NSW Health Infection Prevention and Control Policy Directive 2023 PDF

Policy Directive Infection Prevention and Control in Healthcare Settings Summary This Policy Directive outlines the mandatory infection prevention and control requirements for NSW Health organisations (including inpatient, outpatient, outreach)...

Policy Directive Infection Prevention and Control in Healthcare Settings Summary This Policy Directive outlines the mandatory infection prevention and control requirements for NSW Health organisations (including inpatient, outpatient, outreach). Document type Policy Directive Document number PD2023_025 Publication date 15 September 2023 Author branch Clinical Excellence Commission Branch contact (02) 9269 5500 Replaces PD2017_013 Review date 15 September 2028 Policy manual Patient Matters Manual for Public Health Organisations File number H23/59071 Status Active Functional group Clinical/Patient Services - Governance and Service Delivery, Infectious Diseases, Medical Treatment, Nursing and Midwifery Corporate Administration - Governance Personnel/Workforce - Occupational Health and Safety Population Health - Communicable Diseases, Infection Control Applies to Local Health Districts, Board Governed Statutory Health Corporations, Specialty Network Governed Statutory Health Corporations, Affiliated Health Organisations, NSW Health Pathology, Public Health System Support Division, Cancer Institute, Community Health Centres, NSW Ambulance Service, Dental Schools and Clinics, Public Hospitals Distributed to Ministry of Health, Public Health System, Divisions of General Practice, NSW Ambulance Service, Environmental Health Officers of Local Councils, Private Hospitals and Day Procedure Centres, Health Associations Unions, Tertiary Education Institutes Audience All Staff of NSW Health Secretary, NSW Health This Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for NSW Health and is a condition of subsidy for public health organisations.  NSW Health POLICY DIRECTIVE Infection Prevention and Control in Healthcare Settings POLICY STATEMENT Effective infection prevention and control is central for reducing the burden of healthcare associated infections and providing a safe working environment within the healthcare settings. All health workers must comply with infection prevention and control requirements to prevent, identify, manage, and control healthcare associated infections. SUMMARY OF POLICY REQUIREMENTS This Policy Directive outlines the mandatory infection prevention and control requirements for NSW Health Organisations including inpatient, outpatient, outreach. All NSW Health Organisations must implement the requirements that are set out in this Policy Directive, including: clinical governance oversight of infection prevention and control program legal and legislative framework requirements for the infection prevention and control program. Local infection prevention and control documents are to align with the principles outlined in this Policy Directive and are consistent with the principles and practice outlined within the following NSW Health publications: Infection Prevention and Control Practice Handbook COVID-19 Infection Prevention and Control Manual Respiratory Protection Program Manual NSW Health Policy Directive Cleaning of the Healthcare Environment (PD2023_018). PD2023_025 Issued: September 2023 Page i of ii NSW Health Policy Directive  NSW Health POLICY DIRECTIVE REVISION HISTORY Version Approved By Amendment Notes PD2023_025 Deputy Secretary, Updated to include references to the: September-2023 System Sustainability COVID-19 Infection Prevention and Control Manual and Performance Division Respiratory Protection Program Manual. PD2017_013 Deputy Secretary, Updated and amalgamation of: June-2017 Governance, Workforce Infection Control Policy [PD2007_036] and Corporate Infection Control Program Quality Monitoring [PD2005_414] Infection Control Policy Prevention and Management of Multi-Resistant Organism [PD 2007_084] Hand Hygiene Policy [PD2010_058] Infection Control Policy – Animals as Patients in Health Organisations [PD2009_030] Replace PD2017_013 Infection Prevention and Control PD. PD2023_025 Issued: September 2023 Page ii of ii NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings CONTENTS 1. BACKGROUND.........................................................................................................................4 1.1. The Risk of Healthcare Associated Infection........................................................................4 1.2. About this document............................................................................................................4 1.3. Key definitions......................................................................................................................5 1.4. Legal and legislative framework.........................................................................................11 2. CLINICAL GOVERNANCE REQUIREMENTS.........................................................................11 2.1. National accreditation standards........................................................................................12 2.2. Infection prevention and control committees......................................................................12 2.3. Multimodal improvement strategies....................................................................................12 2.4. Respiratory Protection Program.........................................................................................12 2.5. Infection prevention and control.........................................................................................13 2.6. Reprocessing of reusable medical devices........................................................................13 2.7. Surveillance and response to healthcare associated infections..........................................13 3. RISK MANAGEMENT..............................................................................................................13 3.1. Incident management.........................................................................................................13 3.2. Provision of education........................................................................................................14 3.3. Safety and well-being of health workers and patients.........................................................14 3.4. Staff health and healthcare associated infection risk..........................................................14 3.5. Occupational assessment, screening, and vaccination......................................................15 3.6. Management of health workers with symptomatic illness...................................................15 3.7. Respiratory Protection Program.........................................................................................15 4. RISK IDENTIFICATION REQUIREMENTS..............................................................................16 4.1. Risk assessment of the patient..........................................................................................16 4.2. Risk rating of the clinical area (functional area)..................................................................16 5. COMMUNICATION REQUIREMENTS.....................................................................................17 5.1. Clinical documentation and communication.......................................................................17 5.2. Communication with patients, family, and carers................................................................17 6. RISK MITIGATION REQUIREMENTS.....................................................................................17 6.1. Environmental and engineering controls............................................................................18 6.2. Antimicrobial stewardship...................................................................................................18 6.3. Patient placement..............................................................................................................19 6.3.1. Bed management and patient flow..............................................................................20 7. STANDARD PRECAUTIONS..................................................................................................20 PD2023_025 Issued: September 2023 Page 1 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings 7.1. Hand Hygiene....................................................................................................................21 7.2. Patient, visitor, and carer hand hygiene.............................................................................22 7.3. Personal protective equipment...........................................................................................22 7.3.1. Gloves........................................................................................................................22 7.3.2. Respiratory and facial protection.................................................................................23 7.3.3. Surgical masks............................................................................................................23 7.3.4. Respirators.................................................................................................................24 7.3.5. Eye protection.............................................................................................................24 7.3.6. Gowns and aprons......................................................................................................25 7.4. Aseptic technique...............................................................................................................25 7.5. Safe handling of waste and used linen...............................................................................26 7.6. Respiratory hygiene and cough etiquette...........................................................................26 7.7. Safe use and disposal of sharps........................................................................................26 7.8. Environmental cleaning......................................................................................................27 8. TRANSMISSION BASED PRECAUTIONS..............................................................................27 9. PRECAUTIONS FOR MULTIDRUG-RESISTANT