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Guidelines for Outbreak Prevention, Control and Management in Supportive Living and Home Living Sites
- Millicent Daniels
- 3 years ago
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1 Ppulatin, Public and Abriginal Health Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites (Applicable t Ldges, Retirement Residences & Designated Supprtive Living sites - mre specifically Designated Assisted Living (DAL) sites.) Includes Influenza and Gastrintestinal Illness July 2014 Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
2 TABLE OF CONTENTS Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites Ppulatin, Public and Abriginal Health ACKNOWLEDGEMENTS INTRODUCTION DEFINITION OF TERMS AND GLOSSARY... 6 AHS ZONE PUBLIC HEALTH CONTACTS (REGULAR AND AFTER HOURS) SECTION I - GENERAL GUIDELINES FOR OUTBREAK MANAGEMENT PRINCIPLES OF OUTBREAK MANAGEMENT Surveillance Assessment Outbreak Identificatin Ntificatin Cmmunicatin Infectin Preventin and Cntrl Measures Specimen Cllectin Outbreak Cntrl Strategies Ptential Impact n Well-Being f Residents Mnitring Outbreak Status Declaring Outbreak Over ROLES AND RESPONSIBILITIES Public Health (Medical Officer f Health, Outbreak Respnse Lead) Supprtive Living/Hme Living Management and Staff External Partners (e.g. Cntracted Agencies, Cntracted Husing Owners/ Operatrs and Nn- Cntracted Husing Owners/Operatrs) Wrkplace Health and Safety (WHS) r Designate Prvincial Labratry (PrvLab) fr Public Health CASE AND OUTBREAK DEFINITIONS Table 1: Influenza-like-illness Table 2: Gastrintestinal (GI) Illness REPORTING A SUSPECTED OUTBREAK Table 3: Outbreak Identificatin & Ntificatin Algrithm (example) INITIAL INFECTION PREVENTION AND CONTROL (IPC) MEASURES Strict hand hygiene is the mst imprtant measure in preventing spread f infectins Restrictin f Symptmatic Clients/Residents Staffing (including vlunteers, students) Grup/Scial Activities and Nn-Resident Events Cmmunicatin Table 4: Rutine Practices and Additinal Precautins fr ILI Table 5: Rutine Practices and Additinal Precautins fr GI Illness OTHER RESPIRATORY ORGANISMS COMMONLY ASSOCIATED WITH ILI Table 6: Organisms Cmmnly Assciated with ILI ATTACHMENTS Attachment I.1 WHS Algrithm Attachment I.2 Outbreak Signage SECTION II CONFIRMED INFLUENZA OUTBREAK MANAGEMENT ILI CASE AND OUTBREAK DEFINITIONS OUTBREAK CONTROL STRATEGIES FOR CONFIRMED INFLUENZA Infectin Preventin and Cntrl Measures Administrative Measures Client/Resident Activities Restrictins at the Site Discharges/Transfers frm an Acute Care Site t an Outbreak Site Transfer frm an Outbreak Site t an Acute Care Site/Treatment Centre
3 Ppulatin, Public and Abriginal Health 1.7 Grup/Scial Activities and Other Events Nurishment Areas/Sharing f Fd Clients/Resident Attending Day Prgrams r CHOICE/C3/Bridges Visitrs Vlunteers Staff-related Outbreak Cntrl Measures ATTACHMENTS Attachment II.1 - Data Cllectin fr Respiratry Outbreak Management Attachment II.2 - PrvLab Respiratry Specimen Cllectin Guidelines Attachment II.3 - Admissin, Discharge and Transfers during an Outbreak (Sample Risk Assessment Wrksheet). 38 Attachment II.4 - Outbreak Antiviral Prphylaxis in SL/HL Sites Sample Wrksheet Attachment II.5 - MOH Ntice t all Unimmunized Wrkers - Exclusin frm Wrk (SAMPLE) SECTION III POST EXPOSURE ANTIVIRAL CHEMOPROPHYLAXIS GUIDELINES DURING INFLUENZA OUTBREAKS ATTACHMENTS Attachment III.1 Antiviral (Oseltamivir) Dsing Recmmendatins SECTION IV - GASTROINTESTINAL (GI) ILLNESS OUTBREAK MANAGEMENT GI ILLNESS CASE AND OUTBREAK DEFINITIONS OUTBREAK CONTROL STRATEGIES FOR GI ILLNESS OUTBREAKS Infectin Preventin and Cntrl Measures Strict hand hygiene Statement n Use f Alchl-based Hand Rub during Outbreaks Envirnmental Cleaning Recmmended Disinfectants Laundry Specimen Cllectin Administrative Measures Restrictins n Affected Units/Sites Client Resident Restrictins Staff Restrictins Visitr Restrictins Vlunteer Restrictins Admissin Restrictins Discharges/Transfers frm Acute Care t an SL/HL Outbreak Site Transfers frm an Outbreak Site t Acute Care/Treatment Centre Treatment within the Outbreak Facility Grup/Scial Activities and Other Events Clients/Residents attending Day Prgrams r CHOICE/C3/Bridges Fd Safety Precautins Management f "Relapse" Cases Pst-Outbreak Heightened Surveillance End-f-Outbreak Cleaning ATTACHMENTS Attachment IV.1 - Stl Specimen Cllectin fr GI Illness Outbreaks Attachment IV.2 - Data Cllectin fr GI Illness Outbreak Management Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
4 Ppulatin, Public and Abriginal Health ACKNOWLEDGEMENTS The AHS Outbreak Management Wrking Grup wuld like t acknwledge the wrk previusly dne by znes in develping their lcal utbreak management guidelines. Sme f the material cntained in this updated prvincial dcument has been taken frm varius guidelines frm acrss the Prvince. We acknwledge and thank individuals, prgram managers and leads, as well as Medical Officers f Health wh have cntributed their cmments and suggestins in the develpment f this dcument. The fllwing individuals are members f the riginal AHS Outbreak Management Wrking Grup: Wendy Lau Manager Outbreak Respnse and Plicy Supprt, AHS Carl Andersn Directr Quality Outcmes, Senirs Health, AHS Pamela Armstrng Infectin Cntrl Practitiner, Infectin Preventin & Cntrl (Supprtive Living) Calgary Zne, AHS Lance Hnish Envirnmental Public Health, AHS Jy Jaipaul Manager Ntifiable Disease, Educatin & Practice Develpment, AHS Dr. Judy MacDnald Medical Officer f Health, Cmmunicable Disease Cntrl, AHS Lindsay Nestib Supervisr Ntifiable Disease, Nrth Zne, AHS Chrystyna Tvstiuk Clinical Develpment Nurse, Cmmunicable Disease Cntrl, Edmntn Zne, AHS Onging feedback n this wrking dcument can be directed t any f the fllwing Reviewers: Reviewers 2014 Editin: Angela Jacbs Heather MacLaurin Karen Hpe Jy Jaipaul (Lead) Dr. Judy MacDnald Lance Hnish Lynn Rbertsn Acting Supervisr, Ntifiable Diseases AB Nrth, AHS Infectin Cntrl Practitiner, Integrated Hme Care, Persnal Care Hmes & Hspices, Calgary Zne, AHS Directr, IPC Urban Acute Hspitals Suth, AHS Manager, Ntifiable Disease, Educatin and Practice Develpment, AHS Medical Officer f Health, Cmmunicable Disease Cntrl, AHS Envirnmental Public Health, AHS Directr, Wrkplace Health and Safety Centres f Expertise, AHS Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
5 Ppulatin, Public and Abriginal Health INTRODUCTION The purpse f this dcument is t prvide current best-practice/evidence-based guidelines fr utbreak cntrl and management f respiratry and gastrintestinal (GI) illness in Supprtive Living and Hme Living (SL/HL) sites. This dcument is applicable t Ldges, Retirement Residences and Designated Supprtive Living sites, mre specifically Designated Assisted Living (DAL) sites. Althugh ther Designated Supprtive Living sites such as: persnal care hmes and grup hmes d nt fall under the scpe f these guidelines, Public Health is available t prvide cnsultatin t these ther sites as needed. Infectius disease utbreaks ccur year rund in different cngregate living settings including Ldges, Retirement Residences and Designated Supprtive Living (DSL) Sites. Persns living in cngregate living sites may be vulnerable t illness due t their advancing age as well as pre-existing medical cnditins. Effective utbreak management requires a multidisciplinary apprach and invlves individuals with different respnsibilities. Under the Alberta Cntinuing Care Health Services Standards [Standard 1.7 (a) and (b)], clients in these settings are t receive services prvided in a manner that reduces risk f transmissin f infectins and cmmunicable diseases. There shall be plicies and prcesses in place that address cmmunicable disease surveillance and reprting; and utbreak detectin and respnse. The ntificatin f utbreaks and ther infectius disease threats in Alberta is mandated under Sectin 26 f the prvincial Public Health Act, and each Medical Officer f Health is accuntable fr utbreak investigatin and management (Sectin 29). Early recgnitin f unusual clusters f illness and swift actins in respnse t these episdes are essential fr effective management f utbreaks. Public Health staff wrk cllabratively with Hme Living and Supprtive Living site management and staff, cntracted service prviders (agencies and husing peratrs) and nn-cntracted husing wners/peratrs t facilitate prmpt identificatin, reprting, specimen cllectin, and implementatin f apprpriate infectin preventin and cntrl measures t help minimize the impact f the utbreak. There are several partners that have an imprtant rle in utbreak management in Supprtive Living (SL) and Hme Living (HL) sites. It is recgnized that partner-specific rles may vary slightly frm site-t-site and Zne-t-Zne. Regardless f the type f setting r agencies invlved, the