Implement Source Controls

Implement Source Controls

Source controls are measures that eliminate potential sources of exposure and rank highest in the hierarchy of controls in terms of infection prevention. Examples include:

Source Control / ED / Clinic / In-pt / Comments
Postpone elective visits and procedures for patients with suspected or confirmed influenza until they are no longer infectious / 0 / 0 / 0
Post signage at all points of entry to the facility restricting ill visitors. / 1 / 1 / 1
Minimize outpatient and emergency department visits for patients with mild influenza-like illness (ILI) who do not have risk factors for complications of influenza (http://www.health.state.mn.us/divs/idepc/diseases/flu/hcp/case.html#up) / 1 / 1 / 1 / Public Communication
·  Press Conferences
·  News Releases
·  Triage messaging
Rely on a nurse triage phone system for patients with mild ILI / NA / NA / NA
Establish and implement non-punitive personnel policies that encourage or require ill personnel and volunteers to stay home / 2 / 2 / 2 / Plan developed and implemented with input from Human Resources, Employee Health, Infection Control, Senior Leadership
Establish mechanisms to promptly identify patients with symptoms of ILI / 1 / 1 / 1 / Utilizing Care Process Model
http://javaprod.mayo.edu/ame/openTopic?collection=1&page=14&topicID=1558
http://javaprod.mayo.edu/ame/openTopic?collection=1&page=14&topicID=3891
Place facemasks on symptomatic patients, when tolerated, at facility access points (e.g., emergency rooms) until they can be roomed, or when patients are outside their rooms (e.g. diagnostic testing) / 2 / 2 / 2
Implement respiratory hygiene/cough etiquette and meticulous hand hygiene at all times (applies to staff, visitors and patients). / 2 / 2 / 2

0 = Not Met 1 = Partially Met 2 = Fully Met NA = Non Applicable

Implement Engineering Controls
Engineering controls rank second in the hierarchy of controls. These measures are particularly effective because they reduce or eliminate exposures at the source and can be implemented without placing primary responsibility of implementation on individuals. Examples include:
Engineering Control / ED / Clinic / In-pt / Comments
Install partitions (e.g., transparent panels/windows/desk enclosures) in triage areas as physical barriers to shield staff from direct exposure to symptomatic patients / 2 / 2 / NA / Privacy barriers in place in ED and Clinic settings
Identify a separate waiting area for patients with ILI / 2 (Radiology Waiting area) / 2 / NA / Plan in place for activation of Surge Capacity (Influx of Infectious Patients – Flu Surge)
Consider limiting points of entry to the facility / NA / NA / NA / Same as above
Use local exhaust ventilation (e.g., hoods, tents, or booths) when performing aerosol-generating procedures / NA
/ NA / NA
When feasible, conduct aerosol-generating procedures in an airborne infection isolation room (AIIR) / NA / NA / NA / Airborne Isolation Rooms (13)
2212, 2411, 3205, 4619, 4623, 5409, 5613, ED (8 & 9), Diagnostic Imaging (1852, 1853 & 1856), Cath Lab (CA2-031)
Use closed suctioning systems for airway suctioning in intubated patients / 2 / NA / 2
Use high-efficiency particulate air (HEPA) filters on mechanical and bag ventilators / 2 / 2 / 2

0 = Not Met 1 = Partially Met 2 = Fully Met NA = Non Applicable

Implement Administrative Controls
Administrative controls are required work practices and policies that prevent exposures. The strategies rank third in the hierarchy of controls because their effectiveness depends on consistent implementation by management and personnel.
Administrative Controls / ED / Clinic / In-pt / Comments
Vaccinating as much of the healthcare workforce as possible / 2 / 2 / 2 / Vaccine offered to employees according to vaccine availability and CDC criteria. Staff participation in Mayo Clinic Employee Vaccination Program (100% of employees participated) 89% vaccination rate
Set up triage stations to manage patient flow and assign dedicated staff to minimize the number of healthcare personnel exposed to patients with ILI / 2 / 2 / 2 / Plan in place if necessary to activate Surge Capacity
In-pt setting – dedicated wings and staff for ILI pts. (3000 wing, 4000 wing & 4200 wing) – implemented 12/23/12 (3000 wing)12/26 (4000 wing) & 1/1 (4200 wing)
Develop and implement policies that facilitate the prompt identification and exclusion of personnel with ILI / 2 / 2 / 2 / Employee Daily Illness Report
All ILI employees are screened by EHS before returning to work
Limit the number of personnel and visitors in rooms of patients with ILI at all times and particularly during aerosol-generating procedures / 2 / 2 / 2 / 1/4 Adopted region wide visiting restrictions: Immediate family only, 2 visitors at a time, no ill visitors
Provide tissues, facemasks, and hand sanitizer in waiting areas and other facility locations
·  Visitors should perform hand hygiene before entering and upon leaving a patient’s room
·  Facemasks should be placed on patients symptomatic with
ILI until they can be roomed / 2 / 2 / 2 / Hand Hygiene/Respiratory stations at each point of entry
Signage at each entry point and at entry to each “influenza wing”
Implement routine environmental cleaning/disinfection policies and procedures
·  Consider increasing the frequency of cleaning/disinfecting for high-touch surfaces and in common areas / 2 / 2 / 2
Post signage in appropriate languages to alert staff and visitors of the need for isolation precautions / 2 / 2 / 2 / Process in place for use of Interpreter if needed
Place facemasks on symptomatic patients with ILI during transport when tolerated; limit transport to that which is medically necessary and minimize delays and waiting times during transport / 2 / 2 / 2
Place symptomatic patients with ILI in single rooms or cohort / 2 / 2 / 2 / In-pt setting – dedicated wings and staff for ILI pts. (3000 wing, 4000 wing & 4200 wing)

