency department or outpatient visits related to respiratory infections.

5f. Reprocessing of Reusable Medical Equipment

References and resources: 2-4, 7-8, 11-13

1. Clean and reprocess (disinfect or sterilize) reusable medical equipment (e.g., blood glucose meters and other point-of-care devices, blood pressure cuffs, oximeter probes, surgical instruments, endoscopes) prior to use on another patient or when soiled.
   1. Consult and adhere to manufacturers’ instructions for reprocessing.
2. Maintain separation between clean and soiled equipment to prevent cross contamination.

Manufacturer’s instructions for reprocessing reusable medical equipment should be readily available and used to establish clear operating procedures and training content for the facility. Instructions should be posted at the site where equipment reprocessing is performed. Reprocessing personnel should have training in the reprocessing steps and the correct use of PPE necessary for the task. Competencies of those personnel should be documented initially upon assignment of their duties, whenever new equipment is introduced, and periodically (e.g., annually). Additional details about reprocessing essentials for facilities can be found in HICPAC’s recommendations Essential Elements of a Reprocessing Program for Flexible Endoscopes (Essential Elements of a Reprocessing Program for Flexible Endoscopes – Recommendations of the HICPAC).

Refer to “CDC Guideline for Disinfection and Sterilization in Healthcare Facilities” for details

6. Transmission-Based Precautions

References and resources: 7, 11

1. Implement additional precautions (i.e., Transmission-Based Precautions) for patients with documented or suspected diagnoses where contact with the patient, their body fluids, or their environment presents a substantial transmission risk despite adherence to Standard Precautions
2. Adapt transmission-based precautions to the specific healthcare setting, the facility design characteristics, and the type of patient interaction.
3. Implement transmission-based precautions based on the patient’s clinical presentation and likely infection diagnoses (e.g., syndromes suggestive of transmissible infections such as diarrhea, meningitis, fever and rash, respiratory infection) as soon as possible after the patient enters the healthcare facility (including reception or triage areas in emergency departments, ambulatory clinics or physicians’ offices) then adjust or discontinue precautions when more clinical information becomes available (e.g., confirmatory laboratory results).
4. To the extent possible, place patients who may need transmission-based precautions into a single-patient room while awaiting clinical assessment.
5. Notify accepting facilities and the transporting agency about the need for transmission-based precautions based on suspected or confirmed infections or presence of targeted multidrug-resistant pathogens when patients are transferred.

Implementation of Transmission-Based Precautions may differ depending on the patient care settings (e.g., inpatient, outpatient, long-term care), the facility design characteristics, and the type of patient interaction, and should be adapted to the specific healthcare setting.

Refer to “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007” for details.

7. Temporary invasive Medical Devices for Clinical Management

References and resources: 8, 11

1. During each healthcare encounter, assess the medical necessity of any invasive medical device (e.g., vascular catheter, indwelling urinary catheter, feeding tubes, ventilator, surgical drain) in order to identify the earliest opportunity for safe removal.
2. Ensure that healthcare personnel adhere to recommended insertion and maintenance practices

Early and prompt removal of invasive devices should be part of the plan of care and included in regular assessment. Healthcare personnel should be knowledgeable regarding risks of the device and infection prevention interventions associated with the individual device, and should advocate for the patient by working toward removal of the device as soon as possible.

Refer to “CDC Guidelines for Environmental Infection Control in Health-Care Facilities” and “CDC Guideline for Disinfection and Sterilization in Healthcare Facilities” for details.

8. Occupational Health

References and resources: 1, 7, 18, 19

1. Ensure that healthcare personnel either receive immunizations or have documented evidence of immunity against vaccine-preventable diseases as recommended by the CDC, CDC’s Advisory Committee on Immunization Practices (ACIP) and required by federal, state or local authorities.
2. Implement processes and sick leave policies to encourage healthcare personnel to stay home when they develop signs or symptoms of acute infectious illness (e.g. fever, cough, diarrhea, vomiting, or draining skin lesions) to prevent spreading their infections to patients and other healthcare personnel.
3. Implement a system for healthcare personnel to report signs, symptoms, and diagnosed illnesses that may represent a risk to their patients and coworkers to their supervisor or healthcare facility staff who are responsible for occupational health
4. Adhere to federal and state standards and directives applicable to protecting healthcare workers against transmission of infectious agents including OSHA’s Bloodborne Pathogens Standard, Personal Protective Equipment Standard, Respiratory Protection standard and TB compliance directive.

It is the professional responsibility of all healthcare organizations and individual personnel to ensure adherence to federal, state and local requirements concerning immunizations; work policies that support safety of healthcare personnel; timely reporting of illness by employees to employers when that illness may represent a risk to patients and other healthcare personnel; and notification to public health authorities when the illness has public health implications or is required to be reported.

