Electronic supplementary material: Prince of Wales Hospital SARS Intensive Care Unit infection control procedures, June 2003
Transport of patients out of Intensive Care Unit (ICU): Principles
1) Restrict to essential investigations / procedures only
2) Notify receiving area before the transport
3) Minimize cross contamination
4) All attendants must put on full personal protective equipment (PPE)
5) Choose the shortest route available
6) Use the lift designated for transport of patients with SARS
7) Minimize the number of personnel involved in the transport
8) Minimize the duration outside the ICU
9) Clean and disinfect all transport monitors and equipment after use
10) Ensure a safe transport
Intra-hospital transport of patients from ICU for investigations/ procedures
A). Before the transfer
1) Notify the receiving area
2) Get the SARS-designated lift ( No. 7 ) ready
3) Decide the shortest transport route
4) Preparation of patient
a) Put on disposable cap
b) Change the patient’s clothes, and the top bed sheet and blanket
c) See that spontaneously breathing patient is on a surgical mask
5) Preparation of transport equipment
a) Transport box ( equipments for circulatory and pulmonary resuscitation )
b) Drug box for endotracheal intubation
c) Prepare extra sedatives and muscle relaxants as necessary
d) Manual resuscitator
i). Attach a high quality bacterial/ viral filter between the mask and valve of the bag, and another one to the expiratory port of the resuscitator
e) Disposable end-tidal carbon dioxide monitor (for patients with an endotracheal tube/ tracheostomy tube in place)
f) Portable ventilator ( for patients on mechanical ventilation )
i). Add a high quality bacterial/ viral filter to the expiratory port of the ventilator
6) Put clinical notes inside a plastic bag and attach a red label to it to signify need for special attention
7) Preparation of transport trolley
a) Transport the patient in his/ her own bed
8) Preparation of escort staff
a) Change to a new set of PPE before leaving the unit
c) No need to change the N95 mask. Add a surgical mask on top of the N95 mask.
B). After handling the patient over to responsible staff in receiving area
1) Need to escort patient back to ICU ( e.g. CT, ultrasound )
a) Escort patient back to ICU with PPE on
2) No need to escort patient back to ICU ( e.g. O.T.)
a) Take off PPE, leaving the N95 mask with an overlying surgical mask on, before leaving the receiving area
C). After care of transport equipments
a) Clean and disinfect all equipments and monitors after use
i). Sodium hypochlorite (1:49) for non-metallic surfaces
ii). 70% alcohol for metallic surfaces
Escorting patient from operating theatre to ICU
1) Before leaving ICU
a) Preparation of equipment
i) Bag-valve-filter-mask unit
- Attach a high quality bacterial/viral filter between the mask and the valve of the bag, and another one to expiratory port of the resuscitator
ii) Transport trolley
- Transport the patient from O.T. to ICU in his/ her own bed
b) Preparation of escort staff
i) Gown down in ICU gown-down area
ii) No need to change the N95 mask. Add a surgical mask on top of the N95 mask.
2) After arriving at O.T.
a) Put on PPE in the OT‘Gown-up’ area before receiving patient
b) Escort patient to ICU with PPE on
Transferring patients from SARS area ICU to SARS ward
1) Notify the receiving area
2) Preparation of patient
a) Put on disposable cap
b) Change the patient’s clothes, and the top bed sheet and blanket
c) See that spontaneously breathing patient is on a surgical mask
3) Put clinical notes inside a plastic bag and attach a red label to it to signify need for special attention.
