Marathon

Background: MFHT sees approximately 100 patients per day, many of whom present with infectious illnesses.  There are a few cases of TB in the community however little or no HIV.  There are a number of patients in the community on immunocompromising medications including chemotherapy who are at particular risk of contracting infectious diseases.

By incorporating many of the recommendations of the CPSO guidelines into our office practice it is hoped that the risk of contracting an infection through our clinic will be minimized both for patients utilizing the clinic and for the staff who work there.

Sections:

1. Hand hygiene:

Background: This is the single most important manoeuvre for preventing transmission of infection. Staff will understand that there are two primary types of hand hygiene:  soap and water, and alcohol based hand sanitizer use.  Soap and water must be used if there is visible contamination of the hands with body fluids, and after caring for a patient who has diarrhea.  Hand sanitizer may be used instead of soap and water before and after all other routine clinical contacts.

Policy:
Pump dispensed soap and water will be available in every clinical exam room.  Paper towels will be available in every clinical exam room.  Plain cloth towels will not be available.  When washing with soap and water, paper towel will be used to turn off the faucet.
Hand sanitizer in pump will be available in every clinical exam room.
Hand lotion (non petroleum based) will be available in all clinical areas and administrative areas for staff use.  (Petroleum based hand lotion is to be avoided by health care workers who may have to wear gloves as it interferes with glove integrity)
Hand care posters will be posted in all clinical areas and in administrative areas where hand hygiene.
Hand washing sinks will be used for washing hands only!  Instrument cleaning, and disposal of waste will be done at the designated sink in the cleaning area.

See appendix 1 for protocol for hand washing.

2.  Personal Protective Equipment:

Backround: In addition to proper hand hygiene, use of personal protective equipment can protect health care workers from infections that are airborne, droplet borne or contact related.

Policy:
A.  Gloves:
Gloves will be worn by all clinical staff when there is any contact with contaminated articles, or when direct exposure to blood, body fluids, mucous membranes, non intact skin or undiagnosed rashes is anticipated.
Gloves provided in MFHT will be non latex, and powder free to decrease the risk of allergic reaction.
Hands will be sanitized with either alcohol based product or soap and water after removal of gloves.
Only NON petroleum based hand creams will be used as moisturizers.  Petroleum based hand creams will break down most glove types.

B. Masks:
1.  Surgical masks should be worn by clinical staff in contact with patients who may have all illness spread by droplets (ie. Influenza, RSV, parainfluenza, SARS).
2.   All staff will undergo annual fit testing for N95 masks and the clinic will be stocked with the mask types that fit each provider.
3.  N95 masks are to be worn when health care workers are  in contact with a patient believed to have active TB, measles, or when advised by the MOH in the event of an unknown FRI outbreak.

C. Eye protection:
1.  Plastic safety glasses or plastic eye shields will be stocked in the clinic.
2.  Eye protection should be worn by health care workers when in contact with patients who may have either airborne illnesses (chickenpox, measles, active TB) or droplet borne illnesses (RSV, influenza, parainfluenza, SARS).

See appendix 2 for chart regarding PPE and various illnesses

3.  Sharps:

Background: In health care settings, most blood borne infections are transmitted by needlestick injuries, or sharps.  Proper care and disposal of needles will minimize the risk of these injuries.

Policy:

Needles will not be recapped, but will be disposed of uncapped.
All sharps will be discarded in a biohazardous waste container and there will be one available in every clinical room where injections are given.
The staff using the sharp will be responsible for its disposal in the sharps container.  Sharps will not be left on the counter for employee or patients to discard.
The sharps container will be kept out of the reach of children at all times.
HCA staff will monitor the sharps containers in the exam rooms as part of their nightly closing procedure.  When containers are noted to be 75% full, the lid will be closed securely and the container will be disposed of through the appropriate biohazardous waste containment system.

4.  Patient appointments:

Background: Appropriate booking of potentially infectious patients can help to minimize transmission of infection to other patients. Appropriate follow through of potentially infectious patients during and after appointments with health care use of PPE and with appropriate disinfection of equipment and exam room surfaces can also help to minimize the risk of transmission to HCW’s and to other patients.

Procedure:
At the time of booking the appointment, booking staff will ask patients if they have any of the following:
Do you have fever, cough or worsening shortness of breath?
Do you have diarrhea?
Do you have a new rash?
Have you been exposed to someone with chickenpox, shingles or measles in the last three weeks?

If yes to any of the above a ** will be placed beside their name to flag for the front staff person that this is a patient who may need a mask and may need to be directed to appropriate seating in the waiting room.
HCA’s will know too to remove these individuals from the waiting room as soon as possible to prevent infection transmission.

All patients who have been booked for fever, cough, shortness of breath will be given a surgical mask to wear while in the clinic.

Patients with transmissible infections (possible chicken pox, TB, measles, diarrhea, VRE, MRSA and influenza) will be seen, wherever possible at the end of the day.
The on call day schedule will be modified to have “infectious disease patients” booked from the end of the day backwards to ensure that as few potentially infectious patients as possible are seen early in the day.

A sign will be placed at the entrance to the the waiting room asking patients to identify themselves to the front staff person if they believe they may have an infectious illness.

See appendix 3 for sign

Signs will be posted in the waiting room to highlight the importance of respiratory etiquette.
The waiting room will be arranged such that there will be some seating more than a meter from other patients so that infectious patients can be directed to be seated there.  The front staff person will be responsible for directing patients as to where to be seated.
HCA’s will identify patients from the computer marked with ** and will make every effort to bring them to a room as soon as possible.  Once in a room a sign will be posted on the door to advise the physician of the need for a mask.
For patients who have droplet borne infections (cold, influenza) all clinical staff will wear a mask when in direct contact with the patient.
For patients who are suspected of infectious TB, the HCW will wear an N95 mask.  The HCW will also wear an N95 mask when working with patients with chicken pox or measles if the HCW is are not immune.
Following the patient visit, horizontal surfaces that have been in contact with
the patient, and all equipment that was in contact with the patient (blood pressure cuffs, stethoscopes) will be wiped down with low level disinfection solution by the HCA staff.