Refer to OSHA’s website for specific details on healthcare standards: Occupational Safety and Health Administration – Infectious Diseases (OSHA Healthcare).

Facility professionals routinely perform risk assessments to make sure construction work will have a minimal impact on patient safety and comfort.

Image courtesy of ASHE

Health care facility engineering and maintenance staff play an important role in providing a safe and healing environment for patients, visitors and staff.

The look and feel of a health care facility impacts the first and lasting impressions of patients and visitors. A properly maintained and operated facility provides an environment that patients expect and deserve.

Although facility professionals understand they play a role in reducing or eliminating health care-associated infections (HAIs), a closer look at the many ways they assist in this effort and additional ways they can do even more will prove useful.

Spotting problems

One of the advantages facility professionals have over infection control practitioners is that they are constantly moving throughout the facility and may be able to spot potential problems that infection control staff may not see. Issues facility professionals might find and report or correct can assist the ongoing challenges all health care workers face when trying to reduce HAIs.

Health care maintenance staff are already involved in many activities that impact aspects of infection prevention, and many of these efforts are behind the scenes. Often, this staff is not recognized for the positive impact they play toward keeping patients safe.

For example, work performed on HVAC systems and building equipment have a direct impact on helping to prevent infections.

Related Article

The dangers of mold

Another area that has received more attention and effort in recent years is water management programs. Understanding the water systems in health care facilities, the processes that are in place, and properly maintaining cooling towers, ice machines, water features and the entire water distribution system plays a significant role in infection prevention.

In the area of construction, renovation and building maintenance activities, facility professionals routinely perform infection control risk assessments (ICRAs) and preconstruction risk assessments (PCRAs) to make sure the work performed will have a minimal impact on patient safety and comfort.

A sampling of some of the maintenance activities that have a direct effect on infection prevention includes:

• Changing filters and making sure filters in the air-handling units are installed properly to prevent leakage of air passing the filter.
• Maintenance of condensate pans in air handlers and keeping the interiors of the air handlers clean.
• Controlling the temperature and humidity of critical areas as required to maintain proper space conditions.
• Ongoing monitoring and control of pressure relationships in critical areas such as operating rooms (ORs), airborne isolation rooms, protective environment rooms, procedure rooms, sterile processing, sterile storage areas, and clean and soiled utility rooms.
• Maintenance of the boilers and steam systems to be sure the quality of the steam is suitable for humidification and sterilization.
• Proper maintenance of ice machines and coffee machines.
• Proper cooling tower maintenance and water management.
• Maintaining domestic hot water temperatures and preventing “dead legs” in water systems.
• Decorative fountain and drinking fountain preventive maintenance.

Reducing the risk of HAIs is a team effort, and each staff member has a role to play. This includes the important task of proper handwashing as well as taking time to understand the impact routine activities can have on patient care and patient safety.

Paying attention

“If you see something, say something” is a phrase used by the Department of Homeland Security as part of its national campaign to raise public awareness of the indicators of terrorism and terrorism-related crime, as well as the importance of reporting suspicious activity to law enforcement. The goal is to have everyone pay more attention to their surroundings and to report anything unusual.

This phrase could also be applied to improving the environment for patients, staff and visitors. By paying more attention to surroundings as they move throughout their hospitals and by reporting or correcting issues they find, facility professionals can make their hospitals safer and further reduce the number of HAIs that pose a risk to patients.

Many of these issues and situations could be corrected by facility maintenance staff, while others would require notifying the appropriate clinical staff or infection prevention specialists.

HVAC and building-related issues. HVAC and other building-related issues have a major impact on HAIs. Here are some things to look for:

• Pressure relationships. Many areas of a health care facility require specific pressure relationships to adjacent areas.

  For example, clean areas such as ORs, sterile supply storage areas and protective environment rooms must maintain positive pressure relative to surrounding areas. In addition to proper operation of the HVAC system and related controls, facility professionals should look for doors that may have been propped open that could impact the required pressure relationship.

