Environmental Infection Control in Healthcare-Facilities

A. Use AIA guidelines as minimum standards where state or local regulations are not in place for design and construction of ventilation systems in new or renovated health-care facilities. Ensure that existing structures continue to meet the specifications in effect at the time of construction. (Category IC)

B. Monitor ventilation systems in accordance with engineers’ and manufacturers’ recommendations to ensure preventive engineering, optimal performance for removal of particulates, and elimination of excess moisture. ()

C. Use portable, industrial-grade HEPA filter units capable of filtration rates in the range of 300–800 ft³/min. to augment removal of respirable particles as needed. (Category II)

D. Follow appropriate procedures for use of areas with through-the-wall ventilation units. (Category IC)

E. Conduct an infection-control risk assessment (ICRA) and provide an adequate number of AII and PE rooms (if required) or other areas to meet the needs of the patient population. ()

F. When UVGI is used as a supplemental engineering control, install fixtures:

• on the wall near the ceiling or suspended from the ceiling as an upper air unit;
• in the air-return duct of an AII room; or
• in designated enclosed areas or booths for sputum induction.

(Category II)

G. Seal windows in buildings with centralized HVAC systems and especially with PE areas. ()

H. Keep emergency doors and exits from PE rooms closed except during an emergency; equip emergency doors and exits with alarms. (Category II)

I. Develop a contingency plan for backup capacity in the event of a general power failure. (Category IC)

J. Do not shut down HVAC systems in patient-care areas except for maintenance, repair, testing of emergency backup capacity, or new construction. ()

K. HVAC systems serving offices and administration areas may be shut down for energy conservation purposes, but the shutdown must not alter or adversely affect pressure differentials maintained in laboratories or critical-care areas with specific ventilation requirements (i.e., PE rooms, AII rooms, operating rooms). (Category II)

L. Whenever possible, avoid inactivating or shutting down the entire HVAC system at one time, especially in acute-care facilities. (Category II)

M. Whenever feasible, design and install fixed backup ventilation systems for new or renovated construction for PE rooms, AII rooms, operating rooms, and other critical care areas identified by ICRA. (Category IC)

A. Establish a multidisciplinary team that includes infection-control staff to coordinate demolition, construction, and renovation projects and consider proactive preventive measures at the inception; produce and maintain summary statements of the team’s activities. ()

B. Educate both the construction team and the health-care staff in immunocompromised patient-care areas regarding the airborne infection risks associated with construction projects, dispersal of fungal spores during such activities, and methods to control the dissemination of fungal spores. (Category IB)

C. Incorporate mandatory adherence agreements for infection control into construction contracts, with penalties for noncompliance and mechanisms to ensure timely correction of problems. (Category IC)

D. Establish and maintain surveillance for airborne environmental disease (e.g., aspergillosis) as appropriate during construction, renovation, repair, and demolition activities to ensure the health and safety of immunocompromised patients. (Category IB)

E. Implement infection-control measures relevant to construction, renovation, maintenance, demolition, and repair. ()

F. Use airborne-particle sampling as a tool to evaluate barrier integrity. (Category II)

G. Commission the HVAC system for newly constructed health-care facilities and renovated spaces before occupancy and use, with emphasis on ensuring proper ventilation for operating rooms, AII rooms, and PE areas. (Category IC)

H. No recommendation is offered on routine microbiologic air sampling before, during, or after construction or before or during occupancy of areas housing immunocompromised patients. (No recommendation/unresolved issue)

I. If a case of health-care acquired aspergillosis or other opportunistic environmental airborne fungal disease occurs during or immediately after construction, implement appropriate follow-up measures. (Category IB)

J. If there is epidemiologic evidence of ongoing transmission of fungal disease, conduct an environmental assessment to determine and eliminate the source. (Category IB)

A. Minimize exposures of severely immunocompromised patients (e.g., solid organ transplant patients or allogeneic neutropenic patients) to activities that might cause aerosolization of fungal spores (e.g., vacuuming or disruption of ceiling tiles). (Category IB)

B. Minimize the length of time that immunocompromised patients in PE are outside their rooms for diagnostic procedures and other activities. (Category IB)

C. Provide respiratory protection for severely immunocompromised patients when they must leave PE for diagnostic studies and other activities; consult the most recent revision of CDC’s Guidelines for Prevention of Health-Care Associated Pneumonia for information regarding the appropriate type of respiratory protection. (Category II)

D. Incorporate ventilation engineering specifications and dust-controlling processes into the planning and construction of new PE units. ()