ORGANISMS.............................................28 9.1. Multidrug-resistant organisms screening............................................................................29 9.2. Isolation and placement of patient with multidrug-resistant organisms...............................29 9.3. Contact precautions for multidrug-resistant organisms.......................................................30 9.4. Cleaning of shared equipment...........................................................................................31 9.5. Cleaning of environment....................................................................................................31 9.6. Transfer of patients............................................................................................................31 9.7. Decolonisation...................................................................................................................31 10. SURVEILLANCE REQUIREMENTS........................................................................................31 11. REPROCESSING OF RE-USABLE MEDICAL DEVICES........................................................32 12. SINGLE USE AND SINGLE PATIENT USE DEVICES............................................................33 13. SHARED PATIENT CARE EQUIPMENT.................................................................................33 13.1. Information communication technology..............................................................................33 14. PROCUREMENT OF NEW DEVICES OR EQUIPMENT..........................................................34 15. SAFE INJECTION AND MULTI-DOSE VIALS.........................................................................34 16. SAFE HANDLING AND TRANSPORT OF PATIENT SPECIMENS.........................................35 17. DEVICE RELATED INFECTIONS............................................................................................35 17.1. Medical devices used for diagnostic or treatment purposes...............................................36 18. CONSTRUCTION, RENOVATION AND REFURBISHMENT...................................................36 19. ANIMALS.................................................................................................................................36 PD2023_025 Issued: September 2023 Page 2 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings 19.1. Animal assisted therapy and personal pet visitation...........................................................37 20. OUTBREAK MANAGEMENT REQUIREMENTS.....................................................................37 21. HIGH CONSEQUENCE INFECTIOUS DISEASE MANAGEMENT..........................................37 22. LOOKBACK.............................................................................................................................38 23. ENVIRONMENTAL SUSTAINABILITY....................................................................................38 24. RELEVANT NSW HEALTH POLICIES, GUIDELINES AND MANUALS.................................40 25. REFERENCES.........................................................................................................................41 PD2023_025 Issued: September 2023 Page 3 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings 1. BACKGROUND This Policy Directive is for NSW Health Organisations [including Affiliated Health Organisations] (AHO) so they can effectively prevent, manage, and control healthcare associated infections (HAIs) and minimise adverse health impacts on their patients, visitors, carers, health workers and contractors. Effective infection prevention and control is central to providing high quality healthcare for patients and a safe working environment for those that work in healthcare settings. This Policy Directive must be read in conjunction with the: Infection and Prevention Control Practice Handbook Infection Prevention and Control Manual COVID-19 and other Acute Respiratory Infections Respiratory Protection Program Manual NSW Health Policy Directive Cleaning of the Healthcare Environment (PD2023_018). 1.1. The Risk of Healthcare Associated Infection Healthcare associated infections (HAIs) are one of the most common adverse events in care delivery impacting morbidity, mortality, quality of life and incurring increased burden for patients, families, and carers. Patients with an HAI are more likely to have a longer hospital stay, require second-line or broader-spectrum, more expensive antimicrobials, and place greater demands on the health system. Preventing harm to patients, visitors, volunteers, carers, and health workers due to infection in healthcare facilities is fundamental to achieve quality care, patient safety and health security. This will also reduce HAIs and help mitigate antimicrobial resistance. Similarly, preventing and reducing the transmission of high consequence infectious diseases, such as pandemic influenza, Ebola virus disease and other viral haemorrhagic fevers, or emerging novel communicable disease of significance is paramount. The application of appropriate infection prevention and control strategies by the health worker will reduce the risk of HAIs, as most HAIs are preventable through effective infection prevention and control measures. [5,8] The effectiveness of an infection prevention and control program is dependent on a robust implementation strategy and a well-defined clinical governance structure or system for the adaptation and integration of these measures into the facility. 1.2. About this document This Policy Directive outlines the mandatory infection prevention and control requirements for NSW Health Organisations (including inpatient, outpatient, outreach). The scope of this Policy Directive includes: Requirements for the infection prevention and control program. Direction on governance. PD2023_025 Issued: September 2023 Page 4 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings Infection prevention and control incidents and risk. Quality monitoring (surveillance). Standard and transmission-based precautions. Strategies for the prevention and management of HAIs including those caused by multidrug-resistant organisms (MROs) and communicable diseases. Outbreaks of transmissible infections and communicable diseases. Reprocessing of reusable medical devices. Handling of animals within healthcare settings. Environmental sustainability. The handling and management of body substances and cytotoxic waste (such as body substances and any discarded materials containing unmetabolised or residual cytotoxic and hazardous medication), is outside the scope of this Policy Directive. Guidance on this is provided in NSW Health Policy Directives Clinical and Related Waste Management for Health Services (PD2020_049) and High-Risk Medicines Management (PD2020_045). 1.3. Key definitions Behaviours that are likely to generate higher volumes of Aerosol Generating respiratory secretions and thus increase the risk of transmission Behaviour via aerosols. Aerosol Generating Medical procedures which lead to the generation of respiratory Procedure aerosols of sufficient size to enable microorganism transmission. Aerosols form part of a continuum of particle sizes generated through a range of respiratory activities in humans, which can Aerosols carry infective material and facilitate respiratory disease transmission. Not-for-profit religious, charitable, or other non-government Affiliated Health organisations which provide health services and are recognised Organisations as part of the public health system under the Health Services Act 1997 (NSW). A type of transmission-based precautions, used to interrupt airborne transmission from patients known or suspected to be Airborne precautions infected with agents transmitted person-to-person by the airborne route. Alcohol based hand An alcohol-containing preparation (such as gel, foam, or liquid) rub (ABHR) designed for reducing the number of viable microorganisms on dry, unsoiled hands. PD2023_025 Issued: September 2023 Page 5 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings Alert/ De-Alert Enabling of an electronic communication warning ‘flag’ in a patient’s clinical records that indicates a patient's infectious status, for example: multidrug-resistant organism (MRO) colonisation or infection. De-Alert is the inactivation of the electronic infection control alert (flag). Antimicrobial A chemical substance, usually a medicine, that inhibits or destroys bacteria, viruses, fungi, or protozoa. An ongoing program within a health organisation for judicious Antimicrobial antimicrobial use in order to improve patient outcomes, ensure stewardship cost-effective therapy and reduce adverse sequelae of antimicrobial use, including antimicrobial resistance. Aseptic technique consists of a set of specific practices and procedures performed under carefully controlled conditions. Aseptic technique protects patients during clinical procedures by utilising infection prevention measures that minimise the Aseptic technique presence of microorganisms. While the principles of aseptic technique remain constant for all procedures, the level of practice will change depending upon a standard risk assessment. Any substance produced by, or otherwise expelled, excreted, or extracted from the body. Body substance is used rather than body fluid to emphasise the need for precautions to prevent Body substance contact with solid tissue and faeces as well as blood (including dried blood) and body fluids. This does not include intact skin, hair and sweat. The removal of visible soil (such as inorganic and organic material) from objects and surfaces and is normally Cleaning accomplished manually or mechanically using water with detergents or enzymatic products. A clearly defined framework of accountability at all levels in an Clinical governance organisation for continuously improving the quality of their service and safeguarding high standards of patient care. PD2023_025 Issued: September 2023 Page 6 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings A disease cluster is an unusually high incidence of a particular microorganism occurring in close proximity in terms of both time and geography. Cluster A closely grouped series of events or cases of diseases that fulfils the definition of a case – for example, two or more surgical site infections from the same surveillance period or theatre session of the same type of surgery. Detection of an organism from a site (usually skin, throat, nose, Colonisation or perineum, and/ or chronic ulcers) without signs of invasive infection. The state or fact of touching or being in immediate proximity or association. Contact An individual who may have been exposed to an infected person. A type of transmission-based precautions used to interrupt the Contact precautions transmission of infectious agents that are spread by direct or indirect contact with the patient or the patient’s environment. Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus (a member of a large family of COVID-19 viruses called coronaviruses). ‘CO’ stands for corona, ‘VI’ for virus, and ‘D’ for disease. A medical device that comes into contact with blood or normally sterile tissue and that must be sterile at the time of use. Critical items Note: A critical medical device confers a high risk of infection if it is contaminated with microorganisms. Decolonisation is an evidence-based intervention that can be Decolonisation used to reduce or eliminate colonised microorganisms to prevent healthcare associated infections. A process that eliminates many or all pathogenic Disinfection microorganisms, except bacterial spores, on inanimate objects. A transmission-based precautions used to interrupt droplet transmission occurring from patients known or suspected to be Droplet precautions infected with agents transmitted person-to-person by respiratory droplets. A manual procedure that is used each time a tight-fitting Fit check respirator (particulate filter mask or P2/ N95) is used to ensure a seal is achieved. PD2023_025 Issued: September 2023 Page 7 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings A procedure to evaluate the fit of a tight-fitting respirator Fit test (particulate filter mask or P2/ N95) either qualitatively or quantitatively. A functional area refers to any area in a healthcare facility that requires cleaning. The functional areas have been grouped Functional area under four risk categories: extreme, high, medium, and low. These risk categories reflect the frequency and intensity of cleaning required to meet minimum cleaning standards. A general term referring to action of hand cleansing. Includes washing hands with the use of water, soap, or a soap solution, either non-antimicrobial or antimicrobial, or applying a waterless Hand hygiene alcohol-based hand rub (ABHR) to the surface of the hands. When performed correctly, hand hygiene results in a reduction of microorganisms on hands. Refers to all staff delivering or supporting healthcare services in a public health organisation. Any person employed or contracted Health Worker (HW) by a NSW Health Organisation either on a permanent, temporary, casual, volunteer or agency basis. Refers to infections acquired in healthcare facilities and Healthcare associated infections that occur as a direct or indirect result of healthcare infection (HAI) interventions and which may manifest after people leave the healthcare facility. Also known as Infectious Disease of High Consequence (IDHC). An emerging novel communicable disease of global significance or a high consequence infectious disease (HCID) is defined as a High Consequence disease that has potential to cause a high mortality among Infectious Disease otherwise healthy people, no routine vaccine exists, risk of (HCID) airborne spread or unknown mode of transmission, some types of clinical specimens pose generalised risks to laboratory personnel. Key parts are the sterile components of equipment used during Key part an aseptic procedure, such as bungs, needle hubs, syringe tips, dressing packs. Key sites include any non-intact skin and insertion or access sites for medical devices connected to the patient, such as Key site insertion/ access sites of intravenous devices, urinary devices, open wounds using aseptic technique. PD2023_025 Issued: September 2023 Page 8 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings To check, supervise, observe critically, or record the progress of Monitor an activity, action, or system on a regular basis in order to identify change. Multidrug-resistant MROs are defined as microorganisms, predominantly bacteria, organism (MRO) that are resistant to one or more classes of antimicrobial agents. A Class N isolation room is a negatively pressured single room, with or without an anteroom, with an ensuite that is not shared. It Negative pressure is used for patients who require isolation to reduce airborne room (Class N) transmission of disease (such as varicella, measles, pulmonary or laryngeal tuberculosis). This term refers to local health districts, statutory health corporations, affiliated health organisations and administrative NSW Health units within the Health Administration Corporation, such as the Organisation NSW Ambulance Service, HealthShare NSW and the Ministry of Health, as defined in the Health Services Act 1997 (NSW). Outbreak is the occurrence of disease exceeding the expected level for a given population within a specific timeframe. This includes single cases of some diseases not previously seen or Outbreak those that have previously been eliminated. Typically, in healthcare this has been defined as two or more cases, which should trigger an outbreak management process. [2, 16] Programs provide an extension of healthcare provision aimed to increase access to health services for hard to reach and Outreach program marginalised population such as rural communities and Aboriginal people. Refers to a variety of protective barriers used alone, or in Personal protective combination, to protect mucous membranes, skin, and clothing equipment (PPE) from contact with recognised and unrecognised sources of infectious agents in healthcare settings. The time and location where an interaction between a patient Point of care and clinician occurs for the purpose of delivering care. RPDs (respirator) worn on the face are designed to reduce the Respiratory protective wearers risk of inhaling hazardous airborne particles (including devices (RPDs) dust, infectious agents, aerosols, gases, or vapours). PD2023_025 Issued: September 2023 Page 9 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings All the activities required to ensure that a reusable medical device is safe for its intended purpose. This is a multi-step Reprocessing process that includes cleaning, inspection and assembly, functional testing (if applicable), disinfection (if applicable), packaging and labelling, and sterilisation (if applicable). Satellite reprocessing A satellite reprocessing site is a small unit/ department/ clinic unit that reprocesses (sterilises or high level disinfection) a single specific type of reusable medical device, such as transvaginal transducer, nasendoscope, flexible cystoscope, Trans- oesophageal echocardiogram transducer. Equipment or devices that come into contact with mucosal membranes or non-intact skin. Such items include but are not limited to respiratory therapy and anaesthesia equipment, gastrointestinal endoscopes, bronchoscopes, laryngoscopes, Semi-critical items oesophageal manometry probes, anorectal manometry catheters, endocavitary probes, prostate biopsy probes, infrared coagulation devices, transvaginal probes and diaphragm fitting rings, dental dam, removable dental appliance, dental x-ray holder. Any object capable of inflicting a penetrating injury, which may or may not be contaminated with blood and/ or body Sharp(s) substances. This includes needles and any other sharp objects or instruments designed to perform penetrating procedures. Standard precautions represent the minimum infection prevention measures that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any Standard precautions setting where healthcare is delivered. These evidence-based practices are designed to both protect and prevent spread of infection among patients and health workers. Additional work practices in situations where standard Transmission based precautions alone may be insufficient to prevent transmission of precautions infection , such as contact, droplet and airborne precautions or a combination of these precautions. A person who works in an unpaid role for an NSW Health Volunteer Organisation. Zoning, cohorting or ring fencing refers to the grouping of Zoning patients with the same condition or same risk in the same area. PD2023_025 Issued: September 2023 Page 10 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings 1.4. Legal and legislative framework This Policy Directive must be read and interpreted alongside the following legislation: Health Practitioner Regulation National Law Act 2009 (NSW) Public Health Act 2010 (NSW) Food Act 2003 (NSW) Privacy Act 1988 (Commonwealth) Health Records and Information Privacy Act 2002 (NSW) Therapeutic Goods Act 1989 (Commonwealth) Public Health Regulation 2022 (NSW) Work Health and Safety Act 2011 (NSW) Protection of the Environment Operations Act 1997 (NSW) The Health Practitioner Regulation (New South Wales) Regulation 2016 (NSW) provides infection prevention and control standards for a broad range of health practitioners including medical practitioners, nurses, midwives, pharmacists, physiotherapists, and podiatrists. The Dental Board of Australia expects dental practitioners to practise in a way that maintains and enhances public health and safety by ensuring that the risk of the spread of infection is prevented or minimised and aligned as per the Australian Health Practitioner Regulation Agency (Ahpra) Shared Code of Conduct. NSW Health Organisations and health workers are obliged to comply with relevant Australian Standards with which this Policy Directive is consistent. 