Basic Infection Control And Prevention Plan for

Outpatient Oncology Settings
National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

Preamble
Background
An estimated 1.5 million new cases of cancer were diagnosed in the United States in 2010[1]. With improvements in survivorship and the growth and aging of the U.S. population, the total number of persons living with cancer will continue to increase [2]. Despite advances in oncology care, infections remain a major cause of morbidity and mortality among cancer patients[3-5]. Increased risks for infection are attributed, in part, to immunosuppression caused by the underlying malignancy and chemotherapy. In addition patients with cancer come into frequent contact with healthcare settings and can be exposed to other patients in these settings with transmissible infections. Likewise, patients with cancer often require the placement of indwelling intravascular access devices or undergo surgical procedures that increase their risk for infectious complications. Given their vulnerable condition, great attention to infection prevention is warranted in the care of these patients. In recent decades, the vast majority of oncology services have shifted to outpatient settings, such as physician offices, hospital-based outpatient clinics, and nonhospital-based cancer centers. Currently, more than one million cancer patients receive outpatient chemotherapy or radiation therapy each year[6]. Acute care hospitals continue to specialize in the treatment of many patients with cancer who are at increased risk for infection (e.g., hematopoietic stem cell transplant recipients, patients with febrile neutropenia), with programs and policies that promote adherence to infection control standards. In contrast, outpatient oncology facilities vary greatly in their attention to and oversight of infection control and prevention. This is reflected in a number of outbreaks of viral hepatitis and bacterial bloodstream infections that resulted from breaches in basic infection prevention practices (e.g., syringe reuse, mishandling of intravenous administration sets)[7-10]. In some of these incidents, the implicated facility did not have written infection control policies and procedures for patient protection or regular access to infection prevention expertise.

Scope
A. Intent and Implementation This document has been developed for outpatient oncology facilities to serve as a model for a basic infection control and prevention plan. It contains policies and procedures tailored to these settings to meet minimal expectations of patient protections as described in the CDC Guide to Infection Prevention in Outpatient Settings (available: http://www.cdc.gov/HAI/settings/ outpatient/outpatient-care-guidelines.html). The elements in this document are based on CDC’s evidencebased guidelines and guidelines from professional societies (e.g., Oncology Nursing Society). This plan is intended to be used by all outpatient oncology facilities. Those facilities that do not have an existing plan should use this plan as a starting point to develop a facility-specific plan that will be updated and further supplemented as needed based on the types of services provided. Facilities that have a plan should ensure that their current infection prevention policies and procedures include the elements outlined in this document. While this plan may essentially be used exactly “as is,” facilities are encouraged to personalize the plan to make it more relevant to their setting (e.g., adding facility name and names of specific rooms/locations; inserting titles/positions of designated personnel; and providing detailed instructions where applicable). This plan does not replace the need for an outpatient oncology facility to have regular access to an individual with training in infection prevention and for that individual to perform on-site evaluation and to directly observe and interact regularly with staff. Facilities may wish to consult with an individual with training and expertise in infection prevention early on to assist with their infection control plan development and implementation and to ensure that facility design and work flow is conducive to optimal infection prevention practices. B. Aspects of Care That Are Beyond the Scope of This Plan This model plan focuses on the core measures to prevent the spread of infectious diseases in outpatient oncology settings. It is not intended to address facilityspecific issues or other aspects of patient care such as: • nfection prevention issues that are unique to blood I and marrow transplant centers (a.k.a. bone marrow transplant or stem cell transplant centers) • ccupational health requirements, including recomO mended personal protective equipment for handling antineoplastic and hazardous drugs as outlined by the Occupational Safety and Health Administration and the National Institute for Occupational Safety • ppropriate preparation and handling (e.g., reconA stituting, mixing, diluting, compounding) of sterile medications, including antineoplastic agents • linical recommendations and guidance on approC priate antimicrobial prescribing practices and the assessment of neutropenia risk in patients undergoing chemotherapy For more information on these topics, refer to the list of resources provided in Appendix D of the plan.

. . . . . . . . . . . . . . . . . Topor M. . . Fernandez JR. 7 F. . . . .10:589−97. . .References 1 [Insert Facility Name] Infection Prevention Plan Table of Contents List of Abbreviations . . 2 I . . . . . . . . The epidemiology and treatment of infections in cancer patients. . . . Warren JL. . . . . . . . Nowell PC. . Cancer Invest 2008. . . . Fundamental Principles of Infection Prevention . . . Yabroff KR.142:898−902. . . . Management of health-care−associated infections in the oncology patient. . . . Herndon E. 15 B. . . . . . . . . Meekins A. . . . . . 6 E. . . 2011. . . . . . Tunneled Catheters . . . . . 2 American Cancer Society. . . Epub ahead of print. Rose Cancer Center shut down. . . . . . . .org/Research/CancerFactsFigures/CancerFactsFigures/most-requested-tablesfigures-2010. . . . . . . Prevalence of outpatient cancer treatment in the United States: estimates from the Medical Panel Expenditures Survey (MEPS). Martin K. . . . . Airborne Precautions . . . . . . . Central Venous Catheters . . . . . . . . Cleaning and Disinfection of Devices and Environmental Surfaces. . 15 A. . . . Handschur E et al. . . 2 3 4 II . . . . . 5 D.enterprisejournal. Transmission-Based Precautions . Haas A. . . . . . . . . . Outbreak of catheter-associated Klebsiella oxytoca and Enterobacter cloacae bloodstream infections in an oncology chemotherapy center. . . . . . .26:3242−7. . . . . . . . . . . . . 2009. . . . . . . Moolenaar RL et al. Ann Intern Med 2005. . Reportable Diseases/Conditions . . Nosocomial infections in patients with cancer.26:647−51. Education and Training . . . . . . . http://www. . . . . Contact Precautions . . . . . . . . . . . . . . . . Semple S. . . . 3 IV . . . . . 12 8 VI . . . . . . .165:2639−43. . . . . . . Thompson ND. . . . . 8 5 6 7 V . . . . . . . et al. . . . . Am J Infect Control 2011 Jun 8. . . 2 III . Additional Resources . . . . . . . . . . . . . Hand Hygiene . . . . . Siston AM. Rudowski E. Guinan JL. . 13 C. Brown ML. . . . . . . . Oncology 2003. . 2 B. . . . . . . . . . . . . . . . . Arch Intern Med 2005. Current and future utilization of services from medical oncologists. . . . 2011. . . . . . . . . Maschmeyer G. . . . . . . . . Halpern MT. McGuckin M. . . . Enterprise-Journal. Beck E. . . . J Clin Oncol 2008. Available at: http://www. . . . . . . White KL. . . . . Lancet Oncol 2009. . . . . . Medication Storage and Handling .17:415−20. . . . . . . . . . . July 31. Implanted Ports . . Macedo de Oliveria A. . Droplet Precautions . . . . . 16 C. . . Respiratory Hygiene and Cough Etiquette . . . . . . Injection Safety . An outbreak of hepatitis C virus infections among outpatients at a hematology/oncology clinic. . . . . . . . . . . . . . . 4 C. 17 D. . . . . . . . . . 12 B. CDC Infection Prevention Checklist for Outpatient Settings. Hepatitis B outbreak associated with a hematology-oncology office practice in New Jersey. . . . . . General Maintenance and Access Procedures . 11 B. . .com/news/article_58190090bbb5-11e0-b99d-001cc4c03286. . . . . . . . . . . . 14 9 Appendices . . . . . . . . . . . . Cancer Facts & Figures 2010 Tables & Figures. Standard Precautions . . . Transmission-Based Precautions . . . . . . . . Surveillance and Reporting . . . . . . Beecham BD. . . . . . . . . . . . . . . . .31:193−7. . . . . . . . . . . . . 12 A. . . .html Accessed September 9. . . . . . . . . . Greeley RD. 2 A. Leschinsky DP. . . patients advised to get screening. . . Vogt TM. . . . . 18 10 . . . Personal Protective Equipment . . . . . . . . . . . . . . . . 11 C. Identifying Potentially Infectious Patients . . . . . Int J Antimicrob Agents 2008. . Example List of Contact Persons and Roles/Responsibilities. . . 14 D. . 11 A. Sepkowitz KA. . 11 D. Peripherally Inserted Central Catheters (PICCs) . . . . . . .cancer. . 3 A. . . Standard Precautions . . . . . . . Kamboj M. 3 B. . . Jones RC. . Watson JT. High P. . Mariotto AB. . .