E. Do not use laminar air flow systems in newly constructed PE rooms. (Category II)

F. Take measures to protect immunocompromised patients who would benefit from a PE room and who also have an airborne infectious disease (e.g., acute VZV infection or tuberculosis). ()

G. Maintain backup ventilation equipment (e.g., portable units for fans or filters) for emergency provision of ventilation requirements for PE areas and take immediate steps to restore the fixed ventilation system function. (Category IC)

A. Incorporate certain specifications into the planning, and construction or renovation of AII units. ()

B. Where supplemental engineering controls for air cleaning are indicated from a risk assessment of the AII area, install UVGI units in the exhaust air ducts of the HVAC system to supplement HEPA filtration or install UVGI fixtures on or near the ceiling to irradiate upper room air. (Category II)

C. Implement environmental infection-control measures for persons with known or suspected airborne infectious diseases.

• ≥12 ACH;
• air supply and exhaust rate sufficient to maintain a 2.5 Pa [0.01-inch water gauge] negative pressure difference with respect to all surrounding spaces with an exhaust rate of ≥50 ft³/min.; and
• air exhausted directly outside away from air intakes and traffic or exhausted after HEPA filtration prior to recirculation.

()

D. No recommendation is offered regarding negative pressure or isolation rooms for patients with Pneumocystis carinii pneumonia. (No recommendation/unresolved issue)

E. Maintain back-up ventilation equipment (e.g., portable units for fans or filters) for emergency provision of ventilation requirements for AII rooms and take immediate steps to restore the fixed ventilation system function. (Category IC)

A. Implement environmental infection-control and ventilation measures for operating rooms. ()

B. Follow precautionary procedures for TB patients who also require emergency surgery. ()

C. Use portable, industrial-grade HEPA filters temporarily for supplemental air cleaning during intubation and extubation for infectious TB patients who require surgery. (Category II)

D. If possible, schedule infectious TB patients as the last surgical cases of the day to maximize the time available for removal of airborne contamination. (Category II)

E. No recommendation is offered for performing orthopedic implant operations in rooms supplied with laminar airflow. (No recommendation/unresolved issue)

F. Maintain backup ventilation equipment (e.g., portable units for fans or filters) for emergency provision of ventilation requirements for operating rooms, and take immediate steps to restore the fixed ventilation system function. ()

A. In settings where surgical lasers are used, wear appropriate personal protective equipment, including N95 or N100 respirators, to minimize exposure to laser plumes. (Category IC)

B. Use central wall suction units with in-line filters to evacuate minimal laser plumes. (Category II)

C. Use a mechanical smoke evacuation system with a high-efficiency filter to manage the generation of large amounts of laser plume, when ablating tissue infected with human papilloma virus (HPV) or performing procedures on a patient with extrapulmonary TB. (Category II)

A. Practice hand hygiene to prevent the hand transfer of waterborne pathogens, and use barrier precautions (e.g., gloves) as defined by other guidelines. (Category IA)

B. Eliminate contaminated water or fluid environmental reservoirs (e.g., in equipment or solutions) wherever possible. (Category IB)

C. Clean and disinfect sinks and wash basins on a regular basis by using an EPA-registered product as set by facility policies. (Category II)

D. Evaluate for possible environmental sources (e.g., potable water) of specimen contamination when waterborne microorganisms (e.g., nontuberculous mycobacteria) of unlikely clinical importance are isolated from clinical cultures (e.g., specimens collected aseptically from sterile sites or, if post-procedural, colonization occurs after use of tap water in patient care). (Category IB)

E. Avoid placing decorative fountains and fish tanks in patient-care areas; ensure disinfection and fountain maintenance if decorative fountains are used in the public areas of the healthcare facility. (Category IB)

A. Maintain hot water temperature at the return at the highest temperature allowable by state regulations or codes, preferably ≥124°F (≥51°C), and maintain cold water temperature at <68°F (<20°C). (Category IC)

B. If the hot water temperature can be maintained at ≥124°F (≥51°C), explore engineering options (e.g., install preset thermostatic valves in point-of-use fixtures) to help minimize the risk of scalding. (Category II)

C. When state regulations or codes do not allow hot water temperatures above the range of 105°F– 120°F (40.6°C–49°C) for hospitals or 95°F–110°F (35°C–43.3°C) for nursing care facilities or when buildings cannot be retrofitted for thermostatic mixing valves, follow either of these alternative preventive measures to minimize the growth of Legionella spp. in water systems. (Category II)