2. CLINICAL GOVERNANCE REQUIREMENTS Each NSW Health Organisation must ensure they have an executive sponsor, responsible for their infection prevention and control program. The progress and outcomes of the program must be reported to the highest management level of the organisation aligned with the NSW Health Policy Directive Incident Management (PD2020_047). Supported by executive engagement, strategic and operational planning under the direction of infection prevention and control program, the clinical leaders and senior managers are responsible for implementing and evaluating systems to prevent and manage healthcare associated infections (HAIs). Additional advice and expertise must be sought from individuals skilled in this area and/ or an infection prevention and control committee where required. NSW Health Organisations are to have a dedicated Infection Prevention and Control Program with suitably qualified infection prevention and control professional(s) and a current operational/ risk plan that is in keeping with this Policy Directive. The program must specify the necessary steps to address improvements, education, and training of health workers and measurement tools for HAI prevention and risk management in alignment with NSW Health Organisation’s strategic priorities and directions. Patients and visitors are to be provided the necessary information and education to enable partnership between them and NSW Health Organisation for infection prevention strategies. PD2023_025 Issued: September 2023 Page 11 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings 2.1. National accreditation standards The National Safety and Quality Health Service (NSQHS) Standards , provide a quality assurance mechanism that tests whether relevant systems are in place to ensure that expected standards of safety and quality are met. The Preventing and Controlling Infections Standard along with Australian Commission on Safety and Quality in Health Care Advisories and Clinical Care Standards provide an additional layer of requirements for compliance with infection prevention and control and this Policy Directive. Each NSW Health Organisation must plan for and implement appropriate clinical governance systems and infection prevention and control strategies to prevent and manage HAIs. 2.2. Infection prevention and control committees Each NSW Health Organisation must have a committee that is responsible for the delivery and evaluation of infection prevention and control programs and strategies. The committee structure is required to connect local and local health district (district)/ specialty health network (network) functions to disseminate and communicate reports across the organisation. This committee must have executive membership and must report to the highest management level within the organisation. Structures are to be in place for the provision, oversight and as a point of escalation to ensure appropriate district/ network governance. 2.3. Multimodal improvement strategies Every NSW Health Organisation is to have an infection prevention and control program in place. Multimodal strategies are a core component of effective infection prevention and control at state and facility level. NSW Health Organisations are to implement at least five multimodal strategies such as system change, training, and education, monitoring and feedback, reminders and communication and a culture of safety as per the World Health Organisation (WHO) Multimodal Hand Hygiene Improvement Strategy. The success and effectiveness of such a program requires the development and involvement of suitably qualified personnel or the development of adequate systems to link in (link program or similar) with such expertise. NSW Health Organisations must have clinical governance and quality improvement systems to prevent and control infections, support antimicrobial stewardship and sustainable use of infection prevention and control resources as per the National Safety and Quality Health Service, Standard 3 - Preventing and Controlling Infections Standard. 2.4. Respiratory Protection Program Each NSW Health Organisation must have a process in place to comply with the recommendations and requirements for implementation of the Respiratory Protection Program (RPP) that is compliant with work health and safety standards ensuring that there is clear governance and capacity. PD2023_025 Issued: September 2023 Page 12 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings 2.5. Infection prevention and control Each NSW Health Organisation is to have a process in place to implement the infection prevention and control practices set out in the Infection Prevention and Control Practice Handbook and the resources developed for the management of communicable diseases. Each NSW Health Organisation is to have a process in place to ensure the guidance provided under the Clinical Excellence Commission (CEC) infection prevention and control program is accessible and adhered to by health workers and healthcare consumers. 2.6. Reprocessing of reusable medical devices Each NSW Health Organisation is to comply with the standards set out in the Australia/ New Zealand Standards Reprocessing of reusable medical devices in health service organisations and should refer to current standard version. 2.7. Surveillance and response to healthcare associated infections Each NSW Health Organisation must have a process in place to undertake surveillance, manage and mitigate transmission risk in ensuring there is an effective and timely response and escalation of outbreaks or clusters of HAIs, communicable diseases, multidrug-resistant organisms (MROs) and/ or non-MROs. [23,24] 3. RISK MANAGEMENT NSW Health Organisations must use a risk management framework when considering the implementation of infection prevention and control initiatives. This framework must be used to determine individual and collective risk(s) in specific situations, procedures or programs and inform management options and priorities to reduce the risk of healthcare associated infections (HAIs). The aim of determining a patient’s specific risk(s) is to ensure that appropriate controls are implemented to protect all patients, visitors, carers and health workers without compromising clinical care and psychological support. Guidance is provided in the NSW Health Policy Directive Enterprise-Wide Risk Management (PD2022_023). An operational/ risk plan that includes infection risk must be reviewed and endorsed by the NSW Health Organisations infection prevention and control committee and incorporated into the organisation’s plan(s). 3.1. Incident management To determine whether an infection prevention and control risk or breach constitutes a reportable incident, NSW Health Organisations are to refer to NSW Health Policy Directive Incident Management (PD2020_047) which describes a state-wide system for managing clinical and corporate incidents. One example, it is recommended that Healthcare-associated Staphylococcus aureus bloodstream infections be investigated and managed as a minimum Harm Score 2 incident. PD2023_025 Issued: September 2023 Page 13 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings 3.2. Provision of education NSW Health Organisations must ensure that all health workers are provided with education and training during induction and on an ongoing basis on preventing and controlling the risk of transmitting microorganisms in line with their duties. Online mandatory training is described in the NSW Health Education and Training Institute (HETI) Mandatory Training Matrix and is underpinned by the NSW Health Policy Directive Mandatory Training - Criteria for Approval as a NSW Health Requirement (PD2016_048) for all health workers. Completion of this training is required to meet patient safety programs and National Safety and Quality Health Service (NSQHS) Standard 3. The NSW Health Organisation is responsible for ensuring health workers complete this training. In addition, health workers are to undergo onsite practical training and competency assessments where relevant on the following: hand hygiene, aseptic technique, sharps use and disposal, waste management, donning, and doffing of personal protective equipment (PPE) including respiratory protective devices, cleaning of shared patient equipment and cleaning of healthcare environment. NSW Health Organisations must educate, promote, and facilitate the participation of patients, visitors and carers in infection prevention and control measures. At a minimum patients, visitors and carers must be educated on appropriate hand hygiene and respiratory etiquette, and where required, donning, and doffing of PPE. 3.3. Safety and well-being of health workers and patients Patient and health worker safety within healthcare rely on established infection prevention and control processes that enable effective teamwork which depends on multiple factors, such as: education for patients, visitors, carers, and health workers reasonable workloads adequate staffing for all health workers. Wellbeing, compassion, and kindness are now recognised to be essential for health workers (infection prevention and control professionals, environmental and support services such as administration, engineering, security services, reprocessing, and clinicians, based on bed or chair occupancy and patient risk factors) perspective and resilience. Infection prevention and control programs are required to be adequately resourced to ensure quality and safe delivery of the program across the system. NSW Health Organisations are to ensure processes are in place for both staff well-being and burn-out to reduce adverse outcomes for patients and health workers. 3.4. Staff health and healthcare associated infection risk Health workers’ non-compliance with infection prevention and control can contribute to the potential transmission of microorganisms within healthcare settings. A health worker diagnosed with an infectious condition is required to practice in such a manner that it does not put patients, visitors, carers, or other health workers at risk of infection. PD2023_025 Issued: September 2023 Page 14 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings In some circumstances exclusion from the workplace may be required during the communicability period. Processes must be developed to manage exclusion periods in consultation with infection prevention and control, staff health and infectious diseases teams. In the event of a health worker acquiring an infectious condition from the workplace, they are required to report the incident as per NSW Health Policy Directive Incident Management (PD2020_047). 3.5. Occupational assessment, screening, and vaccination NSW Health Organisations must implement and monitor a risk-based workforce vaccination program for health workers, other clinical personnel and healthcare students in accordance with the NSW Health Policy Directive Occupational Assessment, Screening and Vaccination Against Specified Infectious Diseases (PD2023_022) and Australian Immunisation Guidelines.