and 3) Airborne Precautions.pdf) Transmission-Based Precautions Transmission-Based Precautions are intended to supplement Standard Precautions in patients with known or suspected colonization or infection of highly transmissible or epidemiologically important pathogens. and summary guidance for outpatient settings.gov/hicpac/pdf/isolation/Isolation2007. refer to the following documents: CDC Guide to Infection Prevention in Outpatient Settings (available at: http://www. For diseases that have multiple routes of transmission. Standard Precautions include: 1) hand hygiene. Education and Training Ongoing education and training of facility staff are required to maintain competency and ensure that infection prevention policies and procedures are understood and followed. gloves.cdc. 2) use of personal protective equipment (e.List of Abbreviations ANC APIC CDC DEA EPA FDA HAI HBV HCV Absolute neutrophil count Association for Professionals in Infection Control and Epidemiology. 4) safe injection practices. ambulatory care facilities need to develop specific strategies to control the spread of transmissible diseases pertinent to their setting.gov/HAI/settings/outpatient/ outpatient-care-guidelines. These evidence-based practices are designed to both protect healthcare personnel and prevent the spread of infections among patients. A list of names of designated personnel and their specific roles and tasks and contact information is provided in Appendix A. 3) respiratory hygiene and cough etiquette. facemasks). Education and Training • ll facility staff. a combination of Transmission-Based Precautions may be used. The risk of infection transmission and the ability to implement elements of Transmission-Based Precautions may differ between outpatient and inpatient settings (e. Precautions. These additional precautions are used when the route of transmission is not completely interrupted using Standard Precautions.. The three categories of Transmission-Based Precautions include: 1) Contact II . Fundamental Principles of Infection Prevention Standard Precautions Standard Precautions represent the minimum infection prevention measures that apply to all patient care.. and 5) safe handling of potentially contaminated equipment or surfaces in the patient environment. Whether used singly or in combination. Inc . including contract personnel (e..g. 2) Droplet Precautions.g. depending on the anticipated exposure. However. because patients with infections are routinely encountered in outpatient settings. regardless of suspected or confirmed infection status of the patient. facility design characteristics). they are always used in addition to Standard Precautions.g. A environmental services workers from an outside agency) are educated and trained by designated personnel regarding: • Proper selection and use of PPE • ob- or task-specific infection prevention practices J 2 .cdc.html) CDC 2007 Guideline for Isolation Precautions (available at: http://www. 1. This includes developing and implementing systems for early detection and management of potentially infectious patients at initial points of entry to the facility. For detailed information on Standard and Transmission-Based Precautions. Centers for Disease Control and Prevention Drug Enforcement Administration Environmental Protection Agency Food and Drug Administration Healthcare-associated infection Hepatitis B virus Hepatitis C virus HIV IDSA INS ONS OSHA Human immunodeficiency virus Infectious Diseases Society of America Infusion Nursing Society Oncology Nursing Society Occupational Safety and Health Administration Personal protective equipment Society for Healthcare Epidemiology of America United States Pharmacopeia World Health Organization NIOSH National Institute for Occupational Safety PPE SHEA USP WHO I . in any setting where healthcare is delivered. gowns. Standard Precautions replaces earlier guidance relating to Universal Precautions and Body Substance Isolation.

body fluids or excretions. and improvement of healthcare practices.gov/mmwr/PDF/rr/ rr5116. norovirus). and analyze D relevant data • urveillance reports are prepared and distributed S periodically to appropriate personnel for any necessary follow-up actions (e. Hand hygiene stations should be strategically placed to ensure easy access. A or wound dressings • rior to performing an aseptic task (e. Clostridium difficile. blood. accessing a P port.who. hand hygiene). HAI Surveillance • tandard definitions are developed for specific S HAIs under surveillance (e... hand hygiene.g..pdf) WHO Guidelines on Hand Hygiene in Healthcare 2009 (available at: http://whqlibdoc.. Standard Precautions A. manage.g. outbreak detection. covering all surfaces of hands R and fingers until they are dry (no rinsing is required) Handwashing with Soap and Water: • et hands first with water (avoid using hot water) W • Apply soap to hands • ub hands vigorously for at least 15 seconds. repeated at least T annually and anytime polices or procedures are updated. preparing an injection) • f hands will be moving from a contaminated-body I site to a clean-body site during patient care • After glove removal CDC Guideline for Hand Hygiene in Health-Care Settings (available at: http://wwwdev. IV .int/publications/2009/9789241597906_eng. • esignated personnel collect.. except when hands are visibly soiled (e. in which case soap and water should be used. Competency Evaluations • ompetency of facility staff is documented initially and C repeatedly.pdf) 3 . state and federal reF quirements for reportable diseases and outbreak reporting [see Appendix B]. high incidence of certain HAIs may prompt auditing of specific procedures or a thorough infection control assessment) 1. as appropriate for the specific job or task • egular audits of facility staff adherence to infecR tion prevention practices (e. and is documented as per facility policy 2. or after caring for patients with known or suspected infectious diarrhea (e.• ersonnel providing training have demonstrated P and maintained competency related to the specific jobs or tasks for which they are providing instruction • raining is provided at orientation.g..g. even if gloves will be B worn • efore exiting the patient’s care area after touchB ing the patient or the patient’s immediate environment • fter contact with blood. 1.g. This includes the surveillance of infections associated with the care provided by the facility (defined as healthcare-associated infections) and process measures related to infection prevention practices (e.g. Sample Procedures for Performing Hand Hygiene Using Alcohol-based Hand Rub (follow manufacturer’s directions): • Dispense the recommended volume of product • Apply product to the palm of one hand • ub hands together.cdc. central-line associated bloodstream infections) 2.. dirt. Hand Hygiene Hand hygiene procedures include the use of alcohol-based hand rubs (containing 60-95% alcohol) and handwashing with soap and water. Disease Reporting • acility staff adhere to local. body fluids). Indications for Hand Hygiene Always perform hand hygiene in the following situations: • efore touching a patient.g. covR ering all surfaces of hands and fingers • inse hands with water and dry thoroughly with R paper towel • Use paper towel to turn off water faucet 2. Surveillance and Reporting Routine performance of surveillance activities is important to case-finding. Alcoholbased hand rub is the preferred method for decontaminating hands. environmental cleaning) are performed by designated personnel III .