4) Prepare transport trolley (use bed/trolley from ward)
5) Terminal cleaning and disinfection of the environment and patient care items - follow ‘disinfection guidelines’
Inter-hospital Transfer of Patients with Suspected/ Confirmed SARS
1) Notify receiving area
2) Notify and make arrangement with ambulance service
3) Get the SARS-designated lift ready
4) Preparation of the patient
a) Put on disposable cap
b) Change patient’s clothes, and the top bed sheet and blanket
c) See that spontaneously breathing patient is on a surgical mask
5) Put clinical notes inside a plastic bag and attach a red label to it to signify need for special attention
6) Preparation of transport equipment
a) Transport box ( equipments for circulatory and pulmonary resuscitation )
b) Drug box for endotracheal intubation
c) Prepare extra sedatives and muscle relaxants as necessary
d) Manual resuscitator
i). Attach a high quality bacterial/ viral filter between the mask and the valve of the bag, and another one to the expiratory port of the resuscitator
e) Portable end-tidal carbon dioxide monitor (for patients with an endotracheal tube/ tracheostomy tube in place)
f) Portable ventilator ( for patients on mechanical ventilation )
i). Add a high quality bacterial/ viral filter to the expiratory port of the ventilator
7) Preparation of transport trolley
a) Use stretcher from the ambulance
8) Preparation of escort staff
a) Change into a new set of full PPE before leaving the unit
i). N95 mask, disposable cap, full face shield, disposable gown and gloves
9) Terminal cleaning and disinfection of environment and patient care items
a) Follow ‘disinfection guidelines’
Setting-up of the Environment
Basic points to note:
1) Prominent warning sign on the outside of the isolation area indicating ‘high risk area’
2) Separate entry and exit points
3) Separate gowning-up and gowning-down areas
a) Use different colors to indicate gowning-up and gowning-down areas
i). ‘green’ – gown-up area
ii). ‘red’ – gown-down area
4) Separate undressing and de-masking zones
5) Prominent instruction signs on
a) Gowning up and gowning down steps
b) Prohibiting more than 5 persons in both the gown-up/ gown-down areas at any one time
6) Adequate facilities for hand-hygiene both in the ‘gown-up’ zone and in the ‘gown-down’ zone
7) Clean zones and dirty/contaminated zones should be clearly identified
Setting-up of the Environment
Gown-up room
a) Hand-hygiene facilities
i). Handwash
- Handwash basin
- hand-antiseptic
ii). Hand-rub
- Alcohol-based handrub
iii). Paper hand towels
b) PPE (Personal protective equipment) – adequate amount
i). Disposable particulate respirator
- N95, N100, P100 mask
ii). Protective eyewear
- Visor
- Goggles
iii). Full-face shield
iv). Disposable cap
v). Disposable long-sleeved protective gown
- Water repellent
- Water resistant
vi). Latex gloves
vii). Disposable shoe cover
c) Rubbish bins
i). Line with clinical waste bag
d) Transparent plastic bags for holding stationary and pager ( hung outside the isolation gown )
e) Mirror
f) Clear instructions on correct sequence of putting on PPE
Gown-down area – separate undressing and de-masking zones
a) Hand-hygiene facilities
i). Handwash
- Handwash basin
- Hand antiseptic
ii). Hand-rub
- Alcohol-based handrub
iii). Paper hand towels
b) Rubbish bins
ii). Lidded and foot operated
iii). Lined with designated ‘red’ colored water-proof bags labeled ‘clinical waste’
c) 70% alcohol and gauze packs
iv). For wiping used protective eyewear and full-face shield before putting in paper bag (for temporary storage before reuse)
d) Paper bags
v). For temporary storage of disposable particulate respirators, protective eyewear and full-face shields
e) Bucket for holding used goggles
f) Surgical masks
g) Mirror
h) Prominent instructions on correct sequence of gowning-down
Specimens and documents
a) Put documents and specimens that are sent into and to be sent out of the unit in different places
b) Keep documents and specimens in different trays
c) Place documents that are to be sent out of the unit in a plastic bag, labeled with a red label to signify the need for special attention
d) Minimize the number of documents that have to be sent out of the unit by using facsimile whenever possible.
Reception
a) Intercommunication device, video-phone.
b) Record on particulars of visitors
c) Record on stock and consumption of PPE
Staff toilet
a) Instruction sign on the door of the toilet indicating steps to follow before and after using toilet ( remove gown and gloves and perform hand hygiene before using toilet )
b) Foot-operated lidded rubbish bins lined with designated ‘red’ waterproof bags labeled ‘Clinical Waste’ for used PPE
c) Hand-hygiene facilities
d) PPE
Staff dining area
a) Instruction sign on necessary precautions
i). Sit at least 3 feet apart
ii). Use own eating and drinking utensils
b) Do not talk and cough when not wearing a surgical mask
c) Partition eating area with Perspex partitions
Staff changing room and bathroom
Adequate shower facilities
Personal Protective Equipment
Full Protective Apparel
1) N 95 mask
a) Ensure correct size ( fit test ), and check for leakage ( fit check ) every time when putting on the mask
2) Protective eyewear
a) Visor
b) Goggles for activities / procedures that are likely to generate aerosols or splashes
3) Long-sleeved protective gown
a) Water repellent/ water resistant
b) Water resistant gown for activities/ procedures that are likely to generate aerosols or splashes
4) Full-face shield
5) Cap
6) Latex gloves
7) Footwear precautions
a) Working shoes
8) Full PPE to be worn at all times inside Intensive Care Unit with the exception of rest areas and toilets.