[26, 27] NSW Health Organisations must maintain a central register as evidence of health workers vaccination status, including medical contraindications to vaccination, vaccination refusals and an appropriate risk management strategy to address vaccination refusals and exemptions. Compliance with the program must be reported on and a process for managing non-compliance must be in place. Managers, staff health services or occupational vaccination/ screening services also have a responsibility to minimise the risk of infection to health workers. 3.6. Management of health workers with symptomatic illness Health workers who have a symptomatic illness (such as boils, acute respiratory illness, or gastroenteritis) or conditions that promote the shedding and transmission of microorganisms, such as herpes simplex, exfoliative skin conditions or skin lesions, may increase the risk of the spread of infection to vulnerable patients. The NSW Health Organisation must have systems to ensure compliance with the policy directives that protect health workers. Therefore, NSW Health Organisations must develop a procedure that outlines how they will address: Health worker communication, escalation, reporting and disclosure of their suspected or known communicable pathogen or disease. The mitigation of transmission risks of communicable pathogens or diseases. Human resource issues such as redeployment, sick leave and return to work management. Health workers non-participation in certain clinical procedures (such as exposure prone procedures) that is mandated by policy or legislation. 3.7. Respiratory Protection Program Respiratory protection is required for those organisms that are usually transmitted via respiratory particles (airborne, aerosols). A respiratory protection program must be implemented for health workers that require the use of a respirator when providing care to patients under airborne precautions. PD2023_025 Issued: September 2023 Page 15 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings NSW Health Organisations are required to follow the CEC Respiratory Protection Program Manual for further guidance on program implementation. 4. RISK IDENTIFICATION REQUIREMENTS 4.1. Risk assessment of the patient Assessing a patient’s individual infection risk rating is to determine whether the patient is a potential source of infection to other patients, visitors, carers, and health workers and/ or whether the patient is more susceptible to infection. The higher the risk rating, the greater the priority for infection prevention and control interventions and precautions. 4.2. Risk rating of the clinical area (functional area) All patients, visitors, carers or health workers in a NSW Health organisation are susceptible to acquiring an infection, and/ or transmission of a microorganism or communicable disease. However, there are certain functional areas, such as intensive care units, neonatal units, transplant units, burns units, dialysis, haematology units, and interventional suites/ radiology where patients are at a greater risk of acquiring an infection (for more details on functional areas in each risk category refer to NSW Health Policy Directive Cleaning of the Healthcare Environment (PD2023_018). Patients in these areas are often immunosuppressed, are acutely unwell or have undergone major surgery. These patients have an increased propensity to infection due to: the nature of their condition frequent contact with health workers number and types of indwelling devices the duration of hospitalisation. Each NSW Health Organisation must assign a risk rating to each functional area followed by regular review of risk rating and reassess the risk if the purpose or patient risk category within the functional area changes. The functional areas must be risk rated as one of the following: Extreme risk High risk Medium risk Low risk. In the event of an outbreak, the NSW Health Organisation may adjust the risk rating of a functional area if there is an increased transmission risk of infection to patients, visitors, carers and/ or the health worker and reassess the functional risk rating when the outbreak is over. PD2023_025 Issued: September 2023 Page 16 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings 5. COMMUNICATION REQUIREMENTS 5.1. Clinical documentation and communication A patient’s communicable disease, transmissible infection, or multidrug-resistant organism (MRO) status must be always treated as confidential information. Communication and clinical handover of a patient’s communicable disease, transmissible infection or MRO status is required as part of medical treatment, patient placement and decisions on transmission-based precautions. Health workers are to ensure the required additional precautions are communicated during patient handover and transfer of care. Appropriate signage must be placed at the entrance to the patient room or zone to communicate the type of transmission-based precautions required. Each NSW Health organisation (must have a process to: Assign responsibility for adding infection prevention and control alerts, such as MRO carriage detail (colonisation or infection), site and screening date. Enable an electronic communication warning ‘Alert’ to indicate MRO or infection status in a patient’s clinical records. De-alert, removal of the MRO alert and documentation of the reason and required information, such as MRO screening, met MRO clearance criteria, MRO clearance date. 5.2. Communication with patients, family, and carers Clinicians must provide information to patients, family and carers affected by a communicable disease, transmissible infection or MRO colonisation or infection to establish an understanding of: The communicable disease, transmissible infection, or MRO colonisation. The transmission-based precautions required to prevent further transmission. Their role in preventing transmission, such as hand hygiene, keeping door closed where there is an airborne precaution, when and how to wear a mask, caring of wounds if any. In the event of a healthcare associated infection NSW Health Organisations are to follow the principles outlined in the NSW Health Policy Directive Open Disclosure Policy (PD2014_028). All patient education and communication must be documented in the patients’ healthcare record. A patient’s infection prevention and control information must be evaluated to determine if it meets the needs of the target audience. 6. RISK MITIGATION REQUIREMENTS When implementing infection prevention and control principles in healthcare settings, all levels of controls (administrative controls, environmental and engineering controls, and PD2023_025 Issued: September 2023 Page 17 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings personal protection) must be given appropriate attention for the system to work effectively, and for the different levels to support each other. The adherence to hierarchy of controls including use of personal protective equipment (PPE) is key in supporting the prevention and control of any exposure to communicable diseases and pathogenic organisms. PPE requirements must be based on clinical circumstances and risk assessment. 6.1. Environmental and engineering controls Environmental and engineering controls are an integral part of infection prevention and control that include standards for adequate ventilation, air exchange and filtration of the air according to specific areas in healthcare facilities, adapted structural design, spatial separation as well as adequate environmental cleaning. The management of airflow and the creation of a turbulence-free environment are essential to the control of the spread of infection. For more information refer NSW Health Guideline Engineering Services (GL2023_009). Specialised areas of a healthcare facility (such as operating rooms, interventional rooms, birthing rooms, negatively or positively pressured isolation rooms, burns unit, intensive care units, emergency departments and special treatment or procedural areas) must always provide high quality air. Return air paths in clinical areas will be provided via dedicated return air ducting. All supply air and return air registers and grills must be removable for regular scheduled cleaning. They must not be installed directly above a patient bed. [25, 28] An effective ventilation system to optimise indoor air quality is a key strategy for reducing the spread of infectious diseases. Environments adapted to create separation, isolation, or divisions in multibed bays using temporary solutions are not without risks and lack conclusive evidence. Consideration for the addition of such structures requires consultation with infection prevention and control and other key stakeholders. Additional impacts to airflow and environmental cleaning are to be considered. Removal of temporary structures should not be delayed at conclusion of the causing incident. Healthcare environmental and engineering controls are required to meet rigorous standards as per the Australasian Health Facility Guidelines with preferred approach to centralised and automated systems. The evidence for the routine use of portable air filtration devices in hospital settings is not yet conclusive. The use of these devices is to be limited to situations where the mechanical ventilation system is deficient and not as an adjunct to a well- ventilated environment. Consultation with an environmental engineer, work health and safety and infection prevention and control are recommended before purchasing an air filtration device to ensure all issues and potential safety risks have been considered and a protocol surrounding the safe use, management and storage are to be developed. 