  Some areas that require negative pressure relative to adjacent areas are soiled utility rooms, soiled linen storage rooms, and airborne infectious isolation rooms. Again, facility professionals should watch for doors that may be blocked open or exhaust grills that are dirty and restricting airflow.
• Temperature and humidity control. Critical areas such as ORs, central processing and areas where sterile supplies are stored have specific requirements for temperature and humidity. Responding quickly to any situation where established limits are exceeded can help prevent the possibility of damage to supplies and equipment due to excessive humidity or temperature. Facility professionals should be sure to maintain open communication. If an area is out of compliance, they should make the appropriate staff aware of the situation.
• Improper filter installation. The filters in the air-handling system are critical for providing the clean air needed for patient care. When servicing an air handler, facility professionals always inspect the filters for proper installation to verify there are no gaps between the filters. They also should exercise care when removing filters to minimize the risk of generating dust inside the air handler. Facility professionals also should be sure to communicate when they perform work on any mechanical system controlling critical spaces. It may be necessary to perform terminal cleanings after some mechanical work. An example may be work performed in ORs or on OR air handlers.
• Leaking or damaged windows. Leaking or damaged windows can introduce insects or mold-causing moisture into the building. They can also impact required pressure relationships. Facility professionals should be on the lookout for any windows that do not properly seal.
• Stained ceiling tile. A stained ceiling tile is typically the result of a leak of some sort. This can cause mold to form on the ceiling tile which can present a risk to patients.

  Facility professionals should take precautions when removing a damaged ceiling tile to minimize the risk of distributing mold spores into the air. They should determine the source of the leak and make the needed repair before installing the replacement tile.

  Facility professionals should move as quickly as possible, and make sure they include an on-site infection preventionist (IP). Best practice is to contain the affected area immediately, communicate with the IP and determine the proper steps moving forward.
• Signs of mold. Facility professionals should report any signs of mold, which is often noticed near plumbing fixtures, under sinks or in similar areas. Mold can be very harmful to patients and should always be carefully examined and an approved removal process developed.

Construction activities. The HAI dangers imposed by construction and maintenance activities are well known to facility professionals. Key areas to look for include:

• ICRAs and PCRAs. It is important that facility professionals work closely with infection prevention staff to identify the risk levels of patient care areas so proper precautions can be implemented when performing maintenance activities or construction that could pose a risk to patients.

  Maintenance staff should be familiar with the organization’s ICRA process and be proactive in initiating the process. At times, it may be difficult for a new maintenance staff member to know the risk levels throughout the hospital. To aid in this effort, some facilities have developed color-coded floor plans to indicate the infection control risk levels in every area of the facility. This is a useful document and should always be developed as a group effort with both facilities and infection control staff.

• Construction barriers. Areas under construction should always be sealed off from occupied areas with approved construction barriers. In addition, the construction area should be maintained under negative pressure relative to the adjacent occupied areas.

  Doors to construction areas should remain closed at all times. Facility professionals should report any breach in the construction barrier or if the area is not under negative pressure. If exhaust fans with HEPA filters are used to maintain the negative pressure in construction areas, make sure the HEPA filters are installed properly. Some facilities utilize particulate monitors to periodically test the discharge air from these unit to verify proper operation.
• Construction debris removal. The PCRA should determine how construction debris will be removed, including the route taken through the building. Any trash cart removing debris should be covered with a clean cover to prevent dust from entering the occupied portion of the building and the wheels of the carts or other construction equipment should be cleaned before entering the occupied portion of the building. If walk-off “sticky mats” are used, they should be changed frequently.

Supplies. Proper storage of supplies is very important. Some issues to watch for and to report or correct include:

• Medical supplies on the floor. Medical supplies should always be stored on shelving or in cabinets and should never be stored directly on the floor.
• Cardboard boxes. Outer cardboard shipping boxes should not be placed in clinical or clinical-support areas such as the pharmacy or clean supply rooms. The outer cardboard boxes should be removed at central receiving and should not be brought to the patient floor because they could be infested with insects.
• Missing solid bottom shelving. The bottom shelves of storage units should be covered with a solid, cleanable material such as metal or plastic. This prevents the possibility of water splashing onto supplies when flooring is cleaned.

• Repurposed rooms. Rooms used to store clean supplies and rooms used to store soiled products have specific requirements related to both life safety and pressure relationships. For example, clean supply rooms must maintain positive pressure, while soiled utility and trash rooms must maintain negative pressure relative to adjacent areas.

  Facility professionals should be on the lookout for rooms such as former offices or former patient rooms being used for storage. A former office or patient room would not likely meet the requirements for these other functions.
• Uncovered linen. All linen must be covered unless stored in a linen room that is designated to store linen and nothing else.
• Supplies stored under sinks. Supplies should not be stored under sinks because a plumbing leak could contaminate the supplies. A best practice is to secure the cabinet under the sink. There is no reason for anyone other than the facilities team to have access to the area under the sink.
• Abandoned wooden pallets. Pallets used to deliver material to a hospital should be removed after they are unloaded. They are a potential source of contaminants.