0 = Not Met 1 = Partially Met 2 = Fully Met NA = Non Applicable

Personal Protective Equipment (PPE)
PPE ranks lowest in the hierarchy of controls. It is the last line of defense against hazards that cannot otherwise be eliminated or controlled. Effectiveness of PPE is dependent on several factors. It will not be effective if adherence is incomplete or when exposure to infectious patients or ill co-workers is unrecognized. PPE includes gloves, gowns, facemasks, respirators, and eye protection.
Work Practices to Maximize and Conserve Respiratory Protection Supplies
In an effort to conserve respiratory protection equipment in facilities facing possible shortages of these supplies, consider:
·  Extended (serial) use of disposable respirators
·  Reuse of disposable respirators
Personal Protective Equipment Control / ED / Clinic / In-pt / Comments
Respirators are used in conjunction with the OSHA Respiratory Protection Standard and Respiratory Protection Program:
·  OSHA Respiratory Protection Standard (29 CFR 1910.134): http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=12716 / 2 / 2 / 2 / Droplet precautions: surgical (simple) mask
Aerosol-generating procedures: N95
Extended (serial) use of disposable respirators
The use of a single disposable respirator by a healthcare worker during serial patient encounters without removing or re-donning between encounters. Under extended use:
·  Respirators can be continuously worn between patients without removal as long as the wearer follows Standard Precautions, including hand hygiene
·  Respirators should not be worn between patients after aerosol-generating procedures or surgery, or if the respirator has become contaminated with bodily fluids.
·  The risk of respirator contamination and contact transmission exists, however the risk will be minimized if healthcare personnel always perform hand hygiene before and after touching the respirator / NA / NA / NA
Reuse of disposable respirators
A single wearer uses a disposable respirator that is removed, stored, and re-donned between patient encounters. Under reuse:
·  Disposable respirators should never be shared between wearers
·  Consider use of a face shield over the respirator to prevent surface contamination / NA / NA / NA
Discard respirator if:
·  Contaminated with a hazardous substance, blood, respiratory or nasal secretions, or other bodily fluids
·  Visibly damaged, deformed or unable to form an effective seal
·  Used during an aerosol-generating procedure or during surgery
·  Visibly dirty
·  Breathing through it becomes more difficult / NA / NA / NA
The risk of respirator contamination and contact transmission exists, however the risk will be minimized if healthcare personnel always perform hand hygiene before and after touching the respirator
·  To remove respirator in the context of re-use:
·  Lift the respirator straps from the back of the head;
·  Avoid touching the inside surfaces of the respirator; and
·  Place the respirator in a clean container (e.g. paper bag) labeled with the healthcare personnel’s name or other identifier / NA / NA / NA
Prior to re-donning, inspect the respirator, including straps, clips, sealing surfaces and general condition to assure it is appropriate for reuse
·  If respirator is in good condition, don the respirator according to routine instructions
·  Perform a seal-check after re-donning to ensure the formation of an effective seal
·  After handling the respirator, perform hand hygiene / NA / NA / NA

0 = Not Met 1 = Partially Met 2 = Fully Met NA = Non Applicable

Monitoring and Managing Healthcare Personnel with Influenza-Like Illness
·  Healthcare personnel who develop symptoms of ILI outside of the workplace should be instructed not to report to work.
·  Healthcare personnel who develop symptoms while at work should promptly notify their supervisor or other workplace contact and leave the workplace as soon as possible.
Viral shedding after ILI has been documented. For healthcare personnel with a recent history of ILI or confirmed or suspected influenza, MDH recommends the following steps to protect patients and co-workers, in rank order:
Control / ED / Clinic / In-pt / Comments
Exclude from work until 24 hours after the resolution of fever without fever-reducing medication. This exclusion period is especially important if the healthcare worker is involved in the direct care of patients who are at high-risk of developing influenza-related complications / 2 / 2 / 2 / Messaging sent to all employees – guidelines for returning to work following illness
Employee Daily Illness Report utilized for tracking employee illness
All employees with ILI evaluated by EHS prior to returning to work
Exclude from work until at least 24 hours after the resolution of fever without fever-reducing medication, and for healthcare personnel who do not have a fever, clinical judgment should be used. / 2 / 2 / 2
If an acute cough persists in a healthcare worker who returns to work less than 7 days after symptom onset, the healthcare worker should not be assigned to direct patient care until resolution of acute symptoms. These healthcare personnel should wear a surgical mask when in the facility to protect patients and co-workers

0 = Not Met 1 = Partially Met 2 = Fully Met NA = Non Applicable