I don gloves last 3.gov/hicpac/pdf/isolation/Isolation2007.. peel off and discard • Removal of gowns: • emove in such a way to prevent contamination of R clothing or skin • urn contaminated outside surface toward the inT side • Roll or fold into a bundle and discard • Removal of facemask or respirator • Avoid touching the front of the mask or respirator • rasp the bottom and the ties/elastic to remove G and discard • Removal of goggles or face shield • void touching the front of the goggles or face shield A • emove by handling the head band or ear pieces R and discard • lways perform hand hygiene immediately after reA moving PPE CDC 2007 Guideline for Isolation Precautions (available at: http://www. • ll healthcare personnel that use N95-or higher resA pirator are fit tested at least annually and according to OSHA requirements 2.g. don the gown first and fasten in I back accordingly • If wearing a facemask or respirator: • ecure ties or elastic band at the back of the head S and/or neck • Fit flexible band to nose bridge • Fit snug to face and below chin • f wearing goggles or face shield.. G peel off • Hold removed glove in glove hand • lide ungloved fingers under the remaining glove S at the wrist.cdc. Please note that this section does not address issues related to PPE for the preparation and handling of antineoplastic and hazardous drugs. nonintact skin or contaminated equipment. or other body fluids. tuberculosis). or face shield M alone. Use of PPE Gloves Wear gloves when there is potential contact with blood (e. body fluids or infectious agents. Recommendations for Removing PPE • emove PPE before leaving the exam room or paR tient environment (except respirators which should be removed after exiting the room) • Removal of gloves: • rasp outside of glove with opposite gloved hand..pdf) CDC’s tools for personal protective equipment (available: http://www. put it on face and I adjust to fit • f wearing gloves in combination with other PPE. mucous membranes. Personal Protective Equipment Personal Protective Equipment (PPE) use involves specialized clothing or equipment worn by facility staff for protection against infectious materials. annually) due to new product developments and improvements.g. respiratory secretions. • o not wear the same gown for the care of more D than one patient • emove gown and perform hand hygiene before R leaving the patient’s environment (e. A review of available PPE should be performed periodically (e..cdc. The recommended PPE for those procedures should be determined in accordance with OSHA and NIOSH. nose and eyes Respirators If available.B. wear N95-or higher respirators for potential exposure to infectious agents transmitted via the airborne route (e.gov/HAI/prevent/ppe. nose and eyes • hen placing a catheter or injecting material into W the spinal canal or subdural space (to protect patients from exposure to infectious agents carried in the mouth or nose of healthcare personnel) • ear a facemask to perform intrathecal chemoW therapy Goggles. • ersonal eyeglasses and contact lenses are not conP sidered adequate eye protection • ay use goggles with facemasks. The selection of PPE is based on the nature of the patient interaction and potential for exposure to blood.g.html) 4 . Face Shields Wear eye protection for potential splash or spray of blood.g. Recommendations for Donning PPE • Always perform hand hygiene before donning PPE • f wearing a gown. to protect the mouth. body fluids. 1. exam room) Facemasks (Procedure or Surgical Masks) Wear a facemask: • hen there is potential contact with respiratory seW cretions and sprays of blood or body fluids (as defined in Standard Precautions and/or Droplet Precautions) • ay be used in combination with goggles or face M shield to protect the mouth. during phlebotomy). • ear gloves that fit appropriately (select gloves acW cording to hand size) • o not wear the same pair of gloves for the care of D more than one patient • Do not wash gloves for the purpose of reuse • erform hand hygiene before and immediately after P removing gloves Gowns Wear a gown to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated.

Respiratory Hygiene and Cough Etiquette All persons with signs and symptoms of a respiratory infection (including facility staff) are instructed to: • over the mouth and nose with a tissue when C coughing or sneezing. Healthcare Personnel Responsibilities • ealthcare personnel observe Droplet Precautions H (refer to Section V. refer to Airborne Precautions in Section V. and no-touch waste receptacles F for disposing of used tissues • Dispensers of alcohol-based hand rub 3. including cough.D.g. or increased production of respiratory secretions.C. congestion. 1.).. patients and accompanying family members. Identifying Persons with Potential Respiratory Infection • acility staff remain alert for any persons arriving F with symptoms of a respiratory infection • igns are posted at the reception area instructing S patients and accompanying persons to: • elf-report symptoms of a respiratory infection S during registration • ractice respiratory hygiene and cough etiquette P (technique described below) and wear facemask as needed 2. if an exam room is not available.C. patients are to be inU structed to don a facemask (e. in addition to Standard Precautions.D. patients I are encouraged to reschedule the appointment until symptoms have resolved • pon entry to the facility. the following infection prevention measures are implemented for all potentially infected persons at the point of entry and continuing throughout the duration of the visit. procedure or surgical mask) • lert registration staff ahead of time to place the A patient in an exam room with a closed door upon arrival • If identified after arrival: • rovide facemasks to all persons (including perP sons accompanying patients) who are coughing and have symptoms of a respiratory infection • lace the coughing patient in an exam room with P a closed door as soon as possible (if suspicious for airborne transmission. including staff who are not directly employed by the facility but provide essential daily services • ealthcare personnel with a respiratory infection H avoid direct patient contact.g. Additional precautions (e. Influenza Season) In addition to the aforementioned infection prevention measures. Transmission-Based Precautions) can be found in Section V. if available • f the purpose of the visit is non-urgent. when examining and caring for patients with signs and symptoms of a respiratory infection (if suspicious for an infectious agent spread by airborne route. if possible • nstruct patients with respiratory symptoms to I don a facemask upon entry to the facility 5 . then a facemask should be worn while providing patient care and frequent hand hygiene should be reinforced • ealthcare personnel are up-to-date with all recomH mended vaccinations. • ispose of the used tissue in the nearest waste reD ceptacle • erform hand hygiene after contact with respiratory P secretions and contaminated objects/materials 4. refer to Airborne Precautions in Section V. caregivers. During Periods of Increased Community Respiratory Virus Activity (e. tissues. the patient should sit as far from other patients as possible in the waiting room • ccompanying persons who have symptoms of a A respiratory infection should not enter patient-care areas and are encouraged to wait outside the facility 5. if this is not possible. Staff Communication • esignated personnel regularly review information D on local respiratory virus activity provided by the health department and CDC to determine if the facility will need to implement enhanced screening for respiratory symptoms as outlined in step 7 7.g. including annual influenza vaccine 6. Masking and Separation of Persons with Respiratory Symptoms • If patient calls ahead: • ave patients with symptoms of a respiratory infecH tion come at a time when the facility is less crowded or through a separate entrance. Availability of Supplies The following supplies are provided in the reception area and other common waiting areas: • acemasks. Respiratory Hygiene and Cough Etiquette To prevent the transmission of respiratory infections in the facility. and visitors) with signs and symptoms of respiratory illness..g.). rhinorrhea.. the following enhanced screening measures are implemented: • When scheduling and/or confirming appointments: • re-screen all patients and schedule those with P respiratory symptoms to come when the facility might be less crowded.) • hese precautions are maintained until it is deterT mined that the cause of the symptoms is not an infectious agent that requires Droplet or Airborne Precautions • ll healthcare personnel are aware of facility sick A leave policies. This applies to any person (e..