D. Maintain constant recirculation in hot-water distribution systems serving patient-care areas. (Category IC)

J. Implement facility management procedures to manage a sewage system failure or flooding (e.g., arranging with other health-care facilities for temporary transfer of patients or provision of services), and establish communications with the local municipal water utility and the local health department to ensure that advisories are received in a timely manner upon release. (Category IC)

A. Whenever possible, disconnect the ice machine before planned water disruptions. (Category II)

B. Prepare a contingency plan to estimate water demands for the entire facility in advance of significant water disruptions (i.e., those expected to result in extensive and heavy microbial or chemical contamination of the potable water), sewage intrusion, or flooding. (Category IC)

C. When a significant water disruption or an emergency occurs, adhere to any advisory to boil water issued by the municipal water utility. ()

D. Maintain a high level of surveillance for waterborne disease among patients after a boil water advisory is lifted. (Category II)

E. Corrective decontamination of the hot water system might be necessary after a disruption in service or a cross-connection with sewer lines has occurred. ()

F. Flush and restart equipment and fixtures according to manufacturers’ instructions. (Category II)

G. Change the pretreatment filter and disinfect the dialysis water system with an EPA-registered product to prevent colonization of the reverse osmosis membrane and downstream microbial contamination. (Category II)

H. Run water softeners through a regeneration cycle to restore their capacity and function. (Category II)

I. If the facility has a water-holding reservoir or water-storage tank, consult the facility engineer or local health department to determine whether this equipment needs to be drained, disinfected with an EPA-registered product, and refilled. (Category II)

K. Implement infection-control measures during sewage intrusion, flooding, or other water-related emergencies. ()

L. Remediate the facility after sewage intrusion, flooding, or other water-related emergencies. ()

A. When using a pulse or one-time decontamination method, superheat the water by flushing each outlet for ≥5 minutes with water at 160°F–170°F (71°C–77°C) or hyperchlorinate the system by flushing all outlets for ≥5 minutes with water containing ≥2 mg/L (≥2 ppm) free residual chlorine using a chlorine-based product registered by the EPA for water treatment (e.g., sodium hypochlorite [chlorine bleach]). (Category IB)

B. After a pulse treatment, maintain both the heated water temperature at the return and the cold water temperature as per the recommendation wherever practical and permitted by state codes, or chlorinate heated water to achieve 1–2 mg/L (1–2 ppm) free residual chlorine at the tap using a chlorine-based product registered by the EPA for water treatment (e.g., sodium hypochlorite [bleach]). (Category IC)

C. Explore engineering or educational options (e.g., install preset thermostatic mixing valves in pointof-use fixtures or post warning signs at each outlet) to minimize the risk of scalding for patients, visitors, and staff. (Category II)

D. No recommendation is offered for treating water in the facility’s distribution system with chlorine dioxide, heavy-metal ions (e.g., copper or silver), monochloramine, ozone, or UV light. (No recommendation/unresolved issue)

A. Conduct an infection-control risk assessment of the facility to determine if patients at risk or severely immunocompromised patients are present. (Category IB)

B. Implement general strategies for detecting and preventing Legionnaires disease in facilities that do not provide care for severely immunocompromised patients (i.e., facilities that do not have HSCT or solid organ transplant programs). (Category IB)

C. Maintain a high index of suspicion for health-care associated Legionnaires disease, and perform laboratory diagnostic tests for legionellosis on suspected cases, especially in patients at risk who do not require a PE for care (e.g., patients receiving systemic steroids; patients aged ≥65 years; or patients with chronic underlying disease [e.g., diabetes mellitus, congestive heart failure, or chronic obstructive lung disease]). (Category IA)

D. Periodically review the availability and clinicians’ use of laboratory diagnostic tests for Legionnaires disease in the facility; if clinicians’ use of the tests on patients with diagnosed or suspected pneumonia is limited, implement measures (e.g., an educational campaign) to enhance clinicians’ use of the test(s). (Category IB)

E. If one case of laboratory-confirmed, health-care associated Legionnaires disease is identified, or if two or more cases of laboratory-suspected, health-care associated Legionnaires disease occur during a 6-month period, certain activities should be initiated. (Category IB)

F. If there is evidence of continued health-care associated transmission (i.e., an outbreak), conduct an environmental assessment to determine the source of Legionella spp. (Category IB)

G. If an environmental source is not identified during a Legionnaires disease outbreak, continue surveillance for new cases for ≥2 months. Either defer decontamination pending identification of the source of Legionella spp., or proceed with decontamination of the hospital's water distribution system, with special attention to areas involved in the outbreak. (Category II)

H. No recommendation is offered regarding routine culturing of water systems in health-care facilities that do not have patient-care areas (i.e., PE or transplant units) for persons at high risk for Legionella spp. infection. (No recommendation/unresolved issue)

