When treating patients when do you implement Standard Precautions and transmission-based precautions?

Successful infection prevention and control involves implementing everyday work practices that prevent the transmission of infectious agents through a two-tiered approach:

• Standard precautions:  The routine application of basic infection prevention and control strategies, to minimise risk to both patients and staff. These are the primary strategy for minimising the transmission of healthcare associated infections.
• Transmission based precautions: An additional set of work practices, used in addition to standard precautions.

Standard Precautions

These are work practices that apply to everyone, regardless of their perceived or confirmed infectious status, and ensures a basic level of infection prevention and control. It is essential that standard precautions are applied at all times as:

• People may be placed at risk of infection from others who carry infectious agents,
• Signs or symptoms of disease may not always be present in someone who is infectious, or ambulance care may occur before laboratory tests confirm infection,
• People may be at risk from infectious agents present in the surrounding environment including environmental surfaces or from equipment,
• There is an increased risk of transmission associated with specific procedures and practices.

KEY POINT:

Correct application of standard precautions minimises the risk of transmission, even in high-risk situations. Transmission based precautions should be implemented in high-risk scenarios to further ensure prevention of transmission.

Standard precautions consist of:

• Hand hygiene, consistent with the 5 moments for hand hygiene, where practicable
• The use of personal protective equipment
• The safe use and disposal of sharps
• Routine environmental cleaning
• Reprocessing of reusable medical equipment
• Aseptic technique
• Waste management
• Appropriate handling of linen
• Respiratory hygiene and cough etiquette
• Initial distanced assessment

Standard precautions should also be used in the handling of:

• Blood (including dried blood)
• All other body fluids, secretions and excretions (excluding sweat)
• Non-intact skin and mucous membranes.

Transmission-Based Precautions

Transmission-based precautions, used in addition to standard precautions, are extra work practices recommended for situations where standard precautions alone may be insufficient to prevent transmission.

Transmission-Based precautions are used for patients known or suspected to be infected or colonised with epidemiologically important or highly transmissible pathogens. They are tailored to the particular infectious agent involved and the mode of transmission, and may include one or any combination of the following:

• Continued implementation of Standard precautions
• Wearing specific personal protective equipment (PPE)
• Providing single-use patient-dedicated equipment
• Enhanced cleaning and disinfection of ambulance surfaces and equipment

Transmission based precautions consist of:

• Contact Precautions
• Droplet Precautions
• Airborne Precautions

KEY POINT:

Depending on the pathogen and its mode of transmission, one or more types of precautions may be required.

Contact precautions are used when there is a known or suspected risk of direct or indirect contact transmission of infectious agents that are not effectively contained by standard precautions alone.

• Direct transmission occurs when infectious agents are transferred from one person to another person. For example, blood or other body substances from an infectious person may come into contact with a mucous membrane or breaks in the skin of another person. Breaks in the skin also includes clinical interventions, e.g. intravenous cannulation.

• Indirect transmission involves the transfer of an infectious agent through a contaminated intermediate object (fomite) or person. This can occur by:
  • Contaminated hands of Ambulance personnel
  • Contaminated patient-care devices
  • Contaminated environmental surfaces

KEY POINT:

Effective hand hygiene is particularly important in preventing contact transmission.

A number of infectious agents can be transmitted through respiratory droplets (i.e. large particle droplets ≥ 5 microns) that are generated by a patient who is coughing, sneezing or talking. Transmission requires close contact as the droplets do not remain suspended in the air and only travel over short distances due to gravity (around 1.5 metres). They can however, contaminate surfaces close to the patient, and the hands of Ambulance personnel can become contaminated through contact with those surfaces.

Droplet precautions aim to prevent the inhalation of the infectious microorganisms, and also contact with mucous membranes.

KEY POINT:

Masks protect the wearer from droplet contamination of the nasal or oral mucosa. Eye protection protects against conjunctival contact.

Physical proximity of less than one metre has been associated with an increased risk for transmission of some infections via the droplet route. 

Placing surgical masks on coughing patients can reduce the spread of respiratory secretions.

Airborne Precautions

Certain infectious agents are disseminated through airborne droplet nuclei or small particles that remain infective over time and distance when suspended in the air. Airborne precautions aim to prevent the inhalation of the infectious microorganisms.

KEY POINT:

The use of P2/N95 respirators prevents the inhalation of small particles that may contain infectious agents.

The use of recommended vehicle airflow procedure may assist in the reduction of risk of transmission.

Placing surgical masks on coughing patients can reduce the spread of respiratory secretions.

Patient Assessment

For known or strongly suspected infections, refer to the table (Type of Precautions Required for Specific Diseases) for level of precautions required.

If unknown, perform an initial distanced assessment from >1.5 m away, and assess for:

• Respiratory symptoms
• History of fever (temperature > 38°C)
• Rash in the presence of fever
• Acute/unexplained diarrhoea and/or vomiting
• Unwell following recent overseas travel to a region known to have an outbreak of infection
• Likelihood of exposure to blood or bodily fluids.

If YES to any of the above questions, risk assess the need for transmission-based precautions and the don the appropriate PPE. The selections of PPE should be guided by the anticipated type and amount of exposure to blood and body fluids and the likely transmission route of the suspected pathogen.

If a patient requires immediate attention or is unable to accurately report on symptoms, eye protection and P2/N95 respirator before gap to patient is closed. Risk assess need for other PPE. If in doubt, full PPE should be worn.

Refer to Infection Prevention & Control Guideline – Personal Protective Equipment (PPE).

KEY POINT:

While it is not possible to prospectively identify all patients needing transmission-based precautions in the pre-hospital setting, recognising an increased risk warrants their use.

An aerosol generating procedure (AGPs) is any procedure that provokes coughing or stimulates generation of fine airborne particles, <5 microns, creating the risk of airborne transmission. AGPs in the prehospital setting include;

• Manual or Non-Invasive Ventilation (NIV) – CPAP or BiPAP,
• High flow oxygen (including nebuliser administration),
• Airway management, including suction, the use of adjuncts or other manoeuvres.

The risk of transmission from these procedures is informed by the patient’s clinical presentation and the nature of the procedure.  A risk assessment should be undertaken to determine the level of PPE required ideally before beginning a procedure.

• Droplet and Airborne Precautions are required.

Aerosol Generating Behaviour

There is an increased risk of aerosol generation of respiratory secretions with patients with challenging behaviours such as aggression, shouting, crying  and screaming.

• Droplet and Airborne Precautions are required.

Cardiac Arrest

Defibrillation is not considered an AGP and there is little evidence to show aerosol generation from isolated chest compressions.
As early defibrillation and quality chest compressions are the key to survival in OHCA, donning of PPE should not delay chest compressions or defibrillation.

If able, don airborne PPE prior to patient contact, however a single officer can commence performing chest compressions and defibrillation for a short time frame, until other staff in correct PPE can takeover. The initial member should then retreat and don PPE.

When managing the airway, airborne precautions are required.

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Elements of Standard Precautions.*