Miscellaneous items. Because of their random nature, miscellaneous HAI concerns can sometimes be the hardest to spot. Some things to look for include:

• High levels of dust. Facility professionals should be on the lookout for dust that accumulates on the tops of picture frames, fire alarm devices, sprinkler heads or similar areas. Dust also can accumulate on doors and door frames at locations where the door is rarely opened (e.g., an exit door with delayed egress hardware).
• Evidence of water damage. Water damage that is not quickly repaired can result in mold. Some areas to watch for are behind sinks, under dialysis connection boxes and similar spaces.
• Damaged flooring in clinical areas. Damaged flooring does not provide a smooth, cleanable surface and can result in an infection prevention concern.
• Peeling paint or damaged wall surface. A wall surface that is not smooth is not cleanable and also is an infection prevention concern.
• Damaged plastic laminate, upholstery, doors and similar items. Plastic laminate casework is frequently damaged, resulting in a surface that cannot be cleaned properly. The same applies to damaged upholstery, mattresses and other surfaces. Damaged materials must be repaired or replaced to provide a cleanable surface.

• Dirty floors in areas where clinical staff, supplies or food travel. Floors that are not maintained and cleaned properly provide an opportunity for dirt to be tracked into clinical areas.

  For example, a soiled utility room used by clinical staff caring for critical patients requires a clean floor. Otherwise, staff can track dirt directly into a patient room. The same situation applies to a loading dock that has a very dirty floor. Staff can track this dirt into the kitchen, pharmacy or other clinical areas to which supplies are delivered.
• Tape on walls or flooring. Tape or the residue from tape can result in walls or floors that cannot be properly cleaned.
• Dirty wheels on carts. Dirty cart wheels can be a source of infection because they will transport dirt into a critical clinical area.
• Malfunctioning refrigerators. Refrigerators used for pharmacies, patient food or specimens that do not maintain the required temperatures can create infection control issues.
• Ice machines. Ice machines that are not cleaned properly and routinely pose an infection control risk.
• Overfilled sharps containers. Sharps containers must be emptied as required to prevent overfilling.
• Unfilled or broken hand-hygiene dispensers. Hand hygiene is a crucial component of patient safety and infection prevention. As a result, hand-hygiene dispensers must be available and operable at all times.
• Drinks or food at nurse stations. Food and drink are not permitted at nurse stations.
• Staff using scented lotions. This could affect patients with open wounds or sensitive skin.

Constantly aware

Although the primary role of hospital engineering and maintenance staff is to service and maintain the building and building equipment, it also plays an important role in preventing infections.

By being constantly aware of their surroundings and watching for common issues that can increase the risk of infection, facility professionals can do even more to improve the safety of their buildings.

In short, facility professionals must remember: “If you see something, say something.” 

Please note: An erratum has been published for this article. To view the erratum, please click here.

Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: [email protected]. Type 508 Accommodation and the title of the report in the subject line of e-mail.

Guidelines for Environmental Infection Control in Health-Care Facilities

Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)

Prepared by
Lynne Sehulster, Ph.D.1
Raymond Y.W. Chinn, M.D.2
1Division of Healthcare Quality Promotion
National Center for Infectious Diseases
2HICPAC member
Sharp Memorial Hospital
San Diego, California

The material in this report originated in the National Center for Infectious Diseases, James M. Hughes, M.D., Director; and the Division of Healthcare Quality Promotion, Steven L. Solomon, M.D., Acting Director.

Summary

The health-care facility environment is rarely implicated in disease transmission, except among patients who are immunocompromised. Nonetheless, inadvertent exposures to environmental pathogens (e.g., Aspergillus spp. and Legionella spp.) or airborne pathogens (e.g., Mycobacterium tuberculosis and varicella-zoster virus) can result in adverse patient outcomes and cause illness among health-care workers. Environmental infection-control strategies and engineering controls can effectively prevent these infections. The incidence of health-care--associated infections and pseudo-outbreaks can be minimized by 1) appropriate use of cleaners and disinfectants; 2) appropriate maintenance of medical equipment (e.g., automated endoscope reprocessors or hydrotherapy equipment); 3) adherence to water-quality standards for hemodialysis, and to ventilation standards for specialized care environments (e.g., airborne infection isolation rooms, protective environments, or operating rooms); and 4) prompt management of water intrusion into the facility. Routine environmental sampling is not usually advised, except for water quality determinations in hemodialysis settings and other situations where sampling is directed by epidemiologic principles, and results can be applied directly to infection-control decisions.