* Don respiratory protection, gown, gloves, eye protection, full face shield and cap before entering the isolation room or designated isolation area.
* When removing PPE, use great care to avoid contamination to mucous membranes, skin and clothing.
* Removal of respiratory protection must be done outside of the isolation area and not inside the isolation area
* Do not gown down while in close proximity to others
Important points to note about PPE
1) N95/100 mask
a) Change mask at the end of each shift or if visibly soiled
b) Protect it with an overlying surgical mask/ full face shield and store in a single-use paper bag if the mask is to be re-used.
c) Wash hands thoroughly after putting on mask
2) Disposable protective gown
a) Water repellent/ resistant
b) Use water resistant gown for high risk procedures
3) Visor, full-face shield
a) Discard after high risk procedures and at the end of the shift
b) For short break, wipe with gauze soaked with 70% alcohol and keep in single-use paper bag.
4) Goggles
a) Send to CSSD for disinfection
b) For short break, wipe with gauze soaked with 70% alcohol and keep in single-use paper bag.
5) Gloves
a) Change gloves and practise hand antisepsis after patient contact, after procedures and between patients.
b) Change gloves before touching frequently touched items such as phones, keyboards and intercoms, and before touching patients’ notes and writing notes.
c) Do not wash gloves
d) Double-gloving is not recommended
6) Mask/ respirator with an exhalation valve
a) Should not used when caring for patients with unconfirmed SARS, and around clean/ sterile field. When wearing such kind of mask under these circumstances, add a surgical mask on top.
7) Reusable PPE
a) Users must receive training
b) Proper maintenance is essential ( e.g. charging of batteries, replacement of disposable parts )
c) Clean and disinfect thoroughly after use
8) Change or remove PPE, whichever is appropriate, when moving from a zone of higher risk to a zone of lower risk
9) Change gown/ clothes immediately when soiled
10) Change into new protective clothing after performing high-risk procedures
11) Wash as soon as possible
a) After very high risk procedures
b) Extensive soiling
c) Lapse in infection control
12) All persons inside the hospital compound must wear a mask
Cleaning and Disinfection Guidelines
1. Use disposables if available
2. For reusables, clean and disinfect thoroughly before putting back for communal use
3. Give adequate instructions to cleaning staff on specific precautions to be taken ( e.g. avoid splashes when disposing of excreta )
4. Give adequate instructions to cleaning staff on the items/ areas to be cleaned, disinfection methods (disinfectant, concentration of disinfectant and duration required for thorough disinfection), and cleaning frequency and timing.
5. Delineate responsible personnel.
6. Use a checklist and require responsible personnel to sign for jobs that are finished.
Items/ facilities / Disinfectant / FrequencyClinical area
1) Patient’s immediate environment
(bed unit including machines and monitors ) / Sodium hypochlorite 1:49 / At least twice daily and after patient discharge
2) Floor / Sodium hypochlorite (1:49) / Four times daily
3) Nurses’ station / Sodium hypochlorite (1:49) / Four times daily
4) Common touch items
( door knobs, telephones, intercoms, fax machines and computer keyboard & mouse ) / Sodium hypochlorite ( 1: 49) / Four times daily
5) Phones, keyboards and intercoms / Cover with plastic sheet/ bag / Change the plastic wrap daily.
Disinfect the surface with sodium hypochlorite ( 1:49 ) before applying new plastic wrap
6) Facilities contaminated with blood, vomitus, body secretions and excreta / Sodium hypochlorite ( 1:4 ) / Disinfect immediately
7) Metallic surfaces / 70% alcohol
Patient care equipment
1) Patient care equipment / As usual
- Sodium hypochlorite ( 1:49) or according to manufacturer’s instruction / Regularly & after use
2) Respiratory therapy equipment / As usual (at least high level disinfection)
3) Bedpan / urinal / Bedpan washer
- temperature has to reach at least 80℃ / Weekly and after
Use
4) Urine measuring jug / Immerse in the basin of sodium hypochlorite ( 1:49) designated for urine jugs – for at least 30 minutes
Other patient care items
1) Used linens / Put in designated water-proof bags.
Handle gently.
Waste Management
1) Items to be treated as clinical waste
a) Items listed as clinical wastes under the pre-existing HA guidelines
b) All contaminated / potentially contaminated wastes
c) Disposable PPE
d) Linens heavily soiled with blood, body secretions, vomitus and excreta.