6.2. Antimicrobial stewardship Any facility or organisation within NSW Health is required to have an antimicrobial stewardship (AMS) program. The program should include an AMS policy and an antimicrobial formulary that includes restrictions, rules and approval processes, with appropriate governance to support stewardship activities and a range of quality improvement initiatives to PD2023_025 Issued: September 2023 Page 18 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings prevent and control infections and to meet the National Safety and Quality Health Service (NSQHS) Standards Preventing and Controlling Infections Standard. Where a NSW Health Organisation is responsible for the antimicrobial therapy received by patients in its care, they must ensure that safe and appropriate antimicrobial prescribing is a goal within its clinical governance system and the program is to be overseen by a dedicated specialist of that area. The use of antimicrobial agents to prevent and treat infections must be considered judiciously, using the six essential strategies for effective antimicrobial stewardship: Providing access to and implementation of clinical guidelines consistent with current evidence and Therapeutic Guidelines: Antibiotic that reflect local microbiology and antimicrobial susceptibility patterns. Ensure a formal referral service is in place for anti-infective advice when clinically indicated or if required as per NSW State Formulary restrictions. Review of antimicrobial prescribing with intervention and direct feedback to the prescriber. Implementation of point-of-care interventions to target inappropriate or no longer appropriate antimicrobial use (for example, intravenous to oral switch, and dose optimisation) Monitor performance of antimicrobial prescribing by collecting and reporting unit or ward-specific data, auditing antimicrobial use, and using quality use of medicines indicators. Ensure the clinical microbiology laboratory uses selective reporting of susceptibility testing results that is consistent with current endorsed therapeutic guidelines on antibiotic usage and provides Infectious Diseases and Infection Prevention and Control Practitioners with access to susceptibility and resistance testing results 6.3. Patient placement To ensure the safe and timely placement of a patient with a known or suspected transmissible infection (including multidrug-resistant organism (MRO) infection), patient placement decisions must be made in conjunction with the patient flow team and local infection prevention and control service wherever possible. After hours management of patients are to be determined by local procedures. The decision to place a patient in isolation are to be determined by the following principles: Route(s) of transmission of the known or suspected microorganism and risk assessed as requiring a higher level of precautions above standard precautions. Risk factors for transmission in the patient with an infection. Risk factors for adverse outcomes resulting from a health care associated infection (HAI) in other patients. Risk factors for adverse outcomes if the patient is accommodated in a single room. Availability of single rooms. PD2023_025 Issued: September 2023 Page 19 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings Zoning (cohorting, ring fencing) refers to the grouping of patients with the same condition or same infectious agent in the same area. The aim of zoning or cohorting patients (and the health workers that attend to them) is to minimise interaction between infectious and non- infectious patients as much as possible. The following factors are to be taken into consideration when considering zoning, in particular for situations such as outbreaks: Physical building space including air conditioning and ventilation, egress paths. Availability of single or shared rooms in a specific area to enable zone establishment. Patient ability and acuity, patient safety considerations. Staffing capacity (including cleaning) and access to dedicated shared equipment. Number of suspected or confirmed cases. Number of contacts. Access to bathrooms or risk mitigated local plan to support patient hygiene requirements or needs. 6.3.1. Bed management and patient flow Placement of a patient(s) must be based on a risk assessment that considers the risk ratings of all patients involved, functional area and room availability to meet the patient’s isolation requirements. When considering patient movement or transfer, the receiving department, transport service, or NSW Health Organisation must be notified of a patient’s infection or colonisation status before transfer. The admission and/ or transfer of a patient (including from/ to residential or aged care facilities) must not be delayed or compromised by a patient’s suspected or known infection or colonisation status. Also consider other risk factors such as MRO status, mobility, falls risks or behavioural concerns when patient placement or transfer decision has been made and document the outcome in patient medical record. Patient placement decisions must be made in conjunction with the local patient flow team and infection prevention and control and infectious diseases teams where appropriate to ensure timely patient transfers and admissions. Patients and their nominated next of kin (NOK) are to be engaged as partners in care and as part of shared decision making, and this discussion must be documented. 7. STANDARD PRECAUTIONS Standard precautions are the minimum infection prevention measures that apply to all patient care settings, regardless of suspected or confirmed infection status of the patient. Standard precautions must always be applied when caring for all patients and when handling all body substances, secretions, and excretions (excluding hair and sweat), non-intact skin, and mucosal membranes, including eyes. Standard precautions involve adherence to all the following work practices: Performing hand hygiene. PD2023_025 Issued: September 2023 Page 20 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings Appropriate and correct use of personal protective equipment (PPE). Respiratory hygiene and cough etiquette. Use of aseptic technique. Safe use and disposal of sharps. Performing routine environmental cleaning. Cleaning and disinfection of shared patient equipment. Reprocessing of reusable medical devices. Safe handling and disposal of waste used linen and laboratory specimens. The use of standard precautions must be monitored for compliance and practice improvement within each area within the NSW Health organisation. 7.1. Hand Hygiene NSW Health Organisations must ensure an ongoing hand hygiene awareness program is established for all health workers that is consistent with the National Hand Hygiene Initiative , CEC Hand Hygiene and Patient Safety Programs. For most hand hygiene activities, alcohol-based hand rub (ABHR) is to be used whereas visibly soiled hands must be washed with liquid soap and running water. NSW Health Organisations must ensure that ABHR dispensers are as close as possible to the point of care. Placement and design of ABHR dispensers and hand basins must be consistent with the Australasian Health Facility Guidelines (AusHFG) Part D. The ability to perform effective hand hygiene for clinical care must not be impeded by the wearing of long-sleeved garments or forearm jewellery (for example religious bangles, medical bracelets, or bandages) or long fingernails. NSW Health Organisations must perform a case-by-case risk assessment in consideration to the risk to patients versus the health worker where bare below the elbow cannot be maintained during clinical care (with the exception of applied risk assessed PPE). Hand hygiene compliance auditing is conducted to assess the effectiveness of hand hygiene programs. NSW Health Organisations are required to collect hand hygiene compliance data for national hand hygiene audits unless exempted from this process. The outcome of the hand hygiene compliance audits will be provided to the appropriate committee and evaluated locally to identify opportunities for improvement. Ongoing non-compliance with hand hygiene by a health worker is to be managed within local performance management policies and the frameworks within the following NSW Health policies: NSW Health Policy Directive Managing Complaints or Concerns about Clinicians (PD2018_032) NSW Health Policy Directive NSW Health Code of Conduct (PD2015_049) NSW Health Policy Directive Managing Misconduct (PD2018_031) NSW Health Policy Directive Managing for Performance (PD2016_040). PD2023_025 Issued: September 2023 Page 21 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings 7.2. Patient, visitor, and carer hand hygiene Hand hygiene is to be performed by everyone. Health workers must encourage patients to perform hand hygiene and provide education on the correct hand hygiene technique. Patients must be provided with the means to perform hand hygiene before eating, and after going to the toilet or using a bedpan or urinal, after sneezing, blowing their nose or coughing into hands, and after touching/ handling animals. Visitors, carers, contractors, and volunteers must be provided with the means to perform hand hygiene and be encouraged to perform hand hygiene before and after contact with patients and their surroundings. 7.3. Personal protective equipment Selection of personal protective equipment (PPE) must be based on an assessment of the risk of transmission of infectious agents to the patient, visitor or carer and the risk of contamination of clothing, skin, or mucus membrane of health workers by a patients’ body substances. The Infection Prevention and Control Practice Handbook provides advice on choosing the correct PPE and the sequencing of putting on and removing PPE including the provision of appropriate PPE. Implementation of PPE must consider environmental impact and sustainability in addition to safety requirements. Clinicians are not to bring any PPE (reusable or disposable) into a health facility unless it has been approved for use by the local facility, local health district/ specialty health network, HealthShare NSW and/ or NSW Health. 7.3.1. Gloves Gloves must be used in situations where the health worker is potentially exposed to body substances. When gloves are determined to be necessary, they must be worn on both hands. Gloves must be used for procedures that involve direct or perceived contact with non-intact skin, mucous membranes, and body substances. Sterile gloves must be worn when it is necessary or unavoidable to touch key sites and key parts directly. The wearing of sterile gloves for any specific aseptic technique procedure may be at the discretion or mandate of the NSW Health Organisation. Gloves must be changed and discarded, and hand hygiene performed: as soon as they are torn or punctured or when the integrity has been altered immediately after contact with a patient is complete and before care is provided to another patient when performing separate procedures on the same patient after handling blood and body substances before handling or opening sterile consumables and devices PD2023_025 Issued: September 2023 Page 22 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings before writing in the healthcare record, answering telephones, pagers, mobile phones, using computers and other social environmental actions. Disposable gloves must not be cleaned or reused. Disposable gloves must not be disinfected using ABHR. Double gloving is only permitted in specific settings such as an operating theatre worn by the operating team. No part of the glove is to be tampered with at any time before during or after use, such as fingertip cut off to feel a vein when undertaking cannulation or venepuncture. Hand hygiene must always be immediately performed before and after use of gloves. 