Infection prevention and control: Guideline for speech pathologists, Version 1,2020.

1/114 William Street, Melbourne, Australia 3000 1300 368 835 www.speechpathologyaustralia.org.au

Infection Prevention and Control - Guideline for Speech Pathologists - Version 1, 2020 © 2020 The Speech Pathology Association of Australia Limited. All Rights Reserved

Acknowledgements Speech Pathology Australia BALDAC, Stacey (Manager Professional Standards) CAMERON, Ashley (Project Officer) JOHNSON, Trish (Manager Ethics and Professional Issues)

MULCAIR, Gail (Chief Executive Officer) TORRESI, Kym (Senior Advisor, Aged Care)

Disclaimer: To the best of The Speech Pathology Association of Australia Limited’s (“the Association”) knowledge, this information is valid at the time of publication. Speech Pathology Australia makes no warranty or representation in relation to the content or accuracy of the material in this publication. Speech Pathology Australia expressly disclaims any and all liability (including liability for negligence) in respect of use of the information provided. Speech Pathology Australia recommends you seek independent professional advice prior to making any decision involving matters outlined in this publication. The Speech Pathology Australia COVID-19 Advisory Group has supported the development of the Infection Prevention and Control Guideline for Speech Pathologists . This guideline will be updated as further information or evidence becomes available.

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Contents Disclaimer Acknowledgements

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1.0 Introduction

4 5 5 6 6 6

1.1 Statement

1.2 Summary of Recommendations

1.3 Aim

1.4 Purpose of the Guideline

1.5 How to use the Guideline

2.0 Background Information

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3.0 Origins of the Guideline

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3.1 Rationale 12 4.0 Infection Prevention and Control Framework: Overview 13 5.0 Standard Precautions 21 5.1 Hand Hygiene 22 5.2 Respiratory Hygiene and Cough Etiquette 28 5.3 Personal Protective Equipment 28 5.4 Routine Management of the Physical Environment 42 5.5 Reprocessing of Reusable Medical Equipment and Instruments 44 5.6 Aseptic Technique 47 5.7 Waste Management 48 5.8 Handling of Clothing and Linen 48 6.0 Transmission-Based Precautions 50 7.0 Environmental Cleaning 55 8.0 Risk Management 72 9.0 Conclusion 76 10.0 References 77

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1.0 Introduction

Infection prevention and control principles are fundamental to control and prevent the transmission of an infectious agent such as communicable diseases, transmissible infections and multi-resistant organisms (MROs). To deliver high-quality client care, protect speech pathologists and safeguard the work environment, speech pathologists should establish an informed and considered response to infection prevention and control. Speech pathologists engage with a broad and diverse range of the population across a number of settings to assess and manage individuals with swallowing and communication difficulties. Speech pathologists work: • With infants, children, adolescents, adults, the elderly and their families and carers • With other professions including allied health practitioners, doctors, educators, home care workers, nurses, pharmacists and support staff (e.g., allied health assistants) • In a number of settings including, aged care facilities, allied health clinics, community health and rehabilitation, corporate organisations, correctional institutions (e.g., juvenile justice facilities), disability services, early intervention, childcare, community, schools, hospitals (intensive care units, acute, sub-acute and rehabilitation), in-home, mental health, private practice, supported employment and universities • Across various settings including metropolitan, regional, rural and remote locations across Australia. • Facilitation of speech pathology students during clinical placements. The provision of a service by a speech pathologist typically involves close proximity and contact with clients, oral and nasopharyngeal anatomy (i.e. mucosal membrane), exposure to secretions (e.g., saliva, sputum, respiratory droplets), and their assistive technology, equipment or devices. Routine and risk-based infection prevention and control measures are imperative to prevent and reduce the transmission of communicable diseases, transmissible infections and MROs. Speech pathologists work across a range of low to high-risk areas and make a valuable contribution to supporting the health and wellbeing of the community. The guideline is designed to guide speech pathology practice in implementing standardised infection control protocols within usual service delivery at all times. Adequate consideration must be given to the implementation of appropriate infection prevention and control at all times to ensure the safe delivery of client care protection of speech pathologists, the working environment and equipment used. Additionally, the document seeks to provide frameworks and guidance for additional and transmission based precautions needed to be adopted during outbreaks, epidemics and pandemics. Always consult specific advice in the case of a new infectious agent and during outbreaks, epidemics and pandemics to maintain a safe work environment and ensure the continuity of speech pathology practice. Understanding infectious agents such as communicable diseases, MROs and transmissible infections Communicable diseases Communicable diseases are infectious diseases that can transmission from person to person. Examples, influenza, Norovirus, COVID-19, Scabies. MROs MROs are microorganisms that are resistant to multiple antimicrobial classes. Examples: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), carbapenemase-producing Enterobacterales (CPE), carbapenemase producing Pseudomonas aeruginosa, Candida auris. Transmissible infections Are infections that can be transmission from person to person. Examples: Impetigo (school sores)

(Head lice are considered an infestation [not an infection] and can be transmitted from person to person.)

