Question 28

College answer

1. a)    Neutropenic sepsis
   This patient requires standard precautions in the ICU. These include:
   •    Handwashing before and after every patient contact
   •    Gloves, gown, eye protection on direct patient bedside care
   •    Use of above when removing soiled linen and clothing

   HOWEVER the patient is at risk from staff and other patients. Consider
   Positive pressure room.
   Isolation away from overtly infected patients or visitors especially children,
   Limiting staff contact. (e.g. limiting number of bedside ward rounds or staff entering room)

   b)    Neisseria meningitidis
   Infection control is required to address droplet precautions. In addition to standard precautions:
   •    Private room preferred, cohort if necessary
   •    Wearing of a mask (normal surgical mask OK) within 1m of patient.
   •    Mask of patient (normal surgical mask OK) during transport (although keep transport of patient to a minimum.)
   •    Limitation of staff to high-risk procedures e.g. intubation.
   •    Notifiable disease to public health.
   •    Contact tracing and prophylaxis

   c)    SARS,
   Infection control is targeted to address airborne routes of transmission In addition to standard precautions:
   •    Negative pressure room with room exhaust filtration.
   •    Use of an airborne filtering mask (N95) not just a surgical mask on entering room
   •    Patient N95 masked on transport (minimize transport)
   •    Notifiable disease to public health.
   •    Contact tracing and isolation.

   d)    Norovirus.
   Norovirus is a highly infectious virus
   It is spread predominantly via the fecal oral route AND via airborne route.
   It is able to exist on environmental surfaces for weeks and contact precautions are essential. Infection control measures are required to manage these two routes.

   Standard precautions include:
   •    Handwashing HOWEVER norovirus has no lipid capsule therefore alcohol-based rubs are not recommended. Soap and water especially if hands visibly contaminated.

   Contact precautions in addition to above-
   •    Private room and cohorting of multiple cases if necessary.
   •    Gloves on entering room and changing after contact with contaminated secretions
   •    Gown on entering room in case of touching environmental surfaces as well as patient
   •    Minimize patient transport around hospital unless necessary.
   •    Use of dedicated non-essential equipment. I.e. stethoscopes.
   •    Limitation of staff to high-risk procedures i.e. intubation.
   •    Notifiable disease to public health.
   •    Contact tracing and isolation.
    
   AND managing airborne routes with an N95 mask for staff especially with active vomiting or high-risk procedures such as intubation. Similar to SARS.

Discussion

This question could very well have been worded, "describe what is meant by standard precautions, contact precautions, droplet precautions and airborne precautions". The examiners gave scenarios which are essentially and example of each barrier method.

Neutropenic patients require reverse barrier protective measures:

• Single room
• Filter all incoming air using high efficiency particulate (HEPA) filters
• Direct room airflow with the air supply on one side of the room that moves air across the patient bed and out through an exhaust on the opposite side of the room  
• Positive air pressure in room relative to the corridor 
• Use an anteroom
• At least 12 air changes per hour
• Lower the dust levels:
  • Avoid carpeting in hallways and patient room
  • Prohibit plants
  • Use smooth, nonporous surfaces and finishes that can be scrubbed
• Visitors and staff should use contact and airborne precaution, ideally; but at the very least standard precautions apply

Neisseria meningitidis: From the NSW Health page on Meningococcal disease:

• Droplet precautions: 
  • Daily cleaning and disinfection of patient rooms, with a focus on frequently-touched surfaces
  • Use disposable equipment
  • Limit transport and movement of patients outside of the room
  • For every time you enter the patient's immediate environment, wear a surgical mask
  • If transport or movement in any healthcare setting is necessary, instruct patient to wear a mask (in which case, you yourself don't have to)
  • PPE
    • Wear a gown whenever anticipating that clothing will have direct contact with the patient
    • Wear gloves whenever touching the patient’s intact skin
  • Single rooms
    • Or, cohort patients with the same pathogen in the same room
    • Ensure patients are separated by more than 1m
    • Change protective attire and perform hand hygiene between contact with patients in the same room

SARS: From the NSW Health page on SARS coronavirus (SARS-CoV)

• Airborn precautions
  • Single rooms, or cohort the patients
  • Contact precautions, as below; ALSO:
    • Use a negative pressure room
    • The room has to have 6-12 air changes per hour
    • The exhaust air must go directly outside, i.e. not back into the hospital
    • Restrict susceptible healthcare personnel from entering the room ("susceptible" means not immunised, pregnant, immunosuppressed, etc)
    • Wear a N95 mask
    • When transporting the patient, instruct them to wear the N95 mask

Norovirus:

• Contact precautions:
  • PPE
    • Wear a gown whenever anticipating that clothing will have direct contact with the patient
    • Wear gloves whenever touching the patient’s intact skin
  • Single rooms
    • Or, cohort patients with the same pathogen in the same room
    • Ensure patients are separated by more than 1m
    • Change protective attire and perform hand hygiene between contact with patients in the same room
  • Daily cleaning and disinfection of patient rooms, with a focus on frequently-touched surfaces
  • Use disposable equipment
  • Limit transport and movement of patients outside of the room

Eggimann, Philippe, and Didier Pittet. "Infection control in the ICU." Chest 120.6 (2001): 2059-2093.

CDC Guidelines for Isolation Precautions

NSW Health PHU disease control guidelines