. antiemetics. if an exam room is not available.g. or bags or bottles of intravenous solution to more than one patient (e. U lancets) to obtain samples for checking a patient’s blood glucose. disposable fingerstick devices (e.E. needles. or between a patient and healthcare personnel during preparation and administration of parenteral medications. intravenous tubing. 1. General Safe Injection Practices • se aseptic technique when preparing and adminU istering chemotherapy infusions or other parenteral medications (e. To the extent possible. they are restricted to a dedicated medication preparation area and should not enter the immediate patient treatment area (e. etc. (Medication Storage and Handling). ampoules.gov/ flu/professionals/infectioncontrol/healthcaresettings. respectively.gov/hicpac/pdf/isolation/Isolation2007. patients are provided a facemask and placed in a separate area as far as possible from other patients while awaiting care • f patient volume is anticipated to be higher than I usual with prolonged wait time at registration: i. fingerstick devices. including the appropriate use of single-dose (or single-use) and multi-dose vials and the proper technique for accessing intravascular devices.g.. if an exam room is not available. exam room. punctureresistant. diphenhydramine.cdc. if possible.. as well as in Appendix D.cdc. medication preparation should take place in pharmacy settings and dedicated medication rooms. • f the purpose of the visit is non-urgent. even if the needle is changed or the injection is administered through an intervening length of intravenous tubing • o not reuse a syringe to enter a medication vial or D solution • o not administer medications from single-dose or D single-use vials.g.pdf) CDC recommendations for preventing the spread of influenza in healthcare settings (available at: http://www. syringes. D intravenous tubing) for more than one patient • se single-use. Injection Safety Injection safety refers to the proper use and handling of supplies for administering injections and infusions (e. dexamethasone) • henever possible. facility staff A identify pre-screened patients (from the list) and screen all other patients and accompanying persons for symptoms of respiratory infection • atients identified with respiratory symptoms P are placed in a private exam room as soon as possible. and placed immediately in a private exam room.g.. medication vials. encourage family members. PT/INR. and visitors E with symptoms of respiratory infection to not accompany patients during their visits to the facility • f possible. do not use a bag of saline as a common source supply for multiple patients) • leanse the access diaphragms of medication vials C with 70% alcohol and allow the alcohol to dry before inserting a device into the vial • edicate multi-dose vials to a single patient whenD ever possible. can be found in Section IV. If multi-dose vials must be used for more than one patient. and dispose of them after each use. A separate triage station is established to identify pre-screened patients (from the list) and to screen all other patients and accompanying persons immediately upon their arrival and prior to registration ii. patients I with symptoms of respiratory infection are encouraged to schedule an appointment after symptoms have resolved • ncourage family members.cdc.g. prepare in advance for the registraI tion staff a daily list of patients with respiratory symptoms who are scheduled for a visit • Upon entry to the facility and during visit: • t the time of patient registration. saline and heparin) • void prefilling and storing batch-prepared syringes A except in accordance with pharmacy standards • void unwrapping syringes prior to the time of use A • ever administer medications from the same syringe N to multiple patients. and visitors with symptoms of respiratory infection to not enter the facility CDC 2007 Guideline for Isolation Precautions (available at: http://www. Additional recommendations for safe injection practices.htm) D. gov/flu/weekly/fluactivitysurv.g. caregivers... chemotherapy suite) • ispose of used syringes and needles at the point of D use in a sharps container that is closable. patients are provided a facemask and placed in a separate area as far as possible from other patients while awaiting care • f possible. in Section VI (Central Venous Catheters). These practices are intended to prevent transmission of infectious diseases between one patient and another. caregivI ers. do not use a lancet holder or penlet 6 .g. All staff personnel who use or handle parenteral medications and related supplies should be aware of labeling and storage requirements and pharmacy standards.htm ) CDC’s Flu Activity & Surveillance (available at: www. use commercially manufactured W or pharmacy-prepared prefilled syringes (e. and parenteral solutions). Patients identified with respiratory symptoms are registered in a separate area. and leak-proof • o not use fluid infusion or administration sets (e.

injectable hormonal agents) in accordance with manufacturer’s instructions (e. diagnostic and F therapeutic lumbar punctures) or handling of devices to access the cerebrospinal fluid (e.g. if possible • f the procedure has to be done elsewhere (e. Medication Storage and Handling The measures outlined in this section pertain to the general storage and handling of parenteral medications outside of the pharmacy setting. (Injection Safety).. These functions are performed by personnel who have the appropriate qualifications and training as determined in accordance with the state pharmacy board. However. do not bring com- • • • • mon trays of supplies for phlebotomy or intravenous device access to the patient’s immediate treatment area. Parenteral medications include single-dose and multi-dose vials. use aseptic technique and follow A safe injection practices • acemask can be considered as an additional F precaution 3. 1. chemotherapy suite). temperature) • Use of freezers/refrigerators • tore medications that require refrigeration in S a dedicated.D. and administration should adhere to injection safety measures as outlined in Section IV.pdf) E. ensuring appropriate environmental and engineering controls such as biological safety cabinets and laminar airflow hoods. procedure or A surgical masks) and sterile gloves when injecting material or inserting a catheter into the epidural or subdural space (e.g. mixing. wear a facemask (e. granulocyte-colony S stimulating factors.g. In general.g. Phlebotomy Procedures • hlebotomy procedures are performed in a dediP cated area.gov/injectionsafety/PDF/ Clinical_Reminder_Spinal-Infection_Meningitis. reconstituting.. They are labeled as such by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria.g. this preservative has no effect on viruses and does not fully protect against contamination when safe injection practices are not followed. shelf-life. Ommaya reservoir): • t a minimum. bring only the necessary supplies to the patient side H and hygiene stations (e. Multi-dose vials contain more than one dose of medication.g. labeled refrigerator that meets requirements for such storage (e. including those of the United States Pharmacopeia and the Food and Drug Administration.gov/hicpac/pdf/isolation/Isolation2007.g. ampoules.g... dedicating single-dose vials to single-patient use) • t a minimum.device for this purpose • dhere to federal and state requirements for proA tection of healthcare personnel from exposure to bloodborne pathogens • 2.pdf) CDC Clinical Reminder: Spinal Injection Procedures Performed without a Facemaks Pose Risk for Baterial Meningitis (available at: http://www. separate exterior door for refrigerator and freezer compartments) • esignated personnel maintain temperature log D 7 .g.. administration of intrathecal chemotherapy) • or other spinal procedures (e.. Medication Storage • tore all medications (e. handling.. and proper use of aseptic technique).cdc.g. The appropriate storage and handling (e. Consultation with the state pharmacy board and oncology pharmacy specialists is recommended. compounding) of antineoplastic drugs and other sterile medications that typically require preparation in pharmacy settings should be determined in accordance with established official and enforceable standards for these activities (e..g. I exam room. alcohol-based hand rub dispensers) are readily accessible to the phlebotomist U se aseptic technique to perform the phlebotomy procedure D o not reuse vacutainer holders S harps containers are strategically placed near the phlebotomist to ensure easy access and safe disposal of used supplies M inimize environmental contamination by performing the following: • abel tubes before blood is drawn L • void placing tubes on patient charts or othA er items or surfaces that cannot be properly cleaned • o not process or store blood specimens near D medications or medication preparation area CDC 2007 Guideline for Isolation Precautions (available at: http://www. diluting.. Single-dose vials (or single-use vials) are intended for use in a single patient for a single case/procedure/injection.g. thermostat control.. Single-dose or single-use vials are labeled as such by the manufacturer and typically lack an antimicrobial preservative. Spinal Injection Procedures • se aseptic technique and follow safe injection U practices (e. parenteral medication storage... bags or bottles of intravenous fluids.cdc.