I. No recommendation is offered regarding the removal of faucet aerators in areas for immunocompetent patients. (No recommendation/unresolved issue)

A. When implementing strategies for preventing Legionnaires disease among severely immunosuppressed patients housed in facilities with HSCT or solid-organ transplant programs, incorporate these specific surveillance and epidemiologic measures in addition to the steps previously outlined. ()

B. Implement culture strategies and potable water and fixture treatment measures in addition to those previously outlined. (Category II)

C. If Legionella spp. are determined to be present in the water of a transplant unit, implement certain measures until Legionella spp. are no longer detected by culture. ()

A. When planning construction of new health-care facilities, locate cooling towers so that the drift is directed away from the air-intake system, and design the towers to minimize the volume of aerosol drift. (Category IC)

B. Implement infection-control procedures for operational cooling towers. (Category IC)

C. If cooling towers or evaporative condensers are implicated in health-care associated legionellosis, decontaminate the cooling-tower system. (Category IB)

A. Adhere to current AAMI standards for quality assurance performance of devices and equipment used to treat, store, and distribute water in hemodialysis centers (both acute and maintenance [chronic] settings) and for the preparation of concentrates and dialysate. ()

B. No recommendation is offered regarding whether more stringent requirements for water quality should be imposed in hemofiltration and hemodiafiltration. (No recommendation/unresolved issue)

C. Conduct microbiological testing specific to water in dialysis settings. ()

D. Disinfect water distribution systems in dialysis settings on a regular schedule. Monthly disinfection is recommended. ()

E. Whenever practical, design and engineer water systems in dialysis settings to avoid incorporating joints, dead-end pipes, and unused branches and taps that can harbor bacteria. ()

F. When storage tanks are used in dialysis systems, they should be routinely drained, disinfected with an EPA-registered product, and fitted with an ultrafilter or pyrogenic filter (membrane filter with a pore size sufficient to remove small particles and molecules ≥1 kilodalton) installed in the water line distal to the storage tank. (Category IC)

A. Do not handle ice directly by hand, and wash hands before obtaining ice. (Category II)

B. Use a smooth-surface ice scoop to dispense ice. (Category II)

C. Do not store pharmaceuticals or medical solutions on ice intended for consumption; use sterile ice to keep medical solutions cold, or use equipment specifically manufactured for this purpose. (Category IB)

D. Machines that dispense ice are preferred to those that require ice to be removed from bins or chests with a scoop. (Category II)

E. Limit access to ice-storage chests, and keep the container doors closed except when removing ice. (Category II)

F. Clean, disinfect, and maintain ice-storage chests on a regular basis. (Category II)

G. Install proper air gaps where the condensate lines meet the waste lines. (Category II)

H. Conduct microbiologic sampling of ice, ice chests, and ice-making machines and dispensers where indicated during an epidemiologic investigation. (Category IB)

A. Drain and clean hydrotherapy equipment (e.g., Hubbard tanks, tubs, whirlpools, whirlpool spas, or birthing tanks) after each patient’s use, and disinfect equipment surfaces and components by using an EPA-registered product in accordance with the manufacturer’s instructions. (Category II)

B. In the absence of an EPA-registered product for water treatment, add sodium hypochlorite to the water: (Category II)

C. Clean and disinfect hydrotherapy equipment after using tub liners. (Category II)

D. Clean and disinfect inflatable tubs unless they are single-use equipment. (Category II)

E. No recommendation is offered regarding the use of antiseptic chemicals (e.g., chloramine-T) in the water during hydrotherapy sessions. (No recommendation/unresolved issue)

F. Conduct a risk assessment of patients prior to their use of large hydrotherapy pools, deferring patients with draining wounds or fecal incontinence from pool use until their condition resolves. (Category II)

G. For large hydrotherapy pools, use pH and chlorine residual levels appropriate for an indoor pool as provided by local and state health agencies. (Category IC)

H. No recommendation is offered regarding the use in health care of whirlpools or spa equipment manufactured for home or recreational use. (No recommendation/unresolved issue)

A. Clean, disinfect, and maintain AER equipment according to the manufacturer’s instructions and relevant scientific literature to prevent inadvertent contamination of endoscopes and bronchoscopes with waterborne microorganisms. (Category IB)

B. Use water that meets nationally recognized standards set by the EPA for drinking water (<500 CFU/mL for heterotrophic plate count) for routine dental treatment output water. ()