This report reviews previous guidelines and strategies for preventing environment-associated infections in health-care facilities and offers recommendations. These include 1) evidence-based recommendations supported by studies; 2) requirements of federal agencies (e.g., Food and Drug Administration, U.S. Environmental Protection Agency, U.S. Department of Labor, Occupational Safety and Health Administration, and U.S. Department of Justice); 3) guidelines and standards from building and equipment professional organizations (e.g., American Institute of Architects, Association for the Advancement of Medical Instrumentation, and American Society of Heating, Refrigeration, and Air-Conditioning Engineers); 4) recommendations derived from scientific theory or rationale; and 5) experienced opinions based upon infection-control and engineering practices. The report also suggests a series of performance measurements as a means to evaluate infection-control efforts.

Introduction

Parameters of the Report

This report, which contains the complete list of recommendations with pertinent references, is Part II of Guidelines for Environmental Infection Control in Health-Care Facilities. The full four-part guidelines will be available on CDC's Division of Healthcare Quality Promotion (DHQP) website. Relative to previous CDC guidelines, this report

• revises multiple sections (e.g., cleaning and disinfection of environmental surfaces, environmental sampling, laundry and bedding, and regulated medical waste) from previous editions of CDC's Guideline for Handwashing and Hospital Environmental Control;
• incorporates discussions of air and water environmental concerns from CDC's Guideline for Prevention of Nosocomial Pneumonia;
• consolidates relevant environmental infection-control measures from other CDC guidelines; and
• includes two topics not addressed in previous CDC guidelines --- infection-control concerns related to animals in health-care facilities and water quality in hemodialysis settings.

In the full guidelines, Part I, Background Information: Environmental Infection Control in Health-Care Facilities, provides a comprehensive review of the relevant scientific literature. Attention is given to engineering and infection-control concerns during construction, demolition, renovation, and repair of health-care facilities. Use of an infection-control risk assessment is strongly supported before the start of these or any other activities expected to generate dust or water aerosols. Also reviewed in Part I are infection-control measures used to recover from catastrophic events (e.g., flooding, sewage spills, loss of electricity and ventilation, or disruption of water supply) and the limited effects of environmental surfaces, laundry, plants, animals, medical wastes, cloth furnishings, and carpeting on disease transmission in health-care facilities. Part III and Part IV of the full guidelines provide references (for the complete guideline) and appendices, respectively.

Part II (this report) contains recommendations for environmental infection control in health-care facilities, describing control measures for preventing infections associated with air, water, or other elements of the environment. These recommendations represent the views of different divisions within CDC's National Center for Infectious Diseases and the Healthcare Infection Control Practices Advisory Committee (HICPAC), a 12-member group that advises CDC on concerns related to the surveillance, prevention, and control of health-care--associated infections, primarily in U.S. health-care facilities. In 1999, HICPAC's infection-control focus was expanded from acute-care hospitals to all venues where health care is provided (e.g., outpatient surgical centers, urgent care centers, clinics, outpatient dialysis centers, physicians' offices, and skilled nursing facilities). The topics addressed in this report are applicable to the majority of health-care facilities in the United States. This report is intended for use primarily by infection-control practitioners, epidemiologists, employee health and safety personnel, engineers, facility managers, information systems professionals, administrators, environmental service professionals, and architects. Key recommendations include

• infection-control impact of ventilation system and water system performance;
• establishment of a multidisciplinary team to conduct infection-control risk assessment;
• use of dust-control procedures and barriers during construction, repair, renovation, or demolition;
• environmental infection-control measures for special areas with patients at high risk;
• use of airborne-particle sampling to monitor the effectiveness of air filtration and dust-control measures;
• procedures to prevent airborne contamination in operating rooms when infectious tuberculosis (TB) patients require surgery;
• guidance regarding appropriate indications for routine culturing of water as part of a comprehensive control program for legionellae;
• guidance for recovering from water-system disruptions, water leaks, and natural disasters (e.g., flooding);
• infection-control concepts for equipment using water from main lines (e.g., water systems for hemodialysis, ice machines, hydrotherapy equipment, dental unit water lines, and automated endoscope reprocessors);
• environmental surface cleaning and disinfection strategies with respect to antibiotic-resistant microorganisms;
• infection-control procedures for health-care laundry;
• use of animals in health care for activities and therapy;
• managing the presence of service animals in health-care facilities;
• infection-control strategies for when animals receive treatment in human health-care facilities; and
• a call to reinstate the practice of inactivating amplified cultures and stocks of microorganisms onsite during medical waste treatment.

Topics outside the scope of this report include 1) noninfectious adverse events (e.g., sick building syndrome), 2) environmental concerns in the home, 3) home health care, 4) terrorism, and 5) health-care--associated foodborne illness.