key utbreak preventin, cntrl and management activities utlined in this dcument must take place. Infrmatin is divided int 4 sectins: Sectin I: General Guidelines fr Outbreak Management. Sectin II: Cnfirmed Influenza Outbreak Management Sectin III: Antiviral Chemprphylaxis and Treatment Guidelines during Influenza Outbreaks Sectin IV: Gastrintestinal (GI) Illness Outbreak Management Nte: This is nt a cmprehensive infectin preventin and cntrl dcument. Only the minimum infectin cntrl strategies necessary fr managing utbreaks f respiratry r gastrintestinal illnesses are utlined here. Fr detailed infrmatin abut infectin preventin and cntrl, please cnsult with Public Health r the Infectin Cntrl Practitiner/designate in yur area. If cnsidering implementatin f utbreak cntrl measures beynd thse recmmended in this dcument, it is imprtant t cnsider the ptential impact n the well-being f residents. In the event f an utbreak r threat f an utbreak f an unusual infectius disease, such as a new influenza pandemic r any ther infrequent infectius disease, directin n best practices fr utbreak management will be prvided by the Medical Officer f Health (MOH) r designate and may extend beynd this dcument. While it is recgnized that Clstridium difficile and multi-drug resistant rganisms (e.g. MRSA, VRE) can be respnsible fr clusters r utbreaks, and that sme f the measures utlined in this prtcl may be applicable in preventing r cntrlling them, it is beynd the scpe f this dcument t include these rganisms, due t their unique epidemilgical prperties. Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
6 Ppulatin, Public and Abriginal Health DEFINITION OF TERMS AND GLOSSARY Acute Care - includes all Urban and Rural Hspitals, psychiatric facilities and Urgent Care Facilities. Care is prvided fr clients/residents with acute illnesses r injuries, r wh are recvering frm surgery. Admissin and transfer status - determined in cnsultatin with the Outbreak Respnse Lead and categrized as fllws: Open : The site/unit remains pen t all client/resident admissins, transfers and discharges. Restricted : Depending upn the circumstances and the infectius agent invlved, admissin and transfer status may range frm NO admissin, t selected client admissins, transfers and discharges as permitted under the directin f the Zne Medical Officer f Health (MOH) and in cnsultatin with the Outbreak Respnse Lead. This includes new clients/residents mving int the SL/HL site if feasible. This apprach is intended t be flexible allwing fr individual assessments t be made based n established criteria withut undue risk t residents/clients/prgram/system. AHS - Alberta Health Services Case Manager (CM) r Care Crdinatr - an AHS Supprtive Living/Hme Living Prgrams health care staff wh crdinates and integrates health care services within and acrss the health care system; facilitates access t and cntinuity f health services acrss the cntinuum f care (e.g., when a client is hspitalized r discharged frm ne cntinuing care service/prgram t anther; and assists clients/residents in accessing apprpriate services within the cmmunity. CHOICE (Cmprehensive Hme Optin f Integrated Care fr the Elderly)/C3/Bridges a cmprehensive cmmunity based mdel f crdinated care that helps t supprt lder peple wh are experiencing multiple, nging health prblems and/r thse requiring crdinatin f their care t remain independently in their wn hmes. Day Prgrams a cmmunity based prgram that is ffered in a variety f settings. They ffer assistance with health and supprt services as well as scial activities t supprt individuals t remain living in the cmmunity. Clients refer t individuals wh are receiving supprt services prvided/funded by AHS while residing in Supprtive Living r Hme Living sites. Clsed site - a site that has a fixed residential ppulatin with limited turnver r has units r wards that can be clsed. Cluster aggregatin f similar, relatively uncmmn events r diseases in space and/r time in amunts that are believed r perceived t be greater than culd be expected by chance. CNPHI Canadian Netwrk fr Public Health Intelligence Chrt persns gruped tgether. Cntact - any persn suspected t have been expsed t an infected persn r a cntaminated envirnment t a sufficient degree t have had the pprtunity t becme infected r clnized with an rganism. Cntact Precautins see Rutine Practices and Additinal Precautins, Tables 4 and 5 in Sectin 1. Designated Supprtive Living (DSL) a type f supprtive living husing ptin where AHS prvides funding fr health services (see Supprtive Living). Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
7 Ppulatin, Public and Abriginal Health Emplyee Health r Staff Health - in cntracted and nn-cntracted husing sites, the husing wner/peratr and the cntracted agency service prvider are legally bligated t meet Occupatinal Health and Safety (OHS) requirements fr their emplyees. Exclusin - a measure that prevents symptmatic/infected/susceptible emplyee frm wrking, until such time that the risk f transmissin f infectin fr clients/residents r emplyee is lw r minimal, as recmmended by Public Health r Wrkplace Health and Safety r designate. Expsure Investigatin Number (EI#) - a number assigned by the Prvincial Labratry t Public Health fr the purpse f tracking labratry specimens assciated t a specific event (e.g. a ptential utbreak) at a specific lcatin and time. External Partners - cntracted agencies, cntracted husing wners/peratrs and nn-cntracted husing wners/peratrs. Gastrintestinal (GI) illness -fr GI illness case and utbreak definitins, refer t Table 2 in Sectin I. Health care acquired r Health care assciated infectins - (frmerly knwn as nscmial infectins) are infectins that individuals acquire during the curse f receiving treatment fr ther cnditins within a health care setting. Hme Care - publicly-funded health care and supprt services prvided t eligible clients as gverned by the Alberta Hme Care Prgram Regulatins f the Public Health Act. These services are prvided t individuals living with frailty, disability, acute r chrnic illness living at hme r in a supprtive living setting as defined in the AH/AHS Crdinated Access t Publicly Funded Cntinuing Care Health Services: Directinal and Operatinal Plicy. Hme Living - the primary husing ptin fr persns wh are able t live independently and with minimal supprt services. Hme Living is the husing ptin fr persns wh chse t and wh are able t maintain active, healthy, independent living while remaining in their family hme as lng as pssible. In rder t supprt cntinued independent living, basic Hme Care services may be prvided by r funded thrugh AHS and/r the individual can purchase services frm anther agency. Fr the purpse f this dcument, Hme Living refers t sites that are cnsidered t be cngregate living (e.g. ldges r senir residences), where there is cmmunal dining and ther activities are crdinated fr the residents. Surce: adapted frm Alberta Senirs and Cmmunity Supprts (ASCS) Supprtive Living Framewrk, 2007 Health Care Wrkers (HCW) include physicians, nurses, allied health prfessinals and students with direct resident/client cntact emplyed by AHS, cntracted service prviders r husing site wner/peratrs. Infectin Cntrl Designate (ICD) - smene assigned t be accuntable fr IPC issues in a facility. IPC - Infectin Preventin and Cntrl ILI - influenza-like-illness. Fr ILI case and utbreak definitins, refer t Table 1 in Sectin 1. MOC - Micrbilgist n-call, Prvincial Labratry fr Public Health. MOH - Medical Officer f Health. MOH designate smene in Public Health designated by the Zne MOH t assist with decisin making when there are requests by sites t deviate frm admissin/transfer guidelines described in this dcument. The MOH may designate this rle t the Zne Outbreak Respnse Lead r ther Public Health persnnel. Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