C. Take precautions to prevent waterborne contamination of dental unit water lines and instruments. ()

3. Consult with the dental unit manufacturer on the need for periodic maintenance of anti-retraction mechanisms. (Category IB)

1. Clean noncritical medical equipment surfaces with a detergent/disinfectant. This may be followed with an application of an EPA-registered hospital disinfectant with or without a tuberculocidal claim (depending on the nature of the surface and the degree of contamination), in accordance with disinfectant label instructions. (Category II)

2. Do not use alcohol to disinfect large environmental surfaces. (Category II)

3. Use barrier protective coverings as appropriate for noncritical equipment surfaces that are:

• touched frequently with gloved hands during the delivery of patient care;
• likely to become contaminated with blood or body substances; or
• difficult to clean (e.g., computer keyboards).

(Category II)

1. Use a one-step process and an EPA-registered hospital disinfectant/detergent designed for general housekeeping purposes in patient-care areas when:

• uncertainty exists as to the nature of the soil on these surfaces [e.g., blood or body fluid contamination versus routine dust or dirt]; or
• uncertainty exists regarding the presence or absence of multi-drug resistant organisms on such surfaces.

(Category II)

2. Detergent and water are adequate for cleaning surfaces in nonpatient-care areas (e.g., administrative offices). (Category II)

3. Clean and disinfect high-touch surfaces (e.g., doorknobs, bed rails, light switches, and surfaces in and around toilets in patients’ rooms) on a more frequent schedule than minimal touch housekeeping surfaces. (Category II)

4. Clean walls, blinds, and window curtains in patient-care areas when they are visibly dusty or soiled. (Category II)

1. Prepare cleaning solutions daily or as needed, and replace with fresh solution frequently according to facility policies and procedures. (Category II)

2. Change the mop head at the beginning of the day and also as required by facility policy, or after cleaning up large spills of blood or other body substances. (Category II)

3. Clean mops and cloths after use and allow to dry before reuse; or use single-use, disposable mop heads and cloths. (Category II)

1. Wet-dust horizontal surfaces daily by moistening a cloth with a small amount of an EPAregistered hospital detergent/disinfectant. (Category IB)

2. Avoid dusting methods that disperse dust (e.g., feather-dusting). (Category IB)

1. Do not use phenolics or any other chemical germicide to disinfect bassinets or incubators during an infant’s stay. (Category IB)

2. Rinse disinfectant-treated surfaces, especially those treated with phenolics, with water. (Category IB)

1. Use protective gloves and other PPE appropriate for this task. (Category IC)

2. If the spill contains large amounts of blood or body fluids, clean the visible matter with disposable absorbent material, and discard the contaminated materials in appropriate, labeled containment. (Category IC)

3. Swab the area with a cloth or paper towels moderately wetted with disinfectant, and allow the surface to dry. (Category IC)

1. Use a 1:100 dilution (500–615 ppm available chlorine) to decontaminate nonporous surfaces after cleaning a spill of either blood or body fluids in patient-care settings. (Category II)

2. If a spill involves large amounts of blood or body fluids, or if a blood or culture spill occurs in the laboratory, use a 1:10 dilution (5,000–6,150 ppm available chlorine) for the first application of germicide before cleaning. (Category II)

1. Spot-clean blood or body substance spills promptly. (Category IC)

2. If a spill occurs on carpet tiles, replace any tiles contaminated by blood and body fluids or body substances. (Category IC)

2. If upholstered furniture in a patient’s room requires cleaning to remove visible soil or body substance contamination, move that item to a maintenance area where it can be adequately cleaned with a process appropriate for the type of upholstery and the nature of the soil. (Category II)

1. Maintain the surface integrity of the upholstery by repairing tears and holes. (Category II)

1. Pay close attention to cleaning and disinfection of high-touch surfaces in patient-care areas (e.g., bed rails, carts, bedside commodes, bedrails, doorknobs, or faucet handles). (Category IB)

2. Ensure compliance by housekeeping staff with cleaning and disinfection procedures. (Category IB)

3. Use EPA-registered hospital disinfectants appropriate for the surface to be disinfected (e.g., either low- or intermediate-level disinfection) as specified by the manufacturers’ instructions. ()

4. When contact precautions are indicated for patient care, use disposable patient-care items (e.g., blood pressure cuffs) whenever possible to minimize cross-contamination with multiple-resistant microorganisms. (Category IB)

5. Follow these same surface cleaning and disinfecting measures for managing the environment of VRSA patients. (Category II)

1. Obtain prior approval from infection-control staff and the clinical laboratory before performing environmental surface culturing. (Category II)