be careful to avoid contact with the non-sterile environment during the process • ever leave a needle inserted into the septum N of a medication vial for multiple draws • nsure that any device inserted into the sepE tum (e.. FDA.. Medication Preparation • raw up medications in the Medication Room or D in a designated clean area that is free of any items potentially contaminated with blood or body fluids (e. transporting.. exam rooms) and certain common-use areas (e.gov/injectionsafety/providers/ provider_faqs. Designated Personnel • esponsibilities for cleaning and disinfection of enR vironmental surfaces and medical equipment are assigned to specific personnel (as indicated in Appendix B) • f Environmental Services are only available afterI hours (e.g. then designated facility staff are assigned specific responsibilities for cleaning and disinfection during clinic hours • ll assigned personnel are trained in the appropriA ate cleaning/disinfection procedures and the proper use of PPE and cleaning products 2. USP.. it should be dedicated to that patient and discarded after use • ote: Bags or bottles of intravenous solution (e.(monitor temperature at least twice daily for vaccine storage) and ensure alternative storage method is in place in the event of power or refrigerator failure • ulti-dose vials are stored in the Medication Room M and not in the immediate patient treatment area (e.. the vials should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial CDC 2007 Guideline for Isolation Precautions (available at: http://www. safe use. bathrooms). 1. IV tubing.g. if more than one entry is required. used equipment such as syringes.cdc. the vial should be discarded according to the time the manufacturer specifies for the opened vial or at the end of the case/procedure for which it is being used.html) CDC Vaccine Storage and Handling Toolkit (available at: http://www2a. including state board of pharmacy. • or multidose vials that have been opened or acF cessed (e.pdf) CDC FAQs Regarding Safe Practices for Medical Injections (available at: http://www.. chemotherapy dispensing pins) are used in accordance with manufacturer’s instructions and they do not compromise the integrity of the remaining vial contents • inimize multiple entries into bags of fluid to add M medications.g..g. Cleaning and Disinfection of Devices and Environmental Surfaces The procedures outlined in this section pertain to the cleaning and disinfection of noncritical patient-care devices (e. It should not be stored for future use. When to Discard Medications • edications should always be discarded accordM ing to the manufacture’s expiration date (even if not opened) and whenever sterility is compromised or questionable • or single-dose vials that have been opened or acF cessed (e. and federal authorities. blood pressure cuff) and environmental surfaces in patient-care areas (e. blood collection tubes. and DEA. exam room. whichever comes first.g. contractors from outside agency). storage and dispos- 8 . needle-puncture).. and needle holders) • ote: Multi-dose vials should not be accessed in the N immediate patient treatment area (e.g. Standard procedures and recommended practices for cleaning and disinfecting compounding areas (e. needles.g.g. if a multi-dose vial enters the immediate patient-care area. needle-punctured). exam room.g. pharmacy settings) and the handling... N bag of saline) should not be used for more than one patient • se an aseptic technique to access parenteral mediU cations: • erform hand hygiene before handling the P medication • isinfect the rubber septum with alcohol and D allow the alcohol to dry prior to piercing • lways use a new sterile syringe and sterile A needle to draw up the medication.g. Supplies and Cleaning Products • esignated personnel regularly restock necessary D supplies (e..cdc. amount.gov/hicpac/pdf/isolation/Isolation2007.g. facemasks) and replenish dispensers of alcohol-based hand rub and soap throughout the facility • ollow manufacturer’s instructions for cleaning surF faces and noncritical devices.gov/vaccines/ed/shtoolkit/) F. and disposing of antineoplastic agents should be determined in accordance with local.g..cdc. always use a new sterile syringe and sterile needle and access the bag using aseptic technique 3. gowns.. dilution.g. ensure that the cleaning product used is compatible with the surface/ device being cleaned • se EPA-registered disinfectant with appropriate U germicidal claim for the infective agent of concern (may vary depending on situation) and follow the manufacturer’s safety precautions and instructions (e. gloves..g. state. chemotherapy suite) 2. chemotherapy suite).

thermometers (if disposable oral temperature probes are used.. they should be discarded after each use) Phlebotomy Stations • ocus cleaning on high-touch surfaces (at least daiF ly): patient chair and arm rest.. pulse oximetry sensors (follow manufacturer’s instructions). exam gowns. HIV. PT/INR readers) that utilizes blood samples. the sink. 1:10 dilution prepared fresh) Chemotherapy Suites • lean patient chair. medication preparation areas (outside pharmacy/compounding areas).g. Cleaning Patient-Care Areas General cleaning and disinfection measures that apply to any patient-care area: • Wear appropriate PPE • n general. blood pressure cuff. A feather-dusting) • oncentrate on cleaning high-touch surfaces (areas C frequently touched by patients and facility staff) and those in close proximity to the patient. HBV.g. to prevent bloodborne pathogen transmission. clean high-touch surfaces using a sodium hypochlorite (bleach)based product (e. IV tubing.g.. these I are cleaned after use and allowed to dry before reuse 3. exam bed. HCV). and bathrooms are cleaned at least daily. cleaning should be performed before disI infection unless a one-step detergent disinfectant is used • et-dust horizontal surfaces by moistening a cloth W with a small amount of an EPA-registered disinfectant • void dusting methods that disperse dust (e.. refer to step 8 below for laundering soiled linens • lean any medication preparation area after each C patient encounter and ensure contaminated items (as described above) are not placed in or near the area • ocus cleaning on high-touch surfaces (at least F daily). stethoscope. refer to step 7 for cleaning spills of blood 5. blood pressure cuff. secretions) • he patient-care device involves a blood glucose T meter or other point of care testing device (e. these devices must be cleaned and disinfected after each use in accordance with manufacturer’s instructions 4.g. if medication preparation takes place in the patient treatment area (outside a designated medication room).. needles. procedure table • romptly clean and disinfect surfaces contaminated P by blood using an EPA-registered disinfectant with specific label claims for bloodborne pathogens (e. chair and bedside stool. bedrails. the area around the toilet. annually) due to product developments and improvements and to ensure that the materials used are consistent with existing guidelines and meet the needs of the staff • f reusable mops and cleaning cloths are used. and needle holders) • isinfect bathrooms after use by a patient with D known or suspected infectious diarrhea and before use by another person (refer to step 5 below) • isinfect environmental surfaces and noncritical paD tient-care devices when visibly soiled • isinfect environmental surfaces and noncritical paD tient-care devices in between patient use if: • here was direct contact to non-intact skin or T mucous membrane or potential contamination with body fluids (e. as outlined below for specific rooms/areas • ollow manufacturer’s instructions for cleaning and F maintaining noncritical medical device/equipment • lean walls. e. blood collection tubes. Cleaning Bathrooms • Wear appropriate PPE • lean the toilet.al) for cleaning/disinfection • roducts and supplies are reviewed periodically P (e. and window curtains when they C are visibly dusty or soiled Cleaning and disinfection measures for specific patient-care areas: Exam Rooms • hange the paper covering the exam table and pilC lows between patient use • lace any used linens (e. IV poles/pumps.. used equipment such as syringes.g.g.g. blinds. Frequency of Cleaning Patient-care areas. sheets) in a P designated container located in each exam room after each patient use. and door knob • econtaminate high-touch surfaces using an EPAD registered disinfectant with specific claim labels for the infective agent • f patient has suspected infectious diarrhea and I the infective agent is unknown. with the following exceptions: • romptly clean and decontaminate any location P with spills of blood and other potentially infectious materials (refer to step 7 below) • lean medication preparation areas when visibly C soiled.g. blood.. and side table C between each patient use • lean any medication preparation area after each paC tient encounter and ensure contaminated items (as described above) are not placed in or near the area Triage Stations and/or Locations for Performing Vital Signs (if not done in exam rooms) • ocus cleaning on high-touch surfaces (at least daiF ly): patient chair. C 9 . wall-mounted ophthalmoscope and otoscope (per manufacturer’s instructions)..g. clean this area after each patient encounter: • nsure the medication preparation area is free E of any items contaminated with blood or body fluids (e.