8 Ppulatin, Public and Abriginal Health Occupatinal Health (OH) and Safety (OHS) - OH r OHS staff r designated persnnel respnsible fr emplyee health in an agency, rganizatin r site. In AHS, Wrkplace Health Safety (WHS) is respnsible fr the health and safety f their emplyees. In sites where there is n OHS/WHS/Emplyee Wellness, the wner/peratr/cntracted agency prvider is respnsible fr the ccupatinal health and safety f their emplyees. Outbreak - the perceived r true ccurrence f mre cases f a cmmunicable disease than expected in a given area r amng a specific grup f peple ver a particular perid f time. Outbreak Management Team (OMT) - a grup f key individuals, including but nt limited t, representatives frm Public Health, Infectin Preventin and Cntrl (IPC) r Infectin Cntrl Designate (ICD), Wrkplace Health Safety (WHS), SL/HL management and staff, cntracted service prviders (e.g. cntracted agencies, cntracted husing prviders, nn-cntracted husing wners/peratrs) t ensure a timely and crdinated respnse t a suspect r cnfirmed utbreak. Cmpsitin f the Outbreak Management Team will depend n established partnerships within the znes and disease and type f site. Outbreak Respnse Lead - a Public Health Nurse specialized in Cmmunicable Diseases r an Envirnmental Health Officer assigned t be the Lead fr the specific utbreak investigatin at the Zne level wrking clsely with the Zne MOH. PHAC - Public Health Agency f Canada PPE - Persnal Prtective Equipment PrvLab - Prvincial Labratry fr Public Health Public Health - fr the purpse f this dcument, Public Health encmpasses the Medical Officer f Health (MOH), Outbreak Respnse Lead r a Public Health designate wh prvides cnsultatin and leadership in utbreak investigatins ccurring in the cmmunity and in public r healthcare facilities. Relapse Case - GI illness cases frequently relapse, i.e. experience nset f vmiting r diarrhea after being asymptmatic fr 24 t 48 hurs. The relapse is likely due t malabsrptin during an existing nrvirus infectin rather than being a new infectin. Residents - tenants wh reside in Supprtive Living r Hme Living sites, but nt receiving supprt services prvided r funded by AHS. Service Prvider Agencies - agencies that prvide cntracted health and supprt services t clients/residents in their wn hmes r in Hme Living and Supprtive Living sites. Each Zne has a list f private agencies they cntract services with. Supprtive Living - a hme-like setting where peple can maintain cntrl ver their lives while als receiving the supprt they need. The buildings are specifically designed with cmmn areas and features t allw individuals t age in place. Building features include private space and a safe, secure and barrier-free envirnment. Supprtive living prmtes residents independence and aging in place thrugh the prvisin f services such as 24-hur mnitring, emergency respnse, security, meals, husekeeping, and lifeenrichment activities. Publicly-funded persnal care and health services are prvided t supprtive living residents based n assessed unmet needs. Surce: ASCS Supprtive Living Framewrk, Designated Supprtive Living Level 3 - Assisted Living (SL3) ptin where AHS cntrls access t a specific number f beds accrding t a cntractual agreement between AHS and the peratr. Twenty-fur hur n-site scheduled and unscheduled persnal care and supprt services are Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
9 Ppulatin, Public and Abriginal Health prvided by Health Care Aides. Prfessinal health services including Registered Nurse services with 24 hur n-call availability, case management and ther cnsultative services are prvided thrugh AHS. Designated Supprtive Living Level 4 - enhanced Assisted Living (SL4) ptin where AHS cntrls access t a specific number f beds accrding t a cntractual agreement between AHS and the peratr. Twenty-fur hur n-site scheduled and unscheduled prfessinal and persnal care, and supprt services are prvided by Licensed Practical Nurses and Health Care Aides. Prfessinal health services including Registered Nurse services with 24 hur n-call availability, case management and ther cnsultative services are prvided thrugh AHS. Designated Supprtive Living Level 4 Dementia - enhanced Assisted Living Dementia (SL4-D) ptin prvides services fr individuals with mderate dementia that will prgress t later stages r ther frms f cgnitive impairment wh require a secure therapeutic envirnment. Twenty-fur hur n-site scheduled and unscheduled prfessinal and persnal care, and supprt services are prvided by Licensed Practical Nurses and Health Care Aides. Prfessinal health services including Registered Nurse services with 24 hur n-call availability, case management and ther cnsultative services are prvided thrugh AHS. Surce: AHS Admissin Guidelines fr Publicly Funded Cntinuing Care Living Optins, 2010 Transitin Services - within urban AHS (Edmntn and Calgary), Transitin Services crdinate client mvement between different levels f care including but nt limited t Hme Care services, and placements in Supprtive Living facilities. In ther jurisdictins in AHS, this wrk is carried ut by Hme Care crdinatrs r Placement crdinatrs. TS Thrat Swab UTM Universal Transprt Medium VOC - Virlgist n-call, Prvincial Labratry fr Public Health Wrkplace Health and Safety (WHS) - designated persnnel respnsible fr emplyee health and safety in AHS facilities. In nn-ahs sites, Emplyee Health r the Site Management r the Site Medical Leader may fill this rle. Zne Outbreak Respnse Lead see Outbreak Respnse Lead. Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
10 Ppulatin, Public and Abriginal Health AHS ZONE PUBLIC HEALTH CONTACTS (REGULAR AND AFTER HOURS) AHS ZONE Zne 1 Suth Zne 2 Calgary Zne 3 Central Zne 4 Edmntn Zne 5 Nrth GEO- GRAPHIC SERVICE AREA West East REGULAR HOURS Business hurs may vary slightly frm Zne t Zne, but are typically 8:30 am 4:30 pm Cmmunicable Disease Cntrl Envirnmental Public Health Cmmunicable Disease Cntrl Envirnmental Public Health Cmmunicable Disease Cntrl Envirnmental Public Health Cmmunicable Disease Cntrl Envirnmental Public Health Cmmunicable Disease Cntrl Envirnmental Public Health Cmmunicable Disease Cntrl Envirnmental Public Health CDC Intake EPH CDC Lead CDC Intake EPH CDC Lead CDC Intake EPH Disease Cntrl CDC Intake 24 Hur Intake AFTER HOURS Chink Reginal Hspital Switchbard MOH On-Call CDC On-Call CDC Intake Pager EPH CDC Intake EPH MOH On-Call Public Health On- Call NOTE: Cnfirm utbreak reprting prcedures and business hurs in the Zne in advance f each utbreak seasn. Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
11 Ppulatin, Public and Abriginal Health. SECTION I - GENERAL GUIDELINES FOR OUTBREAK MANAGEMENT 1. Principles f Outbreak Management 1.1 Surveillance Cnduct nging surveillance and mnitring fr unusual clusters f illness in clients/residents and staff, and identificatin f pssible utbreaks. Surveillance takes place prir t, during and after utbreaks. 1.2 Assessment Assess individual cases t cnfirm that the illness meets the ILI r GI illness case definitins utlined in this dcument; see Tables 1 and Outbreak Identificatin Cnfirm that the utbreak definitin criteria utlined in this dcument are met; see Tables 1 and Ntificatin Fllw the facility established internal utbreak ntificatin prtcls t reprt utbreaks t the AHS Zne Public Health Office see AHS Zne Public Health Cntacts n previus page. 1.5 Cmmunicatin Cmmunicate amng partners, agencies and frnt line staff regarding the utbreak and the initiatin f an investigatin by Public Health, including ther facilities at the site (e.g. child care facility). 1.6 Infectin Preventin and Cntrl Measures Implement initial infectin preventin and cntrl measures including hand hygiene, respiratry etiquette, PPE, and islatin f symptmatic clients/residents. 1.7 Specimen Cllectin Cllect specimens as apprpriate and as recmmended by Public Health. 1.8 Outbreak Cntrl Strategies Implement utbreak cntrl strategies as utlined in this dcument: a. authrize and deply additinal resurces t manage the utbreak b. restrict symptmatic residents/clients t their rms (with dedicated bathrm where pssible, meal tray service in rm, etc.) c. cntinue implementing apprpriate infectin cntrl measures d. apply site-level restrictins as recmmended by Public Health (restrict admissins, cancel grup activities, pst utbreak signage, infrm visitrs, etc.) e. enhance envirnmental cleaning and disinfectin f frequently tuched envirnmental surfaces and equipment. Nte: equipment shuld be cleaned and disinfected nly with a prduct listed in and fllwing the prcedures utlined in the manufacturer s directins fr that equipment. f. manage staff as utlined in this dcument g. initiate antiviral prphylaxis as recmmended by Public Health in the event f a cnfirmed influenza utbreak 1.9 Ptential Impact n Well-Being f Residents If cnsidering implementatin f utbreak cntrl measures beynd thse recmmended in this dcument, it is imprtant t cnsider the ptential impact n the well-being f residents. Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
12 Ppulatin, Public and Abriginal Health 1.10 Mnitring Outbreak Status Cmmunicate and track utbreak status by cmpleting and submitting daily case listings. Discuss weekend and hliday case listing reprting with Public Health Declaring Outbreak Over Public Health will declare utbreak ver and lift site restrictins. Fllwing an utbreak, key prgram leads need t review and evaluate their rle in the utbreak management and revise internal prtcls where necessary fr imprvement. A debriefing may be called by any member f the Outbreak Management Team (OMT) t address utbreak management issues. Depending n type and scale f the utbreak, a summary reprt including backgrund, details f the investigatin, results and recmmendatins may be written by a member f the OMT and shared with internal/external partners. Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