2. Infection-control staff, with clinical laboratory consultation, must supervise all environmental culturing. (Category II)

1. In the absence of contamination with central nervous system tissue, extraordinary measures (e.g., use of 2N sodium hydroxide [NaOH] or applying full-strength sodium hypochlorite) are not needed for routine cleaning or terminal disinfection of a room housing a confirmed or suspected CJD patient. (Category II)

2. After removing gross tissue from the surface, use either 1N NaOH or a sodium hypochlorite solution containing approximately 10,000–20,000 ppm available chlorine (dilutions of 1:5 to 1:3 v/v, respectively, of U.S. household chlorine bleach; contact the manufacturers of commercially available sodium hypochlorite products for advice) to decontaminate operating room or autopsy surfaces with central nervous system or cerebral spinal fluid contamination from a diagnosed or suspected CJD patient.

• The contact time for the chemical used during this process should be 30 min–1 hour.
• Blot up the chemical with absorbent material and rinse the treated surface thoroughly with water.
• Discard the used, absorbent material into appropriate waste containment.

(Category II)

3. Use disposable, impervious covers to minimize body substance contamination to autopsy tables and surfaces. (Category IB)

1. Wear PPE appropriate for a surface decontamination and cleaning task. (Category IC)

2. Discard used PPE by using routine disposal procedures or decontaminate reusable PPE as appropriate. (Category IC)

A. Employers must launder workers’ personal protective garments or uniforms that are contaminated with blood or other potentially infectious materials. (Category IC)

A. Maintain the receiving area for contaminated textiles at negative pressure compared with the clean areas of the laundry in accordance with AIA construction standards in effect during the time of facility construction. (Category IC)

B. Ensure that laundry areas have handwashing facilities and products and appropriate PPE available for workers. (Category IC)

C. Use and maintain laundry equipment according to manufacturers’ instructions. (Category II)

D. Do not leave damp textiles or fabrics in machines overnight. (Category II)

E. Disinfection of washing and drying machines in residential care is not needed as long as gross soil is removed before washing and proper washing and drying procedures are used. (Category II)

A. Handle contaminated textiles and fabrics with minimum agitation to avoid contamination of air, surfaces, and persons. (Category IC)

B. Bag or otherwise contain contaminated textiles and fabrics at the point of use. (Category IC)

C. Covers are not needed on contaminated textile hampers in patient-care areas.

(Category II)

D. If laundry chutes are used, ensure that they are properly designed, maintained, and used in a manner to minimize dispersion of aerosols from contaminated laundry. (Category IC)

E. Establish a facility policy to determine when textiles or fabrics should be sorted in the laundry facility (i.e., before or after washing). (Category II)

A. If hot-water laundry cycles are used, wash with detergent in water ≥160°F (≥71°C) for ≥25 minutes. (Category IC)

B. No recommendation is offered regarding a hot-water temperature setting and cycle duration for items laundered in residence-style health-care facilities. (No recommendation/unresolved issue)

C. Follow fabric-care instructions and special laundering requirements for items used in the facility. (Category II)

D. Choose chemicals suitable for low-temperature washing at proper use concentration if lowtemperature (<160°F [<71°C]) laundry cycles are used. (Category II)

E. Package, transport, and store clean textiles and fabrics by methods that will ensure their cleanliness and protect them from dust and soil during interfacility loading, transport, and unloading. (Category II)

A. Do not conduct routine microbiological sampling of clean textiles. (Category IB)

B. Use microbiological sampling during outbreak investigations if epidemiologic evidence suggests a role for health-care textiles and clothing in disease transmission. (Category IB)

A. Use sterilized textiles, surgical drapes, and gowns for situations requiring sterility in patient care. (Category IB)

B. Use hygienically clean textiles (i.e., laundered, but not sterilized) in neonatal intensive care units. (Category IB)

C. Follow manufacturers’ recommendations for cleaning fabric products including those with coated or laminated surfaces. (Category II)

D. Do not use dry cleaning for routine laundering in health-care facilities. (Category II)

E. Use caution when considering the use of antimicrobial mattresses, textiles, and clothing as replacements for standard bedding and other fabric items. EPA has not approved public health claims asserting protection against human pathogens for treated articles. (Category II)

F. No recommendation is offered regarding using disposable fabrics and textiles versus durable goods. (No recommendation/unresolved issue)

A. Keep mattresses dry; discard them if they become and remain wet or stained, particularly in burn units. (Category IB)

B. Clean and disinfect mattress covers using EPA-registered disinfectants, if available, that are compatible with the cover materials to prevent the development of tears, cracks, or holes in the cover. (Category IB)