Wherever possible, the recommendations in this report are based on data from well-designed scientific studies. However, certain of these studies were conducted by using narrowly defined patient populations or specific health-care settings (e.g., hospitals versus long-term care facilities), making generalization of findings potentially problematic. Construction standards for hospitals or other health-care facilities may not apply to residential home-care units. Similarly, infection-control measures indicated for immunosuppressed patient care are usually not necessary in those facilities where such patients are not present.

Other recommendations were derived from knowledge gained during infectious disease investigations in health-care facilities, where successful termination of the outbreak was often the result of multiple interventions, the majority of which cannot be independently and rigorously evaluated. This is especially true for construction situations involving air or water.

Other recommendations were derived from empiric engineering concepts and may reflect industry standards rather than evidence-based conclusions. Where recommendations refer to guidance from the American Institute of Architects (AIA), the statements reflect standards intended for new construction or renovation. Existing structures and engineered systems are expected to be in continued compliance with those standards in effect at the time of construction or renovation.

Also, in the absence of scientific confirmation, certain infection-control recommendations that cannot be rigorously evaluated are based on strong theoretic rationale and suggestive evidence. Finally, certain recommendations are derived from existing federal regulations.

Performance Measurements

Infections caused by the microorganisms described in this guideline are rare events, and the effect of these recommendations on infection rates in a facility may not be readily measurable. Therefore, the following steps to measure performance are suggested to evaluate these recommendations:

1. Document whether infection-control personnel are actively involved in all phases of a health-care facility's demolition, construction, and renovation. Activities should include performing a risk assessment of the necessary types of construction barriers, and daily monitoring and documenting of the presence of negative airflow within the construction zone or renovation area.
2. Monitor and document daily the negative airflow in AII rooms and positive airflow in PE rooms, especially when patients are in these rooms.
3. Perform assays at least once a month by using standard quantitative methods for endotoxin in water used to reprocess hemodialyzers, and for heterotrophic and mesophilic bacteria in water used to prepare dialysate and for hemodialyzer reprocessing.
4. Evaluate possible environmental sources (e.g., water, laboratory solutions, or reagents) of specimen contamination when nontuberculous mycobacteria (NTM) of unlikely clinical importance are isolated from clinical cultures. If environmental contamination is found, eliminate the probable mechanisms.
5. Document policies to identify and respond to water damage. Such policies should result in either repair and drying of wet structural or porous materials within 72 hours, or removal of the wet material if drying is unlikely within 72 hours.

Updates to Previous Recommendations

Contributors to this report reviewed primarily English-language manuscripts identified from reference searches using the National Library of Medicine's MEDLINE, bibliographies of published articles, and infection-control textbooks. All the recommendations may not reflect the opinions of all reviewers. This report updates the following published guidelines and recommendations:

CDC. Guideline for handwashing and hospital environmental control. MMWR 1998;37(No. 24). Replaces sections on microbiologic sampling, laundry, infective waste, and housekeeping.

Tablan OC, Anderson LJ, Arden NH, et al., Hospital Infection Control Practices Advisory Committee. Guideline for prevention of nosocomial pneumonia. Infect Control Hosp Epidemiol 1994;15:587--627. Updates and expands environmental infection-control information for aspergillosis and Legionnaires disease; online version incorporates Appendices B, C, and D addressing environmental control and detection of Legionella spp.

CDC. Guidelines for preventing the transmission of mycobacterium tuberculosis in health-care facilities. MMWR 1994;43(No. RR13). Provides supplemental information on engineering controls.

CDC. Recommendations for preventing the spread of vancomycin resistance: recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR 1995;44(No. RR12). Supplements environmental infection-control information from the section, Hospitals with Endemic VRE or Continued VRE Transmission.

Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996;17:53--80. Supplements and updates topics in Part II --- Recommendations for Isolation Precautions in Hospitals (linen and laundry, routine and terminal cleaning, airborne precautions).

Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection. Infect Control Hosp Epidemiol 1999;4:250--78. Updates operating room ventilation and surface cleaning/disinfection recommendations from the section, Intraoperative Issues: Operating Room Environment.

U.S. Public Health Service, Infectious Diseases Society of America, Prevention of Opportunistic Infections Working Group. USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus. Infect Dis Obstet Gynecol 2002; 10:3--64. Supplements information regarding patient interaction with pets and animals in the home.

CDC, Infectious Diseases Society of America, American Society of Blood and Marrow Transplantation. Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. Cytotherapy 2001;3:41--54. Supplements and updates the section, Hospital Infection Control.