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1.1 Statement The information provided in the guideline has been developed in accordance with available details on standard and transmission-based precautions and the rapidly evolving evidence available at the time of release. The guideline will be reviewed periodically or when new and consequential evidence requires a review to be undertaken. Always consult relevant regulatory bodies and local, state, territory and national advice to comply with the best available information and response guidelines at the time of access. 1.2 Summary of Recommendations • Speech Pathology Australia advises that all speech pathologists in all settings need to undertake appropriate infection prevention and control measures to prevent and minimise the risk of infectious agent transmission • Speech pathologists should regularly review and adhere to the Speech Pathology Australia guideline, workplace policies and procedures, government guidelines, legislation and infection control services • The health and wellbeing of speech pathologists, students, clients, fellow staff and/or employees should be factored into all decision-making • Standard precautions are required for all in-person client interactions regardless of known infection status • Standard precautions aim to reduce the risk of exposure and transmission of infectious agents between speech pathologists, clients and the environment • Hand hygiene is one of the most important strategies in preventing healthcare associated infections, and it should be routinely performed before and after – use of gloves, touching a client and their surroundings, undertaking a procedure or a body substance exposure risk • Respiratory hygiene and cough etiquette minimises the transmission of infectious agents via droplet and airborne routes • Speech pathologists should: o Comply with standard and transmission-based precautions and ensure the appropriate use of personal protective equipment (PPE) , including donning and doffing procedures, as per infection prevention and control policies (e.g., Speech Pathology Australia, organisation or service, and government). o Follow the cleaning requirements and spills management for each precaution type, including the clinical or practice environment, equipment, consumables, resources and materials. o Complete routine cleaning of frequently touched surfaces with detergent daily (minimum) when visibly soiled and after every known suspected or confirmed contamination. o Use surface barriers to protect clinical or practice surfaces and equipment that are frequently touched, are likely to become contaminated (e.g., body substances) or are difficult to clean. o Follow the recommended reprocessing of reusable medical equipment and instruments.

o Use aseptic technique when appropriate to prevent infectious agents on hands, surfaces and equipment from being introduced to susceptible sites during aseptic procedures.

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o Be aware of the appropriate management , containment and disposal of clinical and general waste. o Follow the recommended handling of clothing and linen as it poses a potential risk of transmission of infectious agents. o Implement recommended transmission-based prcaustions: contact, droplet and airborne precautions in addition to standard precautions when suspected or confirmed infectious agents are transmitted by direct or in-direct contact with clients and their environment (i.e. airborne transmission requires airborne precautions). o Consider setting and task modifications (e.g., scheduling or in-person versus telepractice delivery), to reduce transmission risks for infectious clients or during an outbreak, epidemic or pandemic. This may also apply to vulnerable clients during an outbreak, epidemic or pandemic. o Use a risk assessment framework to determine what infection prevention and control precautions are required to proceed with an assessment, intervention, procedure or service delivery. o Complete documentation to indicate modification to clinical assessments, procedures or interventions due to an infection or an outbreak, epidemic or pandemic. o Ensure students are provided access to infection prevention and control information and supervision to keep them safe. 1.3 Aim The guideline aims to prevent the transmission of infectious agents associated with speech pathology services through the implementation of infection prevention and control measures across all practice areas, contexts and sectors. 1.4 Purpose of the Guideline • Provide a background to the development of a profession-relevant guideline • Describe the key definitions and terminology relevant to infection prevention and control recommendations and procedures • Outline standard precautions for all speech pathology practice areas • Identify specific precautions, key considerations and suggested modifications that apply to speech pathologists across a range of clinical or practice contexts, procedures and service delivery settings • Assist speech pathologists in implementing the recommended guideline and task modifications for standard and transmission-based precautions • Guide a risk response to an infectious agent or an outbreak, epidemic or pandemic situation. 1.5 Infection Prevention and Control Guideline for Speech Pathologists User Guide The guideline intends to provide a basis for speech pathologists to develop detailed procedures for infection prevention and control specific to local service or sector settings. The expected audience is Speech Pathology Australia, Speech Pathology Australia members, employers and