C. Maintain the integrity of mattress and pillow covers. (Category II)

D. Clean and disinfect moisture-resistant mattress covers between patients using an EPA-registered product, if available. (Category IB)

E. If using a mattress cover completely made of fabric, change these covers and launder between patients. (Category IB)

F. Launder pillow covers and washable pillows in the hot-water cycle between patients or when they become contaminated with body substances. (Category IB)

A. Follow manufacturers’ instructions for bed maintenance and decontamination. (Category II)

B. Change the polyester filter sheet at least weekly or as indicated by the manufacturer. (Category II)

C. Clean and disinfect the polyester filter sheet thoroughly, especially between patients, using an EPAregistered product, if available.

(Category IB)

D. Consult the facility engineer to determine the proper location of air-fluidized beds in negativepressure rooms. (Category II)

A. Minimize contact with animal saliva, dander, urine, and feces. (Category II)

B. Practice hand hygiene after any animal contact. (Category IB)

A. Avoid selection of nonhuman primates and reptiles in animal-assisted activities, animal- assisted therapy, or resident animal programs. (Category IB)

B. Enroll animals that are fully vaccinated for zoonotic diseases and that are healthy, clean, wellgroomed, and negative for enteric parasites or otherwise have completed recent antihelminthic treatment under the regular care of a veterinarian. (Category II)

C. Enroll animals that are trained with the assistance or under the direction of individuals who are experienced in this field. (Category II)

D. Ensure that animals are handled by persons trained in providing activities or therapies safely, and who know the animals’ health status and behavior traits. (Category II)

E. Take prompt action when an incident of biting or scratching by an animal occurs during an animalassisted activity or therapy. ()

F. Perform an ICRA and work actively with the animal handler prior to conducting an animal-assisted activity or therapy to determine if the session should be held in a public area of the facility or in individual patient rooms. (Category II)

G. Take precautions to mitigate allergic responses to animals. (Category II)

H. Use routine cleaning protocols for housekeeping surfaces after therapy sessions. (Category II)

I. Restrict resident animals, including fish in fish tanks, from access to or placement in patient-care areas, food preparation areas, dining areas, laundry, central sterile supply areas, sterile and clean supply storage areas, medication preparation areas, operating rooms, isolation areas, and PE areas. (Category II)

J. Establish a facility policy for regular cleaning of fish tanks, rodent cages, bird cages, and any other animal dwellings and assign this cleaning task to a nonpatient-care staff member. Avoid splashing tank water or contaminating environmental surfaces with animal bedding. (Category II)

A. Advise patients to avoid contact with animal feces and body fluids such as saliva, urine, or solid litter box material. (Category II)

B. Promptly clean and treat scratches, bites, or other wounds that break the skin. (Category II)

C. Advise patients to avoid direct or indirect contact with reptiles. (Category IB)

D. Conduct a case-by-case assessment to determine if animal-assisted activities or animal-assisted therapy programs are appropriate for immunocompromised patients.

(Category II)

E. No recommendation is offered regarding permitting pet visits to terminally ill immunosuppressed patients outside their PE units. (No recommendation/unresolved issue)

A. Avoid providing access to nonhuman primates and reptiles as service animals. (Category IB)

B. Allow service animals access to the facility in accordance with the Americans with Disabilities Act of 1990, unless the presence of the animal creates a direct threat to other persons or a fundamental alteration in the nature of services. (Category IC)

C. When a decision must be made regarding a service animal’s access to any particular area of the health-care facility, evaluate the service animal, the patient, and the health-care situation on a case-by-case basis to determine whether significant risk of harm exists and whether reasonable modifications in policies and procedures will mitigate this risk. (Category IC)

D. If a patient must be separated from his or her service animal while in the health-care facility:

• Ascertain from the person what arrangements have been made for supervision or care of the animal during this period of separation, and make appropriate arrangements to address the patient’s needs in the absence of the service animal.