and dispose regulated waste. and hand hygiene supplies are available for their use • f laundry equipment is available on premise. and persons • o not sort or rinse soiled linens in patient-care areas D • se leak-resistant containment for linens contamiU nated with blood or body substances.g. H including antineoplastic and hazardous drugs.g. If hot-water laundry cycles are used. HIV.. Waste Disposal • uncture-resistant.pdf) CDC Guideline for the Prevention and Control of Norovirus Gastroenteritis Outberaks in Healthcare Settings (available at: http://www. leak-proof sharps containers are P located in every patient-care area (e.cdc. use a bleach-based I disinfectant (e.g. recap.. and allow the surface to dry • If a bleach-based product is used: • se a 1:100 dilution to decontaminate nonporous U surfaces • f the spill involves large amounts of blood or I body fluids.pdf ) CDC Guideline for Disinfection and Sterilization in Healthcare Facilities.html) APIC Infection Prevention Manual for Ambulatory Care..cdc. 2009 10 . focusing on the toilet and the area around the toilet: • se an EPA-registered disinfectant with specific U claim labels for the infective agent • f infective agent is unknown.cdc. wash with proper concentrations of laundry chemicals that are suitable for lowtemperature washing • f commercial laundry facilities are used. Handling and Laundering Soiled Linens • andle all contaminated linens with minimum agiH tation to avoid contamination of air. then followed by cleaning and subsequent decontamination with 1:100 dilution application 8. do not place loose items in the laundry chute • n the laundry area. clean the visible matter with disposable absorbent material and discard in appropriate containers for biohazardous waste • econtaminate the area using an EPA-registered D disinfectant with specific label claims for bloodborne pathogens (e. transport. >10 mL). R biohazardous material and chemical hazardous waste. use forceps to pick up any sharps and discard in sharps container) • f the spill contains large amounts of blood or body I fluids (e. refer to the state pharmacy board and USP recommendations) • Wear appropriate PPE • lean the countertops and surfaces where medicaC tion preparation occurs at least daily and when visibly soiled • nsure contaminated items (as described above) E are not placed in or near the medication preparation area • efrigerators for storing medications are cleaned R at defined intervals and when soiled. in accordance with state and local regulations CDC Guidelines for Environmental Infection Control in Health-Care Facilities (available at: http://www.g. HBV.g.pdf) CDC Infection Prevention during Blood Glucose Monitoring and Insulin Administration (available at: http://www.gov/hicpac/pdf/norovirus/NorovirusGuideline-2011. HCV) or a freshly diluted bleach-based product (preferably EPA-registered).gov/ hicpac/pdf/guidelines/eic_in_HCF_03. clean the bathroom before it is used again. Cleaning Spills of Blood and Body Substances • ear protective gloves and use appropriate PPE W (e.gov/ hicpac/pdf/guidelines/Disinfection_Nov_2008. do not bend. phlebotomy station) • pecifically for phlebotomy stations. including antineoplastic drugs) are disposed of in their designated containers • ll trash and waste containers are emptied at least A daily by designated personnel • Wear appropriate PPE • andle. Cleaning Medication Rooms (excluding pharmacy settings or locations where sterile compounding is performed.cdc. use I and maintain the equipment according to manufacturer’s instructions • n general. ensure that there is not leakage during transport • f laundry chutes are used. in accordance with manufacturer’s instructions.. ensure that I their laundering process is in accordance with current recommendations 9.. I wash with detergent in water ≥160°F (≥71°C) for ≥25 minutes • f low-temperature (<160°F [<70°C]) laundry cyI cles are used. gloves) I are worn by laundry personnel while sorting soiled linen.g. or break used syringe needles before discarding them into the container • illed sharps containers are disposed of in accorF dance with state regulated medical waste rules • egular trash and regulated medical waste (e. for these locations. surfaces.and faucet handles at least daily. in accordance with manufacturer’s instructions 7. ensure that laundry bags I are closed before tossing the filled bag into the chute. appropriate PPE (e. a sharps S container is located within a short distance of each phlebotomist’s work space • ll sharps are disposed of in the designated A sharps container. and the walls if visibly soiled • f used by a patient with known or suspected infecI tious diarrhea. 1:10 dilution prepared fresh) 6.g. exam room.. chemotherapy suite. 2008 (available at: http://www.gov/ injectionsafety/blood-glucose-monitoring. use a 1:10 dilution for first application of germicide before cleaning..

blood. Contact Precautions • pply to patients with any of the following condiA tions and/or disease: • resence of stool incontinence (may include paP tients with norovirus.F. avoid coming into close contact with other patients.g. Transmission-Based Precautions In addition to consistent use of Standard Precautions.g.g. adenovirus.g. such as a procedure or surgiW cal mask. note: use soap and water when hands are visibly soiled (e. if available.) • nstruct patients with known or suspected infecI tious diarrhea to use a separate bathroom. • PPE use: • ear a facemask. if possible • lert registration staff ahead of time to place A the patient in a private exam room upon arrival if available and follow the procedures pertinent to the route of transmission as specified below • f the purpose of the visit is non-urgent.) • • • 11 . Identifying Potentially Infectious Patients • acility staff remain alert for any patient arriving F with symptoms of an active infection (e. uncontrolled secretions. draining wounds or skin lesions) • If patient calls ahead: • ave patients with symptoms of active infection H come at a time when the facility is less crowded..5. rotavirus. rash.4. respiratory syncytial virus. group A streptococcus • lace the patient in an exam room with a closed P door as soon as possible (prioritize patients who have excessive cough and sputum production). respiratory symptoms. additional precautions may be warranted in certain situations as described below. clean/disinfect the bathroom before it can be used again (refer to Section IV. blood.. the patient is provided a facemask and placed in a separate area as far from other patients as possible while awaiting care. and practice respiratory hygiene and cough etiquette C lean and disinfect the exam room accordingly (refer to Section IV. or uncontrolled secretions • erform hand hygiene before touching patient and P prior to wearing gloves • PPE use: • ear gloves when touching the patient and the W patient’s immediate environment or belongings • ear a gown if substantial contact with the paW tient or their environment is anticipated • erform hand hygiene after removal of PPE.. for close contact with the patient. draining wounds. influenza. diarrhea. for bathroom cleaning/disinfection) C.F.V . note: P use soap and water when hands are visibly soiled (e. if an exam room is not available. the facemask should be donned upon entering the exam room • f substantial spraying of respiratory fluids is anI ticipated. body fluids). A. pressure ulcers. patients I are encouraged to reschedule the appointment until symptoms have resolved B. Clostridium difficile. human metapneumovirus) • Bordetella pertusis • or first 24 hours of therapy: Neisseria meningitiF des. body fluids) I nstruct patient to wear a facemask when exiting the exam room. or after caring for patients with known or suspected infectious diarrhea (e. gloves and gown as well as goggles (or face shield in place of goggles) should be worn P erform hand hygiene before and after touching the patient and after contact with respiratory secretions and contaminated objects/materials. draining wounds and/or skin lesions that cannot be covered. or presence of ostomy tubes and/or bags draining body fluids • Presence of generalized rash or exanthems • rioritize placement of patients in an exam room if they P have stool incontinence. these include. or Clostridium difficile).4. norovirus) • lean/disinfect the exam room accordingly (refer to C Section IV. Droplet Precautions • pply to patients known or suspected to be inA fected with a pathogen that can be transmitted by droplet route.. parainfluenza R virus..g.F. but are not limited to: • espiratory viruses (e.

Curry National Tuberculosis Center.g. if available.. needleless connector) S with an appropriate antiseptic (e. While the recommendations below apply generally. Hickman®. when caring for the patient. adequate wait time may vary depending on the ventilation rate of the room and should be determined accordingly* • f staff must enter the room during the wait time. such as intraperitoneal ports. Several recommendations in this section have been adapted directly from the Oncology Nursing Society Access Devices Guidelines and the Infusion Nursing Society Standards of Practice.gov/hicpac/pdf/isolation/Isolation2007. Central Venous Catheters The procedures outlined below pertain to the access and maintenance of long-term central venous catheters (e. Accessing Central Venous Catheters This procedure applies only to PICCs and tunneled catheters. if available.g. including apheresis catheters. or 70% alcohol). Refer to Part D. but are not limited to: • Tuberculosis • Measles • Chickenpox (until lesions are crusted over) • ocalized (in immunocompromised patient) or L disseminated herpes zoster (until lesions are crusted over) • ave patient enter through a separate entrance to H the facility (e. refer to guidelines from relevant professional societies (e. 2005 (Available at: http://www.. blood. povidone iodine. Only healthcare personnel who have attained and maintained competency should perform these procedures.g. FAQ: “How long does it take to clear the air in an isolation or high-risk procedure room?” (Available at: http://www.g.cdc. chlorhexidine. the respirator should be donned prior to room entry and removed after exiting room • f substantial spraying of respiratory fluids is anI ticipated. such as implanted ports. avoid coming into close contact with other patients . closed catheter access systems should be used preferentially over open systems.. below for accessing implanted ports. gloves and gown as well as goggles or face shield should be worn • erform hand hygiene before and after touching the P patient and after contact with respiratory secretions and/or body fluids and contaminated objects/materials. however. General Maintenance and Access Procedures 1. and practice respiratory hygiene and cough etiquette • nce the patient leaves. note: use soap and water when hands are visibly soiled (e. A. These include peripherally inserted central catheters (PICCs). these include. where indicated. and to change the mask if it becomes wet • nitiate protocol to transfer patient to a healthI care facility that has the recommended infectioncontrol capacity to properly manage the patient • PPE use: • ear a fit-tested N-95 or higher level disposW able respirator. procedure or surgical P mask) to the patient and place the patient immediately in an exam room with a closed door • nstruct the patient to keep the facemask on I while in the exam room. For other types of access devices. There is not a consensus over the use of clean versus sterile gloves when accessing certain vascular access devices. vascular access devices). tunneled catheters (e.. Airborne Precautions • pply to patients known or suspected to be inA fected with a pathogen that can be transmitted by airborne route..cdc. Broviac®.pdf) CDC 2007 Guideline for Isolation Precautions (available at: http://www. and allow to dry (if povidone iodine is used. including tunneled apheresis catheters. the exam room should reO main vacant for generally one hour before anyone enters.D. body fluids) • nstruct patient to wear a facemask when exiting I the exam room. to avoid the reception and registration area • lace the patient immediately in an airborne infecP tion isolation room (AIIR) • If an AIIR is not available: • rovide a facemask (e. In general.g. healthcare personnel are to follow manufacturers’ instructions and labeled use for specific care and maintenance. • Maintain aseptic technique • erform hand hygiene and assemble the necessary P equipment • Wear clean gloves • crub the injection cap (e.g.g.gov/mmwr/pdf/rr/rr5417. Oncology Nursing Society).. and implanted ports.pdf) VI .1.flpic. and Groshong® catheters).. it should dry for at least 2 minutes) 12 . dedicated isolation entrance).com/TB_ air_exchange. I they are required to use respiratory protection *Francis J.pdf) CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings. if possible.. recommendations by specific professional societies are provided.g.