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associated organisations. State and Territory Health Departments may use the guidance as a reference for specific speech pathology infection prevention and control related risks. In the guideline, ‘healthcare’ is a general term used to refer to the activities a speech pathologist undertakes in the management and delivery of assessment, therapeutic and educational services, regardless of the setting. The term client is also used and applies to both patients and residents. Wherever recommendations are made for ‘speech pathologists’ or ‘health practitioners’ within service delivery, these should be taken to refer to both qualified professionals and speech pathologists in training (students). To determine the governance and implementation of infection prevention and control strategies within a speech pathology service, see Checklist A: An implementation checklist for infection prevention and control strategies within a speech pathology service. The checklist will provide the speech pathology service to perform a gap analysis to: • deliver high-quality client care, protect speech pathologists and safeguard the work environment, speech pathologists should establish an informed and considered response to infection prevention and control. • meet the following National Safety and Quality Health Service (NSQHS) Standards: 1.6 National Standards 3.1 The workforce uses the safety and quality systems from the Clinical Governance Standard when: a. Implementing policies and procedures for healthcare-associated infections and antimicrobial stewardship. b. Managing risks associated with healthcare-associated infections and antimicrobial stewardship. c. Identifying training requirements for preventing and controlling healthcare-associated infections, and antimicrobial stewardship. 3.2 The health service organisation applies the quality improvement system from the Clinical Governance Standard when: a. Monitoring the performance of systems for prevention and control of healthcare-associated infections, and the effectiveness of the antimicrobial stewardship program. b. Implementing strategies to improve outcomes and associated processes of systems for prevention and control of healthcare-associated infections, and antimicrobial stewardship c. Reporting on the outcomes of prevention and control of healthcare-associated infections, and the antimicrobial stewardship program. 3.3 Clinicians use organisational processes from the Partnering with Consumers Standard when preventing and managing healthcare-associated infections, and implementing the antimicrobial stewardship program to: a. actively involve patients in their own care b. meet the patient’s information needs c. share decision-making.

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1.0 Checklist A: An implementation checklist for infection prevention and control strategies within a speech pathology service

Yes No N/A Action Required/ Evidence

Do you have an infection prevention and control strategy and/or a framework for managing infection prevention and control in your service? Does your strategy have established policies, procedures or guidelines related to infection prevention and control specific to speech pathology services? Does your strategy have established policies, procedures or guidelines related to staff/ occupational health and strategies to prevent occupational exposure to infectious agent hazards? Are there sufficient resources available to support and maintain all aspects of the infection prevention and control strategy? Are there sufficient resources available to regularly review and/or monitor compliance with the infection prevention and control strategies? Do clients have access to hand hygiene products and adequate information on infection prevention and control within the speech pathology service? Are results from regular reviews and/or monitoring used to drive quality improvement projects? Is there adequate and ongoing infection prevention and control staff training specific for speech pathology practices? Is there adequate and ongoing infection prevention and control staff training and on the use, donning and doffing of PPE to effectively minimise potential hazards? Is there practice-based surveillance of staff and clients, which includes timely mechanisms for feedback and reporting to relevant health practitioners and senior management?

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Do your policies or guidelines addressing notifiable diseases and staff health disclosure take into account the relevant public health, anti-discrimination, privacy, industrial relations and equal employment opportunity legislation in your jurisdiction? Do you have policies, procedures or guidelines inplace for asking clients to disclose their infectious or transmissible disease status when applicable?

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2.0 Background Information

Infectious agents are any microscopic living organisms ( bacteria, viruses, fungi, protozoans or helminths) that are capable of causing disease; also known as a microbe or germ (see Figure 1). 1-3

Figure 1: Types of Infectious Agents

Sourced from Mayo Clinic 2

Endemic is an infectious agent that perpetually exists in a population, environment or area. 4

Outbreaks are a sudden increase in the occurrences of a particular infectious agent above what is typically anticipated (endemic) in a specific area (e.g., community or country) or a single case in a new location. If not controlled, it can escalate to an epidemic. 5 Epidemics can occur when an infectious agent transmits rapidly to a number of people within a community, population or region. 5 Pandemic is a global infectious agent outbreak the affects a significant number of people, transmission across multiple countries or continents.

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The Chain of Infection

The chain of infection displays how infectious agents transmit (see Figure 2). Breaking one or more link in the chain, through removal or protection, will stop the transmission of the infection. 6 The chain of infection transmission and examples of actions to break the chain include:

Chain of Infection

Examples of breaking the chain

Causative agent – the infectious agent itself

• vaccinations against the infectious agent • herd immunity – sufficient number of the population are immune to the infectious agent • diagnose infectious agent and treat. • change appointment until person is considered not infectious • standard precautions to prevent contact with person’s blood or body substances. • regular and targeted hand hygiene • regularly clean and disinfect high-touch areas • respiratory hygiene and cough etiquette • reprocessing (cleaning/disinfection/sterilisation) of equipment • use of standard and transmission based precautions (PPE) • physical distancing • personal hygiene. • stay at home • take precautions such as wearing a mask • regular and targeted hand hygiene.

Reservoir – where the infectious agent lives

Portal of