(Category II)

A. Develop health-care facility policies to address the treatment of animals in human healthcare facilities. ()

B. When animals are treated in human health-care facilities, avoid treating animals in operating rooms or other patient-care areas where invasive procedures are performed (e.g., cardiac catheterization laboratories, or invasive nuclear medicine areas). (Category II)

C. Schedule the animal procedure for the last case of the day for the area, at a time when human patients are not scheduled to be in the vicinity. (Category II)

D. Adhere strictly to standard precautions. (Category II)

E. Clean and disinfect environmental surfaces thoroughly using an EPA-registered product in the room after the animal is removed. (Category II)

F. Allow sufficient ACH to clean the air and help remove airborne dander, microorganisms, and allergens. (Category II)

G. Clean and disinfect using EPA-registered products or sterilize equipment that has been in contact with animals, or use disposable equipment. (Category II)

H. If reusable medical or surgical instruments are used in an animal procedure, restrict future use of these instruments to animals only. (Category II)

A. Use animals obtained from quality stock, or quarantine incoming animals to detect zoonotic diseases. (Category II)

B. Treat sick animals or remove them from the facility. (Category II)

C. Provide prophylactic vaccinations, as available, to animal handlers and contacts at high risk. (Category II)

D. Ensure proper ventilation through appropriate facility design and location. (Category IC)

E. Keep doors to animal research rooms closed. (Category II)

F. Restrict access to animal facilities to essential personnel. (Category II)

G. Establish employee occupational health programs specific to the animal research facility, and coordinate management of postexposure procedures specific for zoonoses with occupational health clinics in the health-care facility. (Category IC)

H. Document standard operating procedures for the unit. (Category IC)

I. Conduct routine employee training on worker safety issues relevant to the animal research facility (e.g., working safely with animals and animal handling). (Category IC)

J. Use precautions to prevent the development of animal-induced asthma in animal workers. (Category IC)

A. Designate the following as major categories of medical waste that require special handling and disposal precautions:

• microbiology laboratory wastes [e.g., cultures and stocks of microorganisms];
• bulk blood, blood products, blood, and bloody body fluid specimens;
• pathology and anatomy waste; and
• sharps [e.g., needles and scalpels].

(Category II)

B. Consult federal, state, and local regulations to determine if other waste items are considered regulated medical wastes. (Category IC)

A. Develop a plan for the collection, handling, predisposal treatment, and terminal disposal of regulated medical wastes. (Category IC)

B. Designate a person or persons to be responsible for establishing, monitoring, reviewing, and administering the plan. (Category II)

A. Inform personnel involved in the handling and disposal of potentially infective waste of the possible health and safety hazards; ensure that they are trained in appropriate handling and disposal methods. (Category IC)

B. Manage the handling and disposal of regulated medical wastes generated in isolation areas by using the same methods as for regulated medical wastes from other patient-care areas. (Category II)

C. Use proper sharps disposal strategies. (Category IC)

D. Store regulated medical wastes awaiting treatment in a properly ventilated area that is inaccessible to vertebrate pests. Use waste containers that prevent the development of noxious odors. (Category IC)

E. If treatment options are not available at the site where the medical waste is generated, transport regulated medical wastes in closed, impervious containers to the on-site treatment location or to another facility for treatment as appropriate. (Category IC)

A. Treat regulated medical wastes by using a method (e.g., steam sterilization, incineration, interment, or an alternative treatment technology) approved by the appropriate authority having jurisdiction (AHJ) (e.g., states, Indian Health Service [IHS], Veterans Affairs [VA]) before disposal in a sanitary landfill. (Category IC)

B. Follow precautions for treating microbiological wastes (e.g., amplified cultures and stocks of microorganisms). (Category IC)

C. Biosafety levels 1 and 2 laboratories should develop strategies to inactivate amplified microbial cultures and stocks onsite by using an approved inactivation method (e.g., autoclaving) instead of packaging and shipping untreated wastes to an offsite facility for treatment and disposal. (Category II)

D. Laboratories that isolate select agents from clinical specimens must comply with federal regulations for the receipt, transfer, management, and appropriate disposal of these agents. (Category IC)

E. Sanitary sewers may be used for the safe disposal of blood, suctioned fluids, ground tissues, excretions, and secretions, provided that local sewage discharge requirements are met and that the state has declared this to be an acceptable method of disposal. (Category II)

A. When discarding items contaminated with blood and body fluids from VHF patients, contain these regulated medical wastes with minimal agitation during handling. (Category II)

B. Manage properly contained wastes from areas providing care to VHF patients in accordance with recommendations for other isolation areas (Category II)

C. Decontaminate bulk blood and body fluids from VHF patients using approved inactivation methods (e.g., autoclaving or chemical treatment) before disposal. ()

D. When discarding regulated medical waste generated during the routine (i.e., non-surgical) care of CJD patients, contain these wastes and decontaminate them using approved inactivation methods (e.g., autoclaving or incineration) appropriate for the medical waste category (e.g., blood, sharps, pathological waste). ()

E. Incinerate medical wastes (e.g., central nervous system tissues or contaminated disposable materials) from brain autopsy or biopsy procedures of diagnosed or suspected CJD patients. (Category IB)