7.3.2. Respiratory and facial protection A Respiratory Protective Device (RPD) is worn on the face, covers the nose and mouth, and is used to reduce the wearer’s risk of inhaling hazardous particles (including dust particles and infectious agents – noting this Policy Directive and Respiratory Protection Program applies to infectious agents). There is a range of RPDs available that provide facial and respiratory protection, and this includes either a surgical mask or a respirator, with or without eye protection. Facial protection is used to protect the mucous membranes of the face (eyes, nose, and mouth) from exposure to body substance splash or spray. The level of protection required are to be determined by the volume and distribution of body substance likely to be encountered during patient care. Respiratory and facial protection is required for those microorganisms that are usually transmitted via the droplet or airborne route and for those procedures with potential for body substance exposure to mucus membranes. 7.3.3. Surgical masks Surgical face masks provide a barrier to splashes and droplets impacting on the wearer’s nose, mouth, and respiratory tract. Based on risk assessment a single use mask is to be worn while performing any procedure where there is a likelihood of splashing or spraying of body substances or mucous membrane exposure to microbial droplets. Choosing a fluid-resistant single use mask, with the level of barrier protection required must be based on the risk of exposure at the time the procedure is performed or the likelihood of mucous membrane exposure to respiratory or oral droplets. Surgical masks are for use in clinical care, dental settings, and surgery as per Standard and Droplet Precautions. Surgical masks must be worn for the duration of the relevant exposure, task, or procedure. Single-use face masks are categorised to provide varying levels of fluid penetration resistance and protection against body substances. The manufacturer’s instructions for use provide the detail on the barrier level and their applications for use. All patients with an acute respiratory infection (ARI) are to be asked to wear a mask on presentation to a health facility and transit if able; and visitors asked to wear a mask during increased respiratory communicable disease transmission risk levels. PD2023_025 Issued: September 2023 Page 23 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings A single use mask must: be worn and applied in accordance with the manufacturer’s instructions cover both the mouth and nose while worn be discarded once it has been worn, or becomes visibly soiled or moist, and must not be used again be removed/ doffed by touching the strings/ ties or loops only. 7.3.4. Respirators A respirator is used by an individual to provide respiratory protection. Respiratory protection is one aspect of both infection prevention and control as well as work health and safety strategies for ensuring health worker safety at work. In the healthcare setting, an air-purifying respirator (or particulate filtering respirator) most commonly relates to the disposable filtering half face respirator also known as a P2 or N95 respirator. A P2/ N95 respirator is applied based on the risk assessment and is to be worn when providing care to patients in airborne precautions. Procedures that increase the release of particles into the air (such as aerosol generating procedures [AGP] or behaviours) potentially carry a greater risk. When performing these procedures or activities on patients with a respiratory communicable disease use of an RPD is required by health workers. Health worker must perform a fit check every time they put on a respirator. NSW Health Organisations must ensure health workers are informed on how to perform a fit check. Fit testing is performed to determine whether a specific type, model and size of respirator is a suitable fit for the wearer and that it is worn correctly to achieve a facial seal and comfort. Health workers who are required to wear a respirator must be trained and assessed for competency in the use of all PPE as part of an ongoing training program. This includes student health workers on placement. Advancement from fit checking to a fit testing program are to be based on the health workers’ level of exposure to known airborne hazards or identification of a new and/ or emerging risk. Implementation of fit testing requires a comprehensive respiratory protection program as outlined in the Clinical Excellence Commission Respiratory Protection Program Manual. A P2/ N95 respirator is not recommended to be worn by a patient. A fluid resistant surgical mask is to be worn by a patient who has a respiratory infection or has an airborne transmissible disease while they are outside their isolation or cohort room or in public areas of the NSW Health Organisation. 7.3.5. Eye protection Eye protection must be worn when there is risk of body substances splashing or spraying into the conjunctiva and/ or while providing care to patients under droplet or airborne precautions. Personal eyeglasses, prescription glasses and contact lenses are not considered adequate eye protection and are not a substitute for eye protection unless they are specified as safety glasses. Eye protection must meet Australian standards and be worn and fitted in accordance with the manufacturer’s instructions for use. PD2023_025 Issued: September 2023 Page 24 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings Goggles with a manufacturer’s anti-fog coating provide reliable, practical eye protection from splashes, sprays, and respiratory droplets from multiple angles. Prescription specific eye protection is considered to provide appropriate eye protection for blood or body fluid splash or droplet exposure if the eyewear: is close fitting, particularly at the corners of the eye and across the brow includes side protection that is indirectly vented can be cleaned and disinfected between use. Visors are transparent personal protective devices intended to shield the face and eyes of a health worker and are suitable for use with prescription glasses and masks. A mask with visor or a face shield is to be used if there is exposure to an excessive amount of splash or spray. Reusable eye protection and face visors/ shields must be cleaned in accordance with the manufacturer’s instructions after use and stored clean and dry. Eye protection labelled single use must not be shared between health workers or reused. 7.3.6. Gowns and aprons A fluid-resistant gown or apron, made of impervious material must be worn: during any procedure or task where there is a likelihood of splashes or contamination with body substances when providing care to patients under transmission-based precautions if contact with the patient or the patient’s environment is likely, and removed before or immediately on exiting the room as a protective layer under a sterile gown that is not made of impervious material. Reusable gowns are not recommended for the management of infectious diseases including reprocessing of reusable gowns. Washable fabric gowns that are laundered provide no protection from body substances and are not recommended for protection against infectious diseases, nor considered part of PPE for infection prevention and control. The need for, and type of gown or apron selected, is based on the nature of the patient interaction, including the anticipated degree of contact with infectious material and potential for blood and body substance penetration of the barrier. Gowns or aprons must be discarded after each use, on exiting the patient room or zone or on completion of a non-clinical task that required a gown to be worn to prevent exposure to contaminants, such as for cleaning. A gown provides increased coverage compared with an apron. Extended use of PPE is not routinely recommended outside of a pandemic and is confined to a specific infection or communicable disease. 7.4. Aseptic technique Aseptic technique is a set of practices to minimise contamination and is used to protect the patient from the risk of acquiring an infection during clinical procedures. NSW Health Organisations are to base their practice on the five principles of aseptic technique as outlined in the Infection Prevention and Control Practice Handbook. PD2023_025 Issued: September 2023 Page 25 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings Each NSW Health Organisation is to undertake a local risk assessment to identify medium and high-risk procedures that require the use of aseptic technique according to the Australian Commission on Safety and Quality in Healthcare (ACSQHC) Aseptic Technique Risk Matrix. Each NSW Health Organisation is to provide its clinical workforce with, or access to, aseptic technique education and maintain records of education, training, and competency assessment. Each NSW Health Organisation is to monitor compliance and report on the results to the appropriate committee. 