Key Terms

Airborne infection isolation (AII) refers to the isolation of patients infected with organisms spread via airborne droplet nuclei <5 µm in diameter. This isolation area receives numerous air changes per hour (ACH) (>12 ACH for new construction as of 2001; >6 ACH for construction before 2001), and is under negative pressure, such that the direction of the air flow is from the outside adjacent space (e.g., the corridor) into the room. The air in an AII room is preferably exhausted to the outside, but may be recirculated provided that the return air is filtered through a high-efficiency particulate air (HEPA) filter. The use of personal respiratory protection is also indicated for persons entering these rooms when caring for TB or smallpox patients and for staff who lack immunity to airborne viral diseases (e.g., measles or varicella zoster virus [VZV] infection).

Protective environment (PE) is a specialized patient-care area, usually in a hospital, with a positive air flow relative to the corridor (i.e., air flows from the room to the outside adjacent space). The combination of HEPA filtration, high numbers of air changes per hour (>12 ACH), and minimal leakage of air into the room creates an environment that can safely accommodate patients who have undergone allogeneic hematopoietic stem cell transplant (HSCT).

Immunocompromised patients are those patients whose immune mechanisms are deficient because of immunologic disorders (e.g., human immunodeficiency virus [HIV] infection or congenital immune deficiency syndrome), chronic diseases (e.g., diabetes, cancer, emphysema, or cardiac failure), or immunosuppressive therapy (e.g., radiation, cytotoxic chemotherapy, anti-rejection medication, or steroids). Immunocompromised patients who are identified as high-risk patients have the greatest risk of infection caused by airborne or waterborne microorganisms. Patients in this subset include persons who are severely neutropenic for prolonged periods of time (i.e., an absolute neutrophil count [ANC] of <500 cells/mL), allogeneic HSCT patients, and those who have received the most intensive chemotherapy (e.g., childhood acute myelogenous leukemia patients).

Abbreviations

AAMI Association for the Advancement of Medical Instrumentation

ACH air changes per hour

AER automated endoscope reprocessor

AHJ authority having jurisdiction

AIA American Institute of Architects

AII airborne infection isolation

ANSI American National Standards Institute

ASHRAE American Society of Heating, Refrigeration, and Air-Conditioning Engineers

BMBL Biosafety in Microbiological and Biomedical Laboratories (CDC/National Institutes of Health)

CFR Code of Federal Regulations

CJD Creutzfeldt-Jakob disease

CPL compliance document (OSHA)

DFA direct fluorescence assay

DHHS U.S. Department of Health and Human Services

DOT U.S. Department of Transportation

EC environment of care

EPA U. S. Environmental Protection Agency

FDA U.S. Food and Drug Administration

HBV hepatitis B virus

HEPA high efficiency particulate air

HIV human immunodeficiency virus

HSCT hematopoietic stem cell transplant

HVAC heating, ventilation, air conditioning

ICRA infection-control risk assessment

JCAHO Joint Commission on Accreditation of Healthcare Organizations

NaOH sodium hydroxide

NTM nontuberculous mycobacteria

OSHA Occupational Safety and Health Administration

PE protective environment

PPE personal protective equipment

TB tuberculosis

USC United States Code

USDA U.S. Department of Agriculture

UV ultraviolet

UVGI ultraviolet germicidal irradiation

VHF viral hemorrhagic fever

VRE vancomycin-resistant Enterococcus

VRSA vancomycin-resistant Staphylococcus aureus

VZV varicella zoster virus

Recommendations for Environmental Infection Control in Health-Care Facilities

Rationale for Recommendations

As in previous CDC guidelines, each recommendation is categorized on the basis of existing scientific data, theoretic rationale, applicability, and possible economic effect. The recommendations are evidence-based wherever possible. However, certain recommendations are derived from empiric infection-control or engineering principles, theoretic rationale, or from experience gained from events that cannot be readily studied (e.g., floods).

The HICPAC system for categorizing recommendations has been modified to include a category for engineering standards and actions required by state or federal regulations. Guidelines and standards published by the AIA, American Society of Heating, Refrigeration, and Air-Conditioning Engineers (ASHRAE), and the Association for the Advancement of Medical Instrumentation (AAMI) form the basis of certain recommendations. These standards reflect a consensus of expert opinions and extensive consultation with agencies of the U.S. Department of Health and Human Services. Compliance with these standards is usually voluntary. However, state and federal governments often adopt these standards as regulations. For example, the standards from AIA regarding construction and design of new or renovated health-care facilities, have been adopted by reference by >40 states. Certain recommendations have two category ratings (e.g., Categories IA and IC or Categories IB and IC), indicating the recommendation is evidence-based as well as a standard or regulation.

Rating Categories

Recommendations are rated according to the following categories:

Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.

Category IB. Strongly recommended for implementation and supported by certain experimental, clinical, or epidemiologic studies and a strong theoretic rationale.