Needleless Connector) This procedure applies only to PICCs and tunneled catheters. Refer to manufacturer’s instructions for how frequently to change the injection cap. precipitate. • Maintain aseptic technique • erform hand hygiene and assemble the necessary P equipment • Wear clean gloves • crub the injection cap and catheter hub with apS propriate antiseptic agent. soiled.g. For catheters without a clamp. if necessary) and promptly dispose of used syringe(s) • Perform hand hygiene when done 3. Peripherally Inserted Central Catheters (PICCs) Refer to steps 1-5 in Section VI.5-1 mL of fluid is flushed • Promptly dispose of used syringe(s) • Perform hand hygiene when done 4. maintaining A aseptic technique • Remove the first 3-5 mL of blood and discard • Obtain specimen • lush with 10-20 mL of normal saline (clamping the F catheter as flushing is completed. if necessary) • Perform hand hygiene when done 2. Changing Catheter Site Dressing This procedure applies only to PICCs and tunneled catheters. flush with normal saline unless otherwise specified) 13 . avoid using a syringe less than 3 mL in I size to flush.A. if there is contraindication to chlorhexidine. if information is not available. perform the following: • ingle-use flushing systems (e. preferably use 10 mL • lush the catheter vigorously using pulsating techF nique and maintain pressure at the end of the flush to prevent reflux • ositive pressure technique (may not apply to P neutral-displacement or positive-displacement needleless connectors): i. Changing the Injection Cap (e. • upplies for site cleansing and dressing changes S should be single-use. continue to hold the plunger of the syringe while closing the clamp on the catheter and then disconnect the syringe ii. or when the septum is no longer intact. use tincture of iodine. including apheresis catheters. leaks. above for PICC access and common maintenance procedures. clamp the catheter if necessary as cap is removed • ttach new cap to catheter hub using aseptic A technique • Perform hand hygiene when done B. single-dose vials. withdraw the syringe as the last 0. or other defects.. refer to manufacturer’s recommendations to ensure compatibility with the catheter material • Maintain aseptic technique • Perform hand hygiene • ear clean or sterile gloves (additional precaution W per Infusion Nursing Society includes use of facemasks and sterile gloves) • emove existing dressing and inspect the site visually R • pply antiseptic to the site using >0.5% chlorhexiA dine preparation with alcohol. in general.. or 70% alcohol as alternative • o not apply topical antibiotic ointment or creams D to catheter site • over with either sterile gauze or sterile. S prefilled syringes) should be used • ccess the catheter as outlined above.• ccess the injection cap with the syringe or IV tubA ing (opening the clamp. cracks. change every week or when there are signs of blood. or nonocclusive • lushing: use of heparin flushes and the recomF mended concentration and frequency of flushing are determined in accordance with manufacturer’s instructions and per the treating clinician’s orders (in general. for valve catheters or closed tip catheters. maintaining A aseptic technique • n general. unless otherwise specified. including apheresis catheters. Flushing Technique Refer to the manufacturer’s instructions of the catheter and the needleless connector for the appropriate technique to use. C semipermeable dressing (refer to catheter-specific recommendations for frequency of dressing changes) • Perform hand hygiene when done 5. an iodophor.g. Flush the catheter. Additional recommendations for routine maintenance and care: • Frequency of dressing change: • Change 24 hours after insertion • ransparent dressing: change every 5-7 days unT less soiled or loose • auze dressing: change every 2 days or as needG ed if wet. transparent. Blood Draws from Central Venous Catheters • ccess the catheter as outlined above.

Recommendations for Nursing Practice and Education. Port Access Procedure • erform hand hygiene first. discomfort. implanted ports should be accessed and flushed every 4-8 weeks to maintain patency) • or blood specimens: discard 5-10 mL of blood. apply gauze and tape for short-term use (such as for outpatient treatment) • Perform hand hygiene when done 2. including examination of the veins of the chest and neck to look for any swelling. prior to each access. S or stabilization device.pdf) 14 .C. Tunneled Catheters Tunneled catheters include Broviac®. wear clean or sterile gloves • Remove dressing and inspect site • emove gloves. Hickman®. unless otherwise specified by manufacturer and/or treating clinician • tabilize port with one hand. and insert nonS coring needle (e. wear clean or sterile P gloves (additional precaution per INS includes use of sterile gloves and facemasks) • Cleanse port site with appropriate antiseptic agent • Administer topical anesthetic. if ordered • tabilize portal body with one hand. Maintenance and Care • or short-term use in outpatient settings. and promptly discard used syringe(s) ONS Access Device Guidelines. and Groshong® catheters. maintain positive pressure while deaccessing by flushing the catheter while withdrawing the needle from the septum • Promptly dispose of needle and syringe • Apply bandage or dressing • Perform hand hygiene when done 3. flush with 10-20 mL of normal saline.gov/ hicpac/pdf/guidelines/bsi-guidelines-2011. for Groshong® catheters. a light F dressing may be used in place of an occlusive dressing during the infusion. valve catheters. as well as apheresis catheters. 2011 INS 2011 Infusion Nursing Standards of Practice CDC Guidelines for the Prevention of Intravascular CatheterRelated Infections. or presence of pain. Refer to steps 1-5 in Section VI. 3rd edition. and remove needle S with the other hand. erythema. Vascular Access Devices chapter.g. perform hand hygiene again. above for catheter access and common maintenance procedures. or tenderness • alpate the outline of the portal body P • erform hand hygiene again. Huber needle) with the other hand until portal backing is felt • nsure patency by blood return and dispose of used E syringe(s) • tabilize needle/port with tape. or closed tip catheters. 2011 (available at: http://www. securement device. Implanted Ports 1. Port De-access Procedure • Perform hand hygiene.A. ensure the needle is secure in the portal septum as described above • se of heparin flushes and the recommended U concentration and frequency of flushing are to be determined in accordance with manufacturer’s instructions and per the treating clinician’s order (in general. or nonocclusive • nce healed. obF tain specimen. Additional recommendations for routine maintenance and care: • Frequency of dressing change: • Change 24 hours after insertion • ransparent dressing: change not more than T once a week unless soiled or loose • auze and tape dressing: change every 2 days or G as needed if wet.. exP amine the site for complications. flush with normal saline unless otherwise specified) D. and R wear new gloves • lush device with 20 mL normal saline followed by F heparin flush. tunneled catheters may go without O a dressing unless the patient is immunocompromised • lushing: use of heparin flushes and the recomF mended concentration and frequency of flushing are determined in accordance with manufacturer’s instructions and per the treating clinician’s orders (in general. soiled.cdc. drainage or leakage. when not in use.