5.  Physical space:

Background: The waiting room is an area where multiple patients may be in contact with each other for prolonged periods of time.  Surfaces, books and toys in the waiting rooms and clinical exam rooms may also be vectors for infection.

Policy:

Waiting room: Furniture in waiting room will be made of materials that can be easily cleaned.
The HCA will clean all horizontal surfaces in the waiting room with disinfecting detergent daily.
The designated front staff person responsible for magazines and books will be responsible for the regular review and disposal of books and magazines in the waiting rooms and in the examination rooms.
No toys will be kept in the waiting room.  Parents will be asked to bring books and toys with them to the clinic for their visit.
Any item in the waiting roomthat is visibly soiled must be washed with soap and water and then disinfected.

Clinical areas:
HCA’s will have two bottles of diluted disinfectant at their station.
Every effort will be made to use the paper cover for the examination table when patients lie on it. Exam tables will be disinfected if used for assessment of a patient believed to have an infectious illness.
Computer keyboards in clinical areas and patient contact areas will be covered with a plastic cover that can be wiped at least daily.

Spot Cleaning of Body Fluid Spills:
The HCA will be notified when there is a significant body fluid spill in the waiting or exam room(ie. bleeding, emesis or urine spill) so that it can immedicately be cleaned.
Household gloves must be worn while cleaning body fluid spills (not simply clinical exam gloves).
Visible body fluid material must be removed with disposable paper towel and placed in a plastic lined garbage bag.
The spill area is then to be cleaned with an appropriate detergent-disinfectant.
The area is then wiped dry.
The area will then be disinfected with a 1:100 bleach solution.

6.  Cleaning and disinfecting of equipment:

This is covered under a separate policy which includes autoclaving and disinfecting of equipment used in direct patient care.

7.  Staff issues in infection control:

1.  Health care workers and staff immunizations and TB skin testing

Policy:

TB skin testing will be done at time of hire and after any significant exposure to a known active case.
Annual TB skin testing will be performed with documentation of results
Chickenpox vaccine will be offered to all staff who are non immune
All staff will document immunization for or immunity to: Polio, measles, rubella, Hepatitis B, tetanus and diphtheria.
All staff will be encouraged to undergo influenza immunization.  For staff that have not undergone immunization, they will be encouraged to take antivirals during times of outbreak or after close contact with an infected individual.

2. Infected health care workers:

Policy:

The common cold:  HCW’s with a common cold are to practice rigourous hand hygiene.  HCW’s with a cold are not to be in contact with immunocompromised patients.
If the HCW must work while ill, they are encouraged to wear a surgical mask and wash hands frequently.
Influenza:  HCW’s with fever or symptoms of influenza are encouraged not to work while ill.
Herpes simplex infections:
Cold sores:  HCW’s should keep active lesions covered while in contact with patients.  Frequent hand hygiene is important.
Herpetic whitlow:  All persons with Herpetic whitlow must be excluded from direct patient contact as gloves will not provide adequate protection for patients from the viral shedding.
Shingles:  HCW’s with shingles may continue to work as long as the shingles lesions are covered. They must avoid contact with immunocompromised patients.
Enteric infections:  HCW’s with vomiting and diarrhea should not work.
TB:  HCW’s with active pulmonary TB will be excluded from work until it is determined reasonable for them to return to work (ie. After 3 negative AFB sputum samples, or in consultation with the MOH).

3.Training of staff:

It is recognized that periodic re-education regarding transmission of infection and best practices in infection control can be part of an effective CQI process.

At MFHT, there will be annual re-education for both clinical and non clinical staff regarding transmission of infection in the office setting.  In addition there will be an annual review of the responsibilities pertaining to one’s own position regarding infection transmission prevention

Appendix 1:  hand hygiene poster
Appendix 2:  Personal protective equipment use chart
Appendix 2:  poster for waiting room
Appendix 3:  respiratory etiquette poster

Reference:  CPSO guideline “Infection Control in the Physicians Office”  2004

SN 2007
Addendum for consideration for new space:

New space requirements
electronic eye faucets on clinical sinks should be considered to reduce the risk of infection transmission
Designated Seating in the waiting room must be arranged with 1 m of space between designated  patient and others in order to minimize risk of contamination
Tile flooring…easily cleaned in event of vomit or bleeding
Tissues and waste containers will be available at the entry to clinic and in the waiting room
Hand sanitizer pumps at point of entry and in waiting room for patients
Hand sanitizer pumps will be available in every clinical exam room
Surgical masks will be available at the front desk check in.
Plexiglass barriers for staff at entrance
All clinical furniture (chairs, etc) will be wipable fabric, not the current fabric that is available on our office furniture.
Computer keyboard covers will be available for all providers who work directly with patients.

Patient information:

For posting to website, for flyer in the office.

MFHT is following guidelines for infection control within our office.

When you come to MFHT, if you have a fever, cough or infectious illness, you will be asked to sit 1 metre from other patients in the waiting room.  You will also be asked to wear a mask while you are in the clinic in order to help to prevent the spread of your illness to other people in the community.

If you are bringing a child, please bring your own toys with you to occupy them.  Although toys in the waiting room are disinfected daily, there is no guarantee that a child with an infection may not have played with the same toy earlier in the day.