Category IC. Required by state or federal regulation, or representing an established association standard. (Note: Abbreviations for governing agencies and regulatory citations are listed where appropriate. Recommendations from regulations adopted at state levels are also noted. Recommendations from AIA guidelines cite the appropriate sections of the standards.)

Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies, or a theoretic rationale.

Unresolved issue. No recommendation is offered. No consensus or insufficient evidence exists regarding efficacy.

Recommendations --- Air

I. Air-Handling Systems in Health-Care Facilities

1. Use AIA guidelines as minimum standards where state or local regulations are not in place for design and construction of ventilation systems in new or renovated health-care facilities. Ensure that existing structures continue to meet the specifications in effect at the time of construction (1). Category IC (AIA: 1.1.A, 5.4)
2. Monitor ventilation systems in accordance with engineers' and manufacturers' recommendations to ensure preventive engineering, optimal performance for removal of particulates, and elimination of excess moisture (1--8). Category IB, IC (AIA: 7.2, 7.31.D, 8.31.D, 9.31.D, 10.31.D, 11.31.D, Environmental Protection Agency [EPA] guidance)
   
   1. Ensure that heating, ventilation, air conditioning (HVAC) filters are properly installed and maintained to prevent air leakages and dust overloads (2,4,6,9). Category IB
   2. Monitor areas with special ventilation requirements (e.g., AII or PE) for ACH, filtration, and pressure differentials (1,7,8,10--26). Category IB, IC (AIA: 7.2.C7, 7.2.D6)
   
       a. Develop and implement a maintenance schedule for ACH, pressure differentials, and filtration efficiencies by using facility-specific data as part of the multidisciplinary risk
           assessment. Take into account the age and reliability of the system.
       b. Document these parameters, especially the pressure differentials.
   
   3. Engineer humidity controls into the HVAC system and monitor the controls to ensure adequate moisture removal (1). Category IC (AIA: 7.31.D9)
   
       a. Locate duct humidifiers upstream from the final filters.
       b. Incorporate a water-removal mechanism into the system.
       c. Locate all duct takeoffs sufficiently downstream from the humidifier so that moisture is completely absorbed.
   
   4. Incorporate steam humidifiers, if possible, to reduce potential for microbial proliferation within the system, and avoid use of cool-mist humidifiers. Category II
   5. Ensure that air intakes and exhaust outlets are located properly in construction of new facilities and renovation of existing facilities (1,27). Category IC (AIA: 7.31.D3, 8.31.D3,
       9.31.D3, 10.31.D3, 11.31.D3)
   
       a. Locate exhaust outlets >25 ft from air-intake systems. 
       b. Locate outdoor air intakes >6 ft above ground or >3 ft above roof level.
       c. Locate exhaust outlets from contaminated areas above roof level to minimize recirculation of exhausted air.
   
   6. Maintain air intakes and inspect filters periodically to ensure proper operation (1,11--16,27). Category IC (AIA: 7.31.D8)
   7. Bag dust-filled filters immediately upon removal to prevent dispersion of dust and fungal spores during transport within the facility (4,28). Category IB
   
       a. Seal or close the bag containing the discarded filter.
       b. Discard spent filters as regular solid waste, regardless of the area from which they were removed (28).
   
   8. Remove bird roosts and nests near air intakes to prevent mites and fungal spores from entering the ventilation system (27,29,30). Category IB
   9. Prevent dust accumulation by cleaning air-duct grilles in accordance with facility-specific procedures and schedules and when rooms are not occupied by patients (1,10--16).
       Category IC, II (AIA: 7.31.D10)
   10. Periodically measure output to monitor system function; clean ventilation ducts as part of routine HVAC maintenance to ensure optimum performance (1,31,32). Category IC, II
         (AIA: 7.31.D10)
    
3. Use portable, industrial-grade HEPA filter units capable of filtration rates in the range of 300--800 ft3/min to augment removal of respirable particles as needed (33). Category II
   
   1. Select portable HEPA filters that can recirculate all or nearly all of the room air and provide the equivalent of >12 ACH (34). Category II
   2. Portable HEPA filter units placed in construction zones can be used later in patient-care areas, provided all internal and external surfaces are cleaned, and the filter replaced or its
       performance verified by appropriate particle testing. Category II
   3. Situate portable HEPA units with the advice of facility engineers to ensure that all room air is filtered (34). Category II
   4. Ensure that fresh-air requirements for the area are met (33,35). Category II
    
4. Follow appropriate procedures for use of areas with through-the-wall ventilation units (1). Category IC (AIA: 8.31.D1, 8.31.D8, 9.31.D23, 10.31.D18, 11.31.D15)
   
   1. Do not use such areas as PE rooms (1