13 Ppulatin, Public and Abriginal Health 2. Rles and Respnsibilities Everyne has a rle in utbreak preventin, cntrl and management in Supprtive Living and Hme Living sites. Regardless f the type f setting r agencies invlved, a crdinated team apprach with internal and external partners is essential when managing utbreaks in these sites. Depending n the partnerships already established within AHS Znes, the rles and respnsibilities may be assigned t different individuals with varying titles and psitins. It is critical that everyne invlved has a clear understanding f their respective rle during an utbreak. It is als imprtant that thse invlved in each Zne wrk tgether within their respective area t frmalize utbreak management rles and respnsibilities fr SL/HL cntracted and nn-cntracted husing sites. Public Health staff will be available t wrk with all identified grups and assist with the management f the utbreak. Mst site utbreaks are caused by seasnal respiratry viruses r seasnal nrvirus. When illness is identified early and apprpriate cntrl measures are implemented in a timely manner, these utbreaks are generally cntrlled quickly. Once an utbreak is identified, an Outbreak Management Team (OMT) may be cnvened t ensure a timely and crdinated respnse t cntrl the utbreak. The OMT usually cnsists f a Zne Public Health Outbreak Respnse Lead, alng with representatives frm AHS Supprtive Living/Hme Living management and staff wh are assigned t r may be wrking at the site, a pharmacy representative (as necessary and as available), the cntracted agency supervisr and/r husing peratr/wner (e.g. ldge r DSL). The size and cmpsitin f the OMT t a large extent will depend n the disease, size and type f site invlved and wrking relatinships that are in place. 2.1 Public Health (Medical Officer f Health, Outbreak Respnse Lead): Sets the standard f practice fr cmmunicable disease surveillance and ntificatin in relatin t utbreak investigatin and management. Prvides cnsultatin n suspected clusters f illness r utbreaks. Determines the need t initiate an utbreak investigatin. Requests infrmatin frm their designated cntact at the Facility (e.g. site Administratr, IPC, ICD) t meet zne-specific Public Health requirements fr utbreak management. Wrks cllabratively with AHS SL/HL management and staff and husing wners/peratrs t direct the investigatin. Facilitates labratry testing by recmmending the type f specimens t be cllected and testing required. Obtains an Expsure Investigatin number (E.I. #) frm PrvLab fr the tracking f all utbreak related specimens and samples and cmmunicate t the site. Nte: Generally, if an EI is already pen fr an utbreak in a facility, a new EI number may nt be necessary fr management f new symptmatic cases in the same utbreak facility, if the new illness cases: Are symptmatic with the same syndrme (e.g. ILI r GI illness) as previusly identified cases, and Are epidemilgically linked t previusly identified cases (e.g. same unit, shared care staff, etc.), and Have symptm nset within ne maximum incubatin perid f latest symptm nset in previusly identified cases (sme exceptins t this guideline may apply, and shuld be determined n a case-by-case basis). Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
14 Ppulatin, Public and Abriginal Health Advises n apprpriate utbreak cntrl measures t be implemented including admissin/transfer status (pen r restricted), immunizatin, chemprphylaxis if apprpriate, and recmmendatins fr management f staff. Crdinates nging surveillance and mnitring during the utbreak. Sends ut utbreak ntificatin and alerts as apprpriate; and if relevant, psts prvincial and natinal public health alerts n Canadian Netwrk fr Public Health Intelligence (CNPHI). Zne MOH/designates shuld cnsider sharing timely utbreak status reprts with Acute Care, Facility Living and/r Supprtive Living partners in their Zne (including nn-ahs facility peratrs), as apprpriate. It must be ensured that any shared reprts cmply with AHS crprate plicies fr cllectin, access, use, retentin and disclsure f persnal and health infrmatin under the care and cntrl f AHS. Reprts utbreaks t Alberta Health (AH) and t AHS Senir Public Health Executives as established within Zne prtcls. Respnds t media inquiries in cnsultatin with AHS Cmmunicatins Media Advisr. Tracks all utbreak samples and clses EI# when utbreak is declared ver. Lifts site restrictins when apprpriate. Arranges and/r participates in debriefing sessins as necessary. 2.2 Supprtive Living/Hme Living Management and Staff (AHS SL levels 3/4 & Hme Care staff): Supprts and encurages the annual seasnal influenza immunizatin f patients, staff and vlunteers. Ensures that SL/HL staff and external partners (cntracted agencies, cntracted husing wners/peratrs and nn-cntracted husing wners/peratrs) are familiar with current guidelines frm Public Health regarding utbreak preventin, management, and cntrl strategies. Reviews and updates internal prcesses/tls/resurces used fr utbreak management t ensure they are in alignment with this dcument. Prvides current lists f facilities (including addresses and key cntact infrmatin) t zne Public Health. Encurages regular visitrs and vlunteers t receive annual influenza immunizatin. Facilitates, if pssible, Hme Care and Supprtive Living clients persnal physicians prvisin f annual standing rders fr antiviral chemprphylaxis fr their clients/residents, fr use in the event f a cnfirmed influenza utbreak. Nte: in sme sites, this is dne in cllabratin with external partners. Prvides Public Health staff with a current list f cntracted and nn-cntracted (if available) SL/HL sites in the Zne, with cntact names and phne numbers. In preparatin fr influenza seasn, cmpiles a list f AHS SL/HL clients (include names, cntact and ther pertinent infrmatin) t be used in the event f an utbreak fr implementing antiviral prphylaxis (example n Attachment II.4). Liaises with AHS WHS t ensure staff have been fit tested if, accrding t a cmpleted hazard assessment, hazards exist that wuld be addressed by apprpriate PPE. Ensures prper use and adequate supplies f PPE (fr their staff) as per AHS infectin preventin and cntrl guidelines. Maintains nging mnitring fr unusual clusters f illness in clients/residents and AHS staff t facilitate early recgnitin f cases, and identificatin f a pssible utbreak at the site. Assesses that illness in individual cases meets the ILI r GI illness case definitins utlined in this dcument (Tables 1 and 2). Ntifies Public Health prmptly fllwing established internal prtcls, when an utbreak is suspected at a site and maintain liaisn with PH thrughut the curse f the utbreak. Wrks cllabratively with external partners and Public Health t facilitate utbreak investigatins and implement apprpriate initial infectin cntrl measures immediately. It is nt necessary t wait until the etilgy is cnfirmed. Facilitates implementing recmmended utbreak cntrl strategies as indicated in this dcument. Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
15 Ppulatin, Public and Abriginal Health Crdinates the cllectin f clinical specimens as apprpriate, under the directin f Public Health. Identifies SL/HL representatives t the OMT. Wrks cllabratively with external partners t ensure nging mnitring and surveillance at the site t identify new case defining illness in clients/residents and staff. Wrks cllabratively with external partners t prvide Public Health with daily status updates n the utbreak (see Attachment II.1 in Sectin II and Attachment IV.2 in Sectin IV fr data elements required fr reprting t Public Health) Maintains clear and cnsistent channels f cmmunicatin within the utbreak site as per established Zne practices. Liaises with physicians and external partners as necessary. Discusses/apprves need fr additinal hurs/shifts with the cntractr. Prvides services t care and treat clients/residents in place. Authrizes additinal prfessinal and supprt services, as needed, t manage the utbreak. (additinal services may include such things as: assessment/mnitring f symptmatic clients/residents, laundry, bathing, meal tray delivery, envirnmental cleaning) Tracks additinal services prvided t symptmatic clients/residents as per AHS SL/HL guidelines. Cmmunicates utbreak status t ther prgrams that may be impacted by the Outbreak (i.e. CHOICE/C3/Bridges r Day Prgrams). Mnitrs and reprts pssible utbreak related AHS SL/HL staff illness and initiate cnsultatin with AHS WHS. Arranges and/r participates in debriefing sessins as necessary. 2.3 External Partners (e.g. Cntracted Agencies, Cntracted Husing Owners/ Operatrs, Nn- Cntracted Husing Owners/Operatrs): Ensures site staff are familiar with current Public Health guidelines regarding utbreak preventin, management, and cntrl strategies. Prmtes annual influenza immunizatin fr staff and clients/residents. Encurages regular visitrs and vlunteers t receive annual influenza immunizatin. In preparatin fr influenza seasn each fall, cmpiles r updates a master list f all individuals living in the building (include names, rm numbers and cntact infrmatin if available) t be used in the event f an utbreak fr implementing antiviral prphylaxis. Where there are AHS clients, AHS nursing staff wuld maintain medical infrmatin n these clients. Ensures staff are N95 mask fit tested as per OHS r Health and Safety regulatins. Ensures prper use and adequate supplies f PPE (fr their staff) as per AHS infectin preventin and cntrl guidelines. Maintains nging mnitring fr unusual clusters f illness in clients/residents and staff t facilitate early recgnitin f cases, and identificatin f a pssible utbreak at the site. Ntifies Public Health r AHS SL/HL staff prmptly fllwing established internal prtcls, when an utbreak is suspected at a site and maintain liaisn with PH thrughut the curse f the utbreak. (Table 3 is ne example f the prcess fr reprting a suspected utbreak.) Wrks cllabratively with Public Health, AHS SL/HL staff and husing staff t cntrl the utbreak. Implements apprpriate initial infectin cntrl measures immediately as described in this dcument and as recmmended by Public Health. It is nt necessary t wait until etilgy is cnfirmed. Wrks cllabratively with AHS SL/HL staff t crdinate the cllectin f clinical specimens as apprpriate under the directin f Public Health. Identifies external partner representatives t the OMT, if an OMT is established. Wrks cllabratively with AHS SL/HL staff t prvide Public Health with status updates f utbreak activity within the site, including daily submissin f accurate updated illness data related t the utbreak (see Attachment II.1 in Sectin II and Attachment IV.2 in Sectin V fr data elements required fr reprting t Public Health). Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
16 Ppulatin, Public and Abriginal Health Ensures clear and cnsistent channels f cmmunicatin are established t ensure that site staff have all the current recmmendatins t manage the utbreak Liaises with physicians and AHS SL/HL staff as necessary. Maintains peratins and prvides care and services fr clients/residents during utbreaks. Identifies the need fr additinal hurs/shifts with AHS SL/HL Obtains authrizatin frm AHS SL/HL fr additinal services as required*. *Nte: External partners may request additinal hurs/shifts/services frm AHS SL/HL as necessary t help manage an utbreak. Prvides additinal supprt services, as authrized, t assist with symptmatic clients/residents and increase supprt services t care and treat in place. (Additinal services may include such things as: laundry, bathing, meal tray delivery, envirnmental cleaning) Prvides cleaning agents necessary fr apprpriate envirnmental cleaning and disinfecting, and husekeeping during an utbreak. Ensures husing site emplyees are advised f the utbreak and that they are wrking as a team with health care persnnel t cntrl the utbreak. Assists with effrts t keep symptmatic clients/residents in their rms. Cmmunicates, as necessary, with clients/residents and their families regarding utbreak management requirement/prtcls. Mnitrs and reprts staff illness suspected t be related t the utbreak as sn as pssible using established internal reprting prtcls and ensures that AHS recmmended exclusin guidelines are fllwed fr all staff under their supervisin. Arranges and/r participates in debriefing sessins as necessary Wrkplace Health and Safety (WHS) r Designate Prmtes and implements annual influenza immunizatin fr staff. Develps, reviews and updates internal prtcls fr management f staff during an utbreak. Supprts illness assessment and surveillance f staff frm utbreak site. Maintains dcumentatin n HCWs health and immunizatin status and prvides the Unit Manager with a list f staff with reprted immunizatin recrds. In a declared utbreak, identifies HCWs wh may be at risk f expsure and infectin (i.e. unimmunized). Supprts recmmendatins frm WHS Medical Cnsultant r Zne MOH, and facilitates cmmunicatin with staff. Prvides infrmatin t individual staff abut wrk restrictins. Fr AHS Staff, see algrithm (Attachment I.1) Assesses HCW s suitability fr return t wrk. Maintains clse cmmunicatin with Frnt line Unit/Site Manager and IPC/ICD including HCWs wrk restrictins/return t wrk assessments. Participates in OMT meetings when indicated Prvincial Labratry (PrvLab) fr Public Health Designates labratry cntact (i.e. micrbilgist r virlgist) fr each utbreak. Assigns EI# t facilitate specimen tracking. Prvides cnsultatin t Public Health n specimen type and testing apprpriate fr the utbreak, including gentyping. Prvides specimen cllectin supplies as required. Ensures Public Health receive results f utbreak specimens. Tracks all utbreak samples. Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
17 Ppulatin, Public and Abriginal Health 3. Case and Outbreak Definitins Early recgnitin f suspected utbreaks is imprtant. Supprtive Living/Hme Living staff, cntracted agency staff and husing site staff shuld cnduct nging surveillance and use the fllwing definitins fr early identificatin f unusual clusters f influenza-like r gastrintestinal (GI) illness and/r utbreaks. The fllwing are Natinal and Prvincial case and utbreak definitins. In practice, each Zne shuld fllw the recmmendatins f their Zne MOH t facilitate early recgnitin and reprting f unusual ILI activity and implementing apprpriate infectin cntrl measures. Sme Znes may chse t use the mre sensitive case definitin. Table 1: Influenza-like-illness (PHAC FluWatch definitin, Seasn) ILI Case Definitin* ILI Outbreak Definitin Acute nset f respiratry illness with fever and cugh, AND with ne r mre f the fllwing: sre thrat jint pain muscle aches severe exhaustin In children under age 5, gastrintestinal symptms may als be present. In persns under age 5 r 65 and lder, fever may nt be prminent. 2 r mre cases f ILI within a 7 day perid, with a cmmn epidemilgical link (e.g. same lcatin r same care giver, and evidence f transmissin within the unit r site), f which at least ne is a labratry cnfirmed case. ** *It is recgnized that the definitins fr influenza-like illness (ILI) in this dcument and the Pint f Care Risk Assessment ( differ slightly. These definitins serve different purpses, the frmer fr ppulatin surveillance and the latter as a means fr staff t assess the infectius risk f clients/residents t themselves and thers and implement apprpriate preventive measures. Therefre althugh slightly different, the discrepancy is valid and acceptable. ** In practice, AHS uses an adapted ILI utbreak definitin whereby there is n requirement fr a labratry cnfirmed case (see Sectin II). Table 2: Gastrintestinal Illness Gastrintestinal (GI) Illness Case Definitin GI Illness Outbreak Definitin At least ONE f the fllwing criteria must be met and nt be attributed t anther cause (e.g. Clstridium difficile diarrhea, medicatin, laxatives, diet r prir medical cnditin etc): 2 r mre episdes f diarrhea (i.e. lse r watery stls) in a 24 hur perid, abve what is nrmally expected fr that individual OR 2 r mre episdes f vmiting in a 24 hur perid OR 1 r mre episdes f vmiting AND diarrhea in a 24 hur perid OR Psitive stl culture f a knwn enteric pathgen AND at least ne symptm cmpatible with a GI illness infectin i.e. nausea, vmiting, diarrhea, abdminal pain r tenderness OR One episde f bldy diarrhea 2 r mre cases (with initial nset within ne 48 hur perid) f GI illness with a cmmn epidemilgical link (e.g. same lcatin r same care giver, and evidence f health care acquired transmissin within the site). Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
18 Ppulatin, Public and Abriginal Health 4. Reprting a Suspected Outbreak Prmpt reprting allws fr early identificatin and implementatin f interventins t interrupt transmissin, thereby reducing mrbidity and mrtality. In rder t initiate an utbreak investigatin prmptly, reprt any suspect cases f ILI r GI illness (see definitins in Tables 1 and 2) t Public Health using established prtcls within yur Zne. Table 3 is ne example f the prcess fr reprting a suspected utbreak. Table 3: Outbreak Identificatin & Ntificatin Algrithm (example) Fr details f utbreak management and cntrl strategies refer t: Sectin II: Cnfirmed Influenza Outbreak Management Sectin III: Antiviral Chemprphylaxis and Treatment Guidelines during Influenza Outbreaks Sectin IV: Gastrintestinal (GI) Illness Outbreak Management Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
19 Ppulatin, Public and Abriginal Health 5. Initial Infectin Preventin and Cntrl (IPC) Measures Based n the type f illness presenting (ILI r GI), implement the initial IPC measures utlined belw as sn as an utbreak is suspected t help reduce the spread f infectin. D nt wait until the causative agent is identified. Rutine practices help prevent the spread f infectin and reduce the pssibility that health care wrkers will sustain accidental expsure t infectius rganisms. Rutine Practices are used fr every patient/client, every time regardless f their diagnsis r infectius status. Additinal precautins such as drplet and cntact precautins are determined and implemented by the presenting symptms (refer t Tables 4 and 5). Sites/flrs/wings experiencing an utbreak must implement additinal IPC precautins t the extent that resurces are available (e.g. private rms with washrm facilities, physical layut f care units, husekeeping prcedures and staffing patterns). 5.1 Strict hand hygiene is the mst imprtant measure in preventing spread f infectins fr bth staff and clients/residents. Frequent and thrugh hand hygiene shuld be perfrmed by bth staff and patients/clients/residents. Hand hygiene is required befre and after prviding care t patients/clients/residents and after tuching used patient care equipment r siled envirnmental surfaces. Assist the patient/client/resident with hand hygiene if required. Hand hygiene shuld be perfrmed in accrdance with the AHS Hand Hygiene Plicy and Prcedure which prvides directin n prduct selectin, lcatin, and use. Alchl based hand rubs cntaining a minimum f 70% alchl are as effective as sap and water when hands are nt visibly siled. They shuld be clearly labeled with a DIN, r claim as being effective and used prir t expiry date. Wash hands with sap and water when: Hands are visibly siled After remval f glves when caring fr a client that has diarrhea and/r vmiting. Glve use is nt a substitute fr hand hygiene; hand washing is needed after glve remval. 5.2 Restrictin f Symptmatic Clients/Residents When pssible, symptmatic clients/residents shuld be advised t stay in their rms with meals served in their rms as recmmended by Public Health. See the apprpriate sectins f this dcument fr specific infrmatin n resident restrictins Sectin II Cnfirmed Influenza and Sectin IV GI Illness. If this is nt practical, symptmatic clients/residents shuld be restricted t their wn flrs and avid cntact with thers in cmmn living areas (e.g. dining rm, scial areas) as much as pssible. Medically necessary appintments shuld be kept unless the client is nt physically able t attend. Discussins shuld ccur between the respnsible staff at the husing site and the health care prfessinals invlved in the appintment t ensure precautins can be taken in transit and at the appintment site. Nte: Clients/residents wh are nt symptmatic are nt restricted frm nrmal daily activities. 5.3 Staffing (including vlunteers, students) Exclude symptmatic staff frm wrking. Specific recmmendatins fr staff exclusins during cnfirmed influenza utbreaks can be fund in Sectin II and fr GI illness utbreaks in Sectin IV. Chrt r assign staff t care fr asymptmatic residents/clients befre symptmatic residents/clients Cnsider minimizing mvement f staff, students r vlunteers between units/flrs, especially if sme units are nt affected If pssible, during initial investigatins f ILI (influenza like illness,) assign staff that have been immunized against influenza t care fr symptmatic clients/residents Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
20 Ppulatin, Public and Abriginal Health Ideally, staff assigned t husekeeping duties shuld nt be invlved in fd preparatin r fd service during utbreaks. If this is nt pssible, ensure meticulus attentin is paid t IPC practices 5.4 Grup/Scial Activities and Nn-Resident Events When a GI illness utbreak investigatin has been initiated, Public Health advises that: All previusly scheduled resident scial and special events/activities (e.g. special hliday meal celebratins, birthday parties, entertainers, schl grups, cmmunity presentatins) are cancelled/pstpned effective immediately n all affected units/sites r entire facility (as applicable) until the utbreak is declared ver by Public Health. As a general principle, it is als recmmended that nn-resident events previusly bked fr areas in the utbreak facility (e.g. meetings) als be cancelled r pstpned. When an ILI utbreak investigatin has been initiated, Public Health will advise if similar restrictins are t be implemented. Cnsult Public Health with any questins abut grup/scial activities during utbreaks. 5.5 Cmmunicatin Use utbreak signage t ntify and infrm staff and visitrs that an utbreak is being investigated in the facility. Encurage visitrs t pstpne visiting if pssible. Visitrs wh chse t visit shuld be advised f ptential risk f expsure, and t practice gd hand hygiene, visit ne (1) client/resident nly and exit the site immediately after their visit. Ensure individuals visiting symptmatic clients/residents are wearing apprpriate PPE. Demnstrate fr visitrs hw t utilize PPE apprpriately. Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
21 Ppulatin, Public and Abriginal Health Table 4: Rutine Practices and Additinal Precautins fr ILI Cnduct Pint f Care Risk Assessment check AHS website (search: infectin cntrl ) fr mst current recmmendatin. Implement Cntact and Drplet Precautins in additin t Rutine practices when caring fr symptmatic clients/residents t cntrl the spread f respiratry viruses such as influenza: Client/resident Placement and Signage - Single-rm preferred - maintain a distance f tw (2) metres between clients/residents sharing a rm Mask - Wear prcedure/surgical mask fr any encunter with a client/resident wh has, r is suspected f having ILI. - N95 Respiratr (fit-tested) fr aersl generating medical prcedures (AGMP) Client/resident underging an aersl generating medical prcedures (AGMP) i.e. BiPAP, intubatin, manual ventilatin, pen endtracheal suctining, CPR, brnchscpy, sputum inductin, nebulized therapy, surgery and autpsy, trachestmy care, chest physical therapy, naspharyngeal aspirate, high-frequency scillatry ventilatin Eye Prtectin - When a mask r N95 respiratr is wrn, eye prtectin r face shields shuld als be wrn fr all client/resident care activities - Persnal (prescriptin) eyewear des nt prvide adequate prtectin Gwn - Fr direct cntact f clthing r frearms with client/resident r their envirnment Glves - Wear clean nn-sterile glves fr direct cntact with resident r resident's envirnment Hand Hygiene - Befre cntact with a client/resident r client/resident s envirnment including but nt limited t: putting n (dnning) persnal prtective equipment; befre entering a client/resident s rm; and, befre prviding client/resident care. - Befre a clean r aseptic prcedure including but nt limited t: wund care; handling intravenus devices; handling fd; r, preparing medicatins. - After expsure (r risk f expsure) t bld and/r bdy fluids including but nt limited t: when hands are visibly siled; fllwing remval f glves. - After cntact with a client/resident r client/resident s envirnment including but nt limited t: remving (dffing) persnal prtective equipment; leaving a client/resident s envirnments and after handling client/resident care equipment. Client/resident Care Equipment - Dedicate t this client/resident r clean and disinfect after use Client/resident Transprt - Transprt fr essential purpses nly - Client/residents wear mask during transprt - Ntify receiving department AHS PPE Dnning and Dffing psters (check AHS website) Visitrs: discuss precautins with nursing staff befre entering client/resident s rm. Envirnmental Services: change mp head, clths and cleaning slutin after cleaning rm r bed space. Fr detailed utbreak cntrl strategies refer t: Sectin II: Cnfirmed Influenza Outbreak Management Sectin III: Antiviral Chemprphylaxis and Treatment Guidelines during Influenza Outbreaks Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
22 Table 5: Rutine Practices and Additinal Precautins fr GI Illness Ppulatin, Public and Abriginal Health Implement Cntact Precautins in additin t Rutine Practices fr symptmatic clients/residents. Cntact Precautins are implemented fr symptmatic clients/residents t cntrl the spread f gastrintestinal viruses during GI illness utbreaks. Implement Cntact and Drplet Precautins if client/resident is actively vmiting. Wear clean Glves t enter client/resident rm r bed-space when prviding direct care t symptmatic clients/residents r when having any cntact with items in the client/resident rm; when cleaning an area cntaminated with feces r vmitus, r gathering/handling specimens. Wear a new Gwn t enter client/resident rm r bed-space when prviding direct care t symptmatic clients/residents r when having any cntact with items in the client/resident s rm r when cleaning areas cntaminated with feces r vmitus t prtect against pssible cntaminatin f clthing. Wear Eye Prtectin and a Prcedure Mask t prtect yur face when there is any risk f sprays f bdy fluids r when caring fr clients/residents wh are actively vmiting. All PPE must be remved and hand hygiene perfrmed befre leaving the client/resident s rm. Maintain at least ne (1) metre f physical separatin between bed/stretcher spaces. Statement n use f Alchl-based Hand Rub during GI Illness Outbreaks Alchl-based hand rubs (minimum 70% alchl) are an acceptable alternative t hand washing during GI illness utbreaks, when used accrding t label directins. If hands are visibly siled, instead wash hands with sap and warm running water. Plain sap and water are recmmended fllwing glve remval when caring fr clients/residents with diarrhea and/r vmiting. Fr detailed utbreak cntrl strategies refer t: Sectin IV: Gastrintestinal (GI) Illness Outbreak Management 6. Other Respiratry Organisms Cmmnly Assciated with ILI In additin t influenza A and B, there are ther respiratry rganisms cmmnly assciated with ILI (e.g. RSV, Parainfluenza, human metapneumvirus, enter/rhinvirus, crnavirus) and these are summarized in Table 6. Apprpriate infectin cntrl practices and additinal precautins will be reviewed at the time the utbreak is cnfirmed. Antiviral chemprphylaxis is currently nt recmmended fr rganisms ther than cnfirmed Influenza A r B. Depending n the circumstances, ther recmmendatins fr utbreak management and cntrl, including facility restrictins, may be made by Public Health at the time f the utbreak. Nte: In the event that the utbreak is cnfirmed t be an rganism ther than influenza, apprpriate utbreak cntrl measures wuld cntinue until the utbreak is declared ver. (See Table 6.) 7. Attachments Attachment I.1 - WHS Algrithm Attachment I.2 - Outbreak Signage Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
23 Ppulatin, Public and Abriginal Health Table 6: Organisms Cmmnly Assciated with ILI ORGANISM SYMPTOMS MODE OF TRANSMISSION INCUBATION PERIOD PERIOD OF COMMUNICABILITY OUTBREAK RESTRICTIONS/ RECOMMENDATIONS fr Supprtive Living/Hme Living Sites INFLUENZA TYPE A OR B Sudden nset f fever, ften with chills r rigrs, nnprductive cugh, headache, malaise, myalgia, runny nse, sre thrat Nte: fever may nt be prminent in thse >65 years Persn t persn by drplets r direct cntact with articles recently cntaminated with respiratry secretins. 1 t 3 days Usually 3-5 days frm clinical nset in adults, and up t 7 days in children Cases shuld remain in their rms until 5 days* frm the nset f acute illness OR until they are ver the acute illness and have been afebrile X 48 h Admissins/transfers restrictins fr cnfirmed influenza remain in place fr 8 days after nset symptms in the last case. RESPIRATORY SYNCYTIAL VIRUS (RSV) Similar t cmmn cld symptms; usually mild but can be mderate t severe Severe lwer respiratry tract disease can ccur in the elderly Persn t persn usually by direct r clse cntact with cntaminated secretins which may invlve drplets. Virus may live n envirnmental surfaces fr many hurs and fr a half-hur r mre n hands. 2 t 8 days, average 4 t 6 days Perid f viral shedding is usually frm 3-8 days Admissin/transfer restrictins nly when recmmended by lcal MOH. It is recmmended that cnfirmed r symptmatic cases remain in their rms fr 8 days frm nset f symptms. PARAINFLUENZA Type 1, 2, 3, 4 Similar t cmmn cld symptms. Can als cause serius lwer respiratry tract disease with repeat infectin (e.g. pneumnia, brnchitis, and brnchilitis) in the elderly. Persn t persn thrugh direct cntact with infected persns r expsure t respiratry secretins n cntaminated surfaces r bjects. 2 t 6 days Varies with different types Admissin/transfer restrictins nly when recmmended by lcal MOH. It is recmmended that cnfirmed r symptmatic cases remain in their rms fr the duratin f the illness HUMAN METAPNEUMOVIRUS (hmpv) The clinical features f hmpv are similar t thse caused by RSV. Illness may range frm mild upper respiratry tract infectins t severe brnchilitis and pneumnia. Transmissin is likely t ccur thrugh direct r clse cntact with cntaminated secretins. Estimated t be 3 t 5 days Cmmn cld like symptms. Other Cmmn Respiratry Viruses such as: Enter/Rhinvirus, Crnavirus Sneezing, runny nse, cugh, sre thrat, sinus cngestin, malaise, headache, myalgia and/r lw grade fever Nte: Fever is uncmmn in children ver 3 and rare in adults. Direct cntact r inhalatin f airbrne drplets, indirect transmissin thrugh hands and articles freshly siled by nse and thrat discharges f an infected persn. *First day wuld be designated as Day 0, the first 24 hurs after wuld be designated as Day 1. Enter / Rhinviruses: usually 2-6 days Crnaviruses: usually 2-5 days The perid f viral shedding has nt been determined, but individual cases in which therwise healthy infants shed virus fr mre than a week have been reprted. 24 hurs befre nset up t 5 days after nset Admissin/transfer restrictins nly when recmmended by lcal MOH. It is recmmended that cnfirmed r symptmatic cases remain in their rms fr the duratin f the illness Admissin/transfer restrictins nly when recmmended by lcal MOH. It is recmmended that cnfirmed r symptmatic cases remain in their rms fr the duratin f the illness Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
24 Ppulatin, Public and Abriginal Health Attachment I.1 - WHS Algrithm Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
25 Ppulatin, Public and Abriginal Health Attachment I.2 - Outbreak Signage Clr Versin Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
26 Ppulatin, Public and Abriginal Health Outbreak Signage Black and White Versin Guidelines fr Outbreak Preventin, Cntrl and Management in Supprtive Living and Hme Living Sites
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text:
Station 5-Panel - Grey/Teal
Garment Info:
A five panel to stand the test of time. This thing is durable, it will get you out of trouble if and when the time permits. Keep this in your arsenal at all times, you never know when you might need it.
• Each individual piece of headwear is packaged into a Geedup headwear logistics box
• Applique is Embossed Leather
• 100% cotton/faux suede
• Designed in Sydney, Australia
• One-size fits all
• Leather strap-back
All orders are shipped via AusPost, and take approximately 3-7 days nationwide and 3-14 days worldwide. If you are located in major metropolitan areas across Australia, your order will be received the day after you receive your tracking number, supplied by both Geedup Co. and AusPost.
Returns & Exchanges Policy
Below is our refund and returns policy – please have a read over before you buy with us. We pride ourselves on being able to keep a close connection with all our customers, so we thought we'd fill you in on how things operate at our space before you join the Geedup family.
- If a change of mind occurs, all items are subject to either an exchange or store credit to the same dollar value, and these two options only.
- Refunds are NOT provided, unless a purchased item is faulty and returned within 30 days of purchase.
- Item(s) must be unworn, unwashed, or otherwise unused with all original tags/labels attached.
- Gift cards, sale, and clearance items are not eligible for a refund or exchange if you change your mind on anything around the purchase, including size. Please choose very carefully your size as heavily discounted sale items are not eligible for an exchange.
- If a refund does occur, the purchase price (excluding delivery charges for online) will be refunded to you using the original payment method, once we have received the returned item back and confirmed that it meets the conditions stated above.
- You are responsible for any costs associated with returning the item to us.
All returns should be made in person, or via post to our headquarters located at:
59 Flinders Street, Darlinghurst 2010
Thankyou for your cooperation, and your support!

subset: commoncrawl


text:
Dog journals
Life can be a bitch, is the general opinion. Well, since I like mine so much, I must be a dog...
Saturday, June 23, 2007
Friday, June 22, 2007
Senthil visited me last night. He brought beer and we sat on the balcony and talked about photography and work and drank. He borrowed my film SLR body and the Canon 28 mm prime lens. While looking for them to give to him, I came across the set of four screw-on magnification lenses which I had bought once upon a time. These are simple magnifying lenses with optics designed for photography. They reduce the depth of field of shots taken, so one has to be careful of not shooting with the lens wide open. When Senthil left, he forgot to take his Zippo with him. I shot a couple of pictures of the lighter with the magnification lenses, and am quite happy with this shot.
Canon EOS 400D
Canon 50mm lens
f/8.0, 1/3s
Handheld, with a +4 magnification filter
Canon EOS 400D
Canon 50mm lens
f/8.0, 1/3s
Handheld, with a +4 magnification filter
Tuesday, June 05, 2007
Kind of blue
After reading comments from various people on how there was so much noise in pictures taken by the 500mm reflex lens that I have, I decided to calibrate the sharpness and resolution of that lens against the other zoom lens that I have, the Canon 75-300 USM III. After many trial shots, I came to the conclusion that the reflex lens is probably better off being used as a flower pot (after I take out the lens). It has very bad resolution, and it extremely difficult to focus. However, a very nice shot resulted from the entire exercise, which I present for you, wonderful readers. Hope you like it.
Canon 75-300 mm lens @ 300 mm
f/45, 13 seconds


text:
Clean Team Ambassadors
The Clean Team program delivers supplemental maintenance services through the Capitol Hill BID's Ready, Willing & Working program that serves men who were formerly homeless and/or formerly incarcerated by providing them with job training, supportive services and paid employment experience.
Uniformed in royal blue and gold, cleaning crews are deployed 7 days a week from 7:00am to 4:00pm, cleaning streets, collecting and bagging refuse, removing graffiti, cleaning street furniture and shoveling snow.
The Capitol Hill BID Clean Team is currently fully staffed and not accepting applications at this time.


text: Good morning, I'm hoping that someone on here can help me. I host a few websites using ISPConfig 3. I have registered one of these sites with GoDaddy and have registered a nameserver with GoDaddy to point to my server. The problem that I'm having is that I wish to use one name server for all the sites that I am hosting. For example, I registered ns1.mydomainname.com with GoDaddy and pointed it to my server. Another site that I have been asked to host is called www.myfriendssite.com. I have changed the DNS settings for this domain to use ns1.mydomainname.com as it's DNS server. When I browse to www.mydomainname.com I can see my site however when I browse for www.myfriendssite.com I get the default Apache page saying "It Works!" Can someone tell me what settings I need to add to my DNS settings so that I can use ns1.mydomain.com to access the www.myfriendssite.com site. I hope I've made this clear and I really hope that someone can help me out. Thanks in advance. Mick


text:
Preservation Alert
May 14, 2013
Movie Houses of Worship spotlights theaters in need
Christopher Campbell's Movie Houses of Worship spotlighted numerous cinemas in need of financial assistance to keep going. The Bijou in Eugene, the Eaton in Charlotte, the Kuhn in Lebanon, the Northwest Film Forum in Seattle, the Rio in Monte Rio and the Towne in Watertown make the list.
April 24, 2013
Iconic Istanbul theatre facing demolition
ISTANBUL, TURKEY — The oldest theatre in town, the 1924 Emek Sinemasi is in danger of being torn down completely by a developer. The site has been a source of history for the country as a headquarters for revolts and protests of the years. Now the protests are about the fate of the theatre as plans are in motion to tear it down and build an entertainment complex.
Read more in the Guardian.
April 17, 2013
Help restore the Bohm Theatre
ALBION, MI — Albion Community Foundation has been selected to support one of the 200 causes selected as finalists in the State Farm Neighborhood Assist™ program! Our submission, along with the other finalists, are live on Facebook and anyone who gets the State Farm Neighborhood Assist Facebook application can log on and vote for our cause. The 40 causes that receive the most votes will be announced on April 29 and a $25,000 grant will be awarded to the affiliated nonprofits to implement the solution.
The Bohm Theatre Restoration project will help us restore the interior of the theatre so that we can again have movies and stage performances in downtown Albion. In order to make the theatre safe we will upgrade all mechanical, electrical and plumbing systems. In order to better meet the needs of the community we will remove the balcony multiplex, bringing the theatre back to its single screen grand appearance, stabilize the stage area for live performance use, add main floor bathrooms, upgrade existing bathrooms, install digital projection equipment and repair water damaged ceilings, walls and floors.
April 3, 2013
Castro Theatre's endangered "Mighty Wurlitzer"
SAN FRANCISCO, CA —Please visit http://www.sfcoda.org, the website of our newly formed 510©(3) organization dedicated to saving the Castro Wurlitzer.
Links on the site point to two recent news articles (one in the San Francisco Chronicle), as well as additional information about the project vision, created by the board of the Castro Organ Devotees Association (CODA). Visitors to the site can make a tax-deductible donation via PayPal and/or sign up for our e-mail newsletter.
Bill Coale, Secretary Castro Organ Devotees Association (CODA)
(Thanks to Tinseltoes.
April 1, 2013
Go Digital or Go Dark for the Rio
MONTE RIO, CA — The Rio Theater is in danger of closing if it cannot raise $60,000 by May 7 to purchase a digital projector. They've launched a Kickstarter Campaign where you can receive special gifts for pledges of different levels. Help save this small-town by donating now.
March 15, 2013
Skyline in danger of closing
CANON CITY, CO — The cinema future of Canon City is looking grim with both of its theaters in need of digital projection. Both the Creekside Cinemas and the single-screen Skyline are hoping to raise the necessary funds, possibly through a Kickstarter campaign.
Read more in the Denver Business Journal.
(Thanks to Chuck1231 for providing the photo.)
February 28, 2013
Group out to revive town movie theater
LEONARDTOWN, MD — Friends of the Leonardtown Theater has been established to save the New Theatre. They hope to get the state to make the area an arts and entertainment district so they can receive incentives for investing in bringing back the theatre. They intend to show a mix of independent, foreign and classic films there.
Read more in Southern Maryland News.
February 25, 2013
Lights dimming on Sunnyside movie theater's run
SUNNYSIDE, NY — The Center Cinemas has a new owner and there are already rumors of a demolition. Its lease runs through the end of 2014 but Queens' theaters have been closing rapidly.
Read more in the Observer.
(Thanks to Ed Solero for providing the photo.)
January 9, 2013
Higginsville's campaign to save movie theater comes up short
HIGGINSVILLE, MO — Even winning a Reader's Digest grant isn't enough to keep the beloved Davis Theatre open. Its owners are putting it up for sale for $320,000 after a slow year and no funds to purchase a digital projector.
Read more in the Kansas City Star.
December 6, 2012
OAKHURST, CA — Despite closing last month, there's a loyal fanbase trying to save the MET Cinema. Three childhood friends have created a website and a membership program so the theatre can reopen and become a local entertainment center.
Read the full story in the Sierra Star.


text:
Today I want to tell you about a new juices label out there in Paris. It is called Juice Lab. And it's pure wonder. Really.
Products are fresh like paradise, it's also the reason why they can't deliver to far destinations, you'll have to come to Paris to try them !
They are doing fruits and vegetables juices, mixed with some superfood ingredients, like Chia or pumpkin seeds, bee pollen, curcuma...
I am a strong fan of super juices like this, and those ones are certainly the best i've had.
Perfect match : matcha tea, chia seeds, pumpkin seeds, cardamone, vanilla and agave syrup.
Date me : almond, bee pollen, cinnamon, nutmeg, medjool date.
Eat clean i must say.
Wake me up : Orange, jasmin tea, grapefruit, litchi, lemon, rosemary, mint.
Forever Young : beetroot, pomegranate, grape, orange.
King kale : pineapple, kale, Granny apple, spinach, ginger.
And is it good ?


text: NORTHAMPTON, Mass., March 27 -- The US Navy recently awarded a $12.4 million contract to Kollmorgen Electro-Optical Div., a subsidiary of the Danaher Corp., for the delivery of nine MK46 Mod 1 optical sight systems (OSS) for DDG-51 Arleigh Burke Class destroyers. This contract includes options for an additional eight systems to be exercised over the next three years, for a total contract value of over $25.1 million. The MK46 Mod 1 Optical Sight System is a two-axis, gyro-stabilized sensor platform containing a high-performance color daylight imaging sensor, thermal imaging sensor and eye-safe laser rangefinder. The MK46 OSS is highly integrated into the MK34 gun weapon system, allowing the ship's primary gun system to use either radar or electro-optical target tracking and imaging data. Kollmorgen Electro-Optical, with facilities in Massachusetts and Vermont, has been the sole supplier of MK46 OSS systems since 1990. Kollmorgen has also been the primary designer of all submarine periscopes used in the Navy since 1916.


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