7.5. Safe handling of waste and used linen NSW Health is committed to the delivery of an environmentally sustainable footprint, including transitioning to a low-waste system. Consideration should be given to alternate waste streams, in addition to general waste stream disposal for non-clinical waste. This may include recycling waste streams where appropriate. There is a potential risk of microorganism transmission via exposure to waste or contaminated linen. Health workers are to handle waste as follows: Clinical waste must be disposed of in clinical waste streams and sharps must be discarded into a sharps bin. All non-clinical waste must be disposed of into general waste stream or into a specific recycling bin if a recycling program is in place. PPE is considered general waste unless contaminated with bulk blood and or body substances. Refer to the NSW Health Policy Directive Clinical and Related Waste Management for Health Services (PD2020_049) for further information. Health workers are to handle, dispose and process used linen, or linen soiled with body substances in a manner that prevents exposure to skin and mucous membranes, contamination of clothing and transfer of microorganisms to other persons and the environment. [37, 38] 7.6. Respiratory hygiene and cough etiquette To minimise the risk of transmission of infection to others, everyone entering, visiting, or working within a NSW Health Organisation presenting with the signs and symptoms of an acute respiratory infection are to have access to hand hygiene products and single use masks to enable them to practice respiratory hygiene and cough etiquette. Health workers must not attend work with symptoms of acute respiratory infection. Local or state protocols may apply for people presenting with an acute respiratory infection. 7.7. Safe use and disposal of sharps The potential for exposure to bloodborne viruses is greatest when medical devices such as needles, scalpels, or other sharp instruments are used and contaminated with body PD2023_025 Issued: September 2023 Page 26 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings substances. Therefore, the use of sharps must be minimised wherever possible and when used be disposed of immediately into a sharps bin at the point of care. Each NSW Health Organisation must have procedures in place for the safe handling, transportation, and disposal of sharps including management of occupational exposures. Where available NSW Health Organisations are to use safety engineered devices. NSW Health Organisations must provide training to health workers on sharps handling and disposal. [37,38] 7.8. Environmental cleaning Each NSW Health Organisation must have an environmental cleaning program in place that is managed by suitability qualified personnel with an understanding of environmental cleaning and overseen by an appropriate committee or directorate. Environmental cleaning must be performed in accordance with NSW Health Policy Directive Cleaning of the Healthcare Environment (PD2023_018). This includes cleaning of patient areas during and after a patient’s stay (such as between patients). A risk assessment must be done for each functional area to determine the level and frequency of cleaning required based on the number of people using each facility or unit. The performance of cleaning in all functional areas must be regularly audited as per the auditing schedule described in NSW Health Policy Directive Cleaning of the Healthcare Environment (PD2023_018). The transport vehicle should be considered as part of the health facility and is to be cleaned and disinfected (as required) after the patient is transported. Follow local cleaning and disinfection procedures. 8. TRANSMISSION BASED PRECAUTIONS Transmission-based precautions must be used in addition to standard precautions when standard precautions alone are insufficient to interrupt the transmission of a known or suspected pathogen. The three main types of transmission-based precautions are contact, droplet and airborne (these can be combined for specific transmissible infections or communicable diseases). Implementation of transmission-based precautions must include an education program on how to risk assess for type of precautions, patient placement and selection of personal protective equipment (PPE). Transmission-based precautions consist of: Appropriate patient placement (such as use of negative pressure rooms, isolation, cohorting). Appropriate PPE selection and use based on risk assessment. Gloves as per standard precautions, don immediately before patient contact and change between different tasks on same patient and must be changed between patients. Limit transport and movement of patients where possible and practical. PD2023_025 Issued: September 2023 Page 27 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings Where practical use disposable or dedicated patient care equipment, clean and disinfect reusable shared equipment in between use. Clean and disinfect the patient environment. Some microorganisms can be transmitted simultaneously via more than one transmission route. To mitigate the transmission of these microorganisms, more than one type of transmission-based precautions must be employed in addition to standard precautions. Each NSW Health organisation must develop a procedure that outlines how they will minimise the risk of contact, droplet, or airborne transmission as well as address visitor access and any restrictions based on risk assessment. To support the requirements of each of the transmission-based precautions, a NSW Health Organisation must provide the required PPE, appropriate patient accommodation and patient care equipment. Patients and their nominated next of kin (NOK) are to be engaged as partners in care, and this discussion must be documented. 9. PRECAUTIONS FOR MULTIDRUG-RESISTANT ORGANISMS Multidrug-resistant organisms (MRO) are defined as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents. In most instances, MRO infections have clinical manifestations that are similar to infections caused by susceptible pathogens. However, options for treating patients with these infections may be extremely limited, and may be associated with increased lengths of stay, costs, and mortality. To minimise MRO transmission and infection, various types of infection prevention and control principles and interventions are required. In addition, local risk assessments must be conducted to assess the risk to inform the requirements of specific infection prevention measures [39, 40] for the management of patients who are MRO colonised or infected. This includes: Screening for MROs (see Section 9.1). Appropriate patient placement. Hand hygiene, standard and transmission-based precautions. Prompt and effective communication (such as electronic medical record alert to identify patients MRO status). Maintaining staffing level appropriate to patient care requirements. Infection prevention and control service involvement in analysis, structure, process, and outcomes when designing interventions. Compliance monitoring and timely feedback on adherence to recommended precautions and management. Antimicrobial stewardship. Educational intervention for health workers, patients, family, and carers. Environmental cleaning and monitoring. PD2023_025 Issued: September 2023 Page 28 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings Decolonisation program. 9.1. Multidrug-resistant organisms screening In acute-care settings, NSW Health Organisations must have a targeted MRO screening plan. The decision to screen for specific MROs is to be based on the level of risk and the local epidemiology of the specific MRO. Organism-specific approach is the use of knowledge of the epidemiology of specific MROs to reduce the risk of transmission and outbreaks. These strategies include targeted screening and identification, management of cases and screening and management of contacts. When implementing an MRO screening program NSW Health Organisations are to consider factors such as: Local prevalence of the MRO. The reason for admission of the patient. The potential risk of transmission to others. The functional risk status of the unit to which the patient is admitted. The likelihood that the patient is carrying an MRO. Admissions from an international facility into Australian facilities. Screening results, as well as any results obtained through diagnostic testing, are to be used to inform subsequent infection prevention and control actions. Ongoing MRO screening may be necessary in clinical areas where there may be a high risk of transmission or where the clinical impact of MRO transmission would be severe (such as dialysis units, haematology units, oncology units, neonatal intensive care units, intensive care units). A major risk factor for acquiring an MRO is overseas travel, especially when medical care or treatment in an overseas healthcare facility is involved. A risk assessment must be conducted at admission to identify people who require screening for specific MROs. Preoperative screening for Staphylococcus aureus including Methicillin resistant Staphylococcus aureus (MRSA) and Methicillin sensitive Staphylococcus aureus (MSSA) is recommended for elective procedures such as coronary artery bypass graft (CABGs) and joint replacements (total hip replacement and total knee replacements). A risk assessment must be conducted at admission to identify people who require screening for specific MROs. 9.2. Isolation and placement of patient with multidrug-resistant organisms A single-patient room is recommended for patients who require transmission-based precautions. Patient placement decisions must be made based on a risk assessment in consultation with local infection prevention and control services and the infectious diseases team. The decision needs to consider the prioritisation of isolation or single rooms or dedicated areas for other important uses beyond the management of infectious diseases, PD2023_025 Issued: September 2023 Page 29 of 44 NSW Health Policy Directive  NSW Health Infection Prevention and Control in Healthcare Settings such as providing end-of-life care, falls risk or ensuring appropriate patient security and safety. Isolation of a patient must not compromise clinical care. Patients must be provided with information on the isolation requirements, specific information on the organism and infection prevention measures. Extended periods of isolation require regular assessment by teams involved in patient care. The reason for isolation must be documented in the patient’s healthcare records and reviewed by the infection prevention and control service. Patients with significant neutropenia and transplant recipients may require protective isolation. When single rooms with dedicated toilets are not available a dedicated commode must be assigned. Where single rooms are not available in a high-risk clinical area, cohorting patients with the same confirmed infectious agent may need to occur. A decision to cohort patients must be made carefully with consultation between treating clinicians and the infection prevention and control service and/ or an infectious diseases physician. Cleaning and disinfection of patient care items