Cleaning/disinfection of spills of blood or other potentially infectious materials should be assigned to personnel trained to handle such situation. Ensure this task is assigned to personnel who are available to respond in a timely manner.. ES/housekeeping staff may be better equipped to handle this type of cleaning/disinfection. change paper covering exam table. manage.. and implementation • ncluding a protocol for transferring patients who require I Airborne Precautions (if applicable) • ducate and train facility staff (including Environmental E Services/housekeeping) • ssess for competency of jobs/tasks (examples provided): A • Hand hygiene performance/compliance • Proper use of PPE • Environmental cleaning/disinfection • Triage/screening. c 15 . clean chemotherapy chair) • Patient-care areas after contamination with body fluidsc • Monitor medication/vaccine refrigerator temperature log • nsure alternative storage method is in place in the event of E power failure (specify method) Phone: Pager: Email: Phone: Pager: Email: a b Several roles/tasks may be performed by the same person. in some facilities. this may include facility staff other than ES/housekeeping staff. update/ A revision.g. Infection Prevention personnel. Example List of Contact Persons and Roles/Responsibilities Contact Person(s)a (Names/Titles) Contact Information Phone: Pager: Email: Roles/Responsibilities • Infection prevention personnel/consultant • ssists with infection control plan development. taking vital signs • Phlebotomy service • etermine when to implement enhanced respiratory screening D measures • Ensure facility sick leave policies are in place and followed • Collect. and analyze HAI data for surveillance purposes • Prepare and distribute surveillance reports • otifies state and local health departments of reportable N diseases/conditions and outbreaks • rovides fit-testing for N-95 respirators (if used in facility) and P appropriate respiratory protection training to facility staff Phone: Pager: Email: Phone: Pager: Email: Phone: Pager: Email: Phone: Pager: Email: Phone: Pager: Email: • ssess patients presenting with symptoms of active infection A (may be notified by registration staff upon patient arrival) • Determine patient placement as needed Environmental Services (ES) /housekeeping staff • Responsible for (specify tasks. examples provided): • Medication preparation area after each patient encounter • Patient-care devices after each use • xam rooms and/or chemotherapy suite after each patient E encounter (e. or by more than one person. e.g. examples provided): • Ensure supplies are restocked • Daily cleaning of patient-care areas • Disinfect bathrooms as needed • leaning large spills of blood or other potentially infectious C materialsb • Empty regular trash and dispose regulated waste accordingly • lean/disinfect areas and/or surfaces that require more frequent C cleaning or are not routinely cleaned by ES/housekeeping staff (specify areas/surfaces and specific situations.Appendix A.

Reportable Diseases/Conditions [Insert a list of reportable disease/conditions specific to your state and the appropriate contact information for your local and state health authorities.org/dnn/ProgramsandActivities/PublicHealthInformatics/PHIStateReportableWebsites/tabid/136/ Default.aspx ] 16 . This information may be found at your state department of health website and/or at the following weblink: http://www. cste.Appendix B.

e. These may include.cdc. as needed.Appendix C.. Personnel and Patient-Care Observations) and modify and/or further supplement.pdf There are two sections to the checklist: I) Administration Policies and Facility Practices. to include specific practices and procedures relevant to their setting. oncology facilities should use Section II of the checklist (i. 17 . performing hand hygiene) when accessing central venous catheters. and II) Personnel and Patient-Care Observations. CDC Infection Prevention Checklist for Outpatient Settings The Infection Prevention Checklist for Outpatient Settings is a companion to the CDC Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care and can be accessed at the following weblink: http://www. For the purpose of evaluating personnel competency and adherence to recommended infection prevention practices.gov/HAI/pdfs/guidelines/ ambulatory-care-checklist-07-2011. but are not limited to.g. assessing personnel adherence to donning appropriate PPE and using aseptic technique (e.

cdc.gov/dts/osta/otm/otm_ vi/otm_vi_2.idsociety. and recommended personal protective equipment for handling antineoplastic agents and other hazardous drugs • uideline for infection control in healthG care personnel (available at http://www.pdf) • IOSH Preventing Occupational ExpoN sure to Antineoplastic and Other Hazardous Drugs in Health Care Settings (available at: http://www.sagepub.pdf) • IOSH Personal Protective Equipment N for Health Care Workers Who Work with Hazardous Drugs (available at: http:// www.asco.s o l utions/2009-106/pdfs/2009-106.gov/niosh/ docs/2004-165/pdfs/2004-165.a.gov/mmwr/preview/ mmwrhtml/00050577.pdf) • ractice Guidelines for Outpatient ParenP teral Antimicrobial Therapy (available at: http://www.g. diluting.Appendix D.nccn. A reconstituting.htm) • uidelines for Preventing Infectious ComG plications among Hematopoietic Cell Transplantation Recipients: A Global Perspective (available at: http://www.org/uploadedFiles/ IDSA/Guidelines-Patient_Care/PDF_Library/OPAT.htm) • SHA Bloodborne Pathogens and O Needlestick Prevention (available at: http://www.org/ uploadedFiles/IDSA/Guidelines-Patient_ Care/PDF_Library/FN.pdf) • ccupational health requirements.k.osha.. healthcare personnel immunizations. org/ASCOv2/Practice+%26+Guidelines/ Guidelines) • linical Practice Guideline for the Use of C Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of America ( available: http://www.org/uploadedFiles/IDSA/GuidelinesPatient_Care/PDF_Library/OI. including appropriate antimicrobial prescribing practices and prechemotherapy assessment of neutropenia risk • ational Comprehensive Cancer Network N Guidelines and Clinical Resources (available at: http://www.idsociety.pdf) • mmunization of Health-Care WorkI ers: Recommendations of the Advisory Committee on Immunization (available at: http://www.cdc.gov/ niosh/docs/2010-167/pdfs/2010-167.asp) • merican Society of Clinical Oncology A Guidelines (available at: http://www.osha.idsociety.cdc.html) • SHA Controlling Occupational ExpoO sure to Hazardous Drugs (available at: http://www.cd c .gov/hicpac/pdf/InfectControl98.ashp.pdf) • ppropriate preparation and handling (e. cdc. includO ing bloodborne pathogen training.html) • IOSH List of Antineoplastic and Other N Hazardous Drugs in Healthcare Settings 2010 (available at: http://www.g ov/n i o s h /d o c s /w p .aspx) • linical recommendations and guidance for C treatment of patients with cancer.gov/mmwr/preview/ mmwrhtml/rr4910a1.pdf) 18 . Additional Resources Detailed information about each of the topics below can be found in the accompanying resources.cdc. including antineoplastic agents • nited States Pharmacopeia Chapter U <797> Guidebook to Pharmaceutical Compounding—Sterile Preparations • nternational Society of Oncology PharI macy Practitioners Standards of Practice (available at: http://opp. compounding) of sterile medications.com/ content/13/3_suppl) • merican Society of Health-System PharA macists Guidelines for Handling Hazardous Drugs (available at: http://www. bone marrow transplant or stem cell transplant centers) • uidelines for Preventing Opportunistic G Infections Among Hematopoietic Stem Cell Transplant Recipients (available at: http://www. mixing. • nfection prevention issues unique to blood I and marrow transplant centers (a.org/professionals/physician_gls/f_guidelines.gov/SLTC/bloodbornepathogens/index. org/DocLibrary/BestPractices/PrepGdlHazDrugs.

please visit cdc.gov/cancer/preventinfections .To learn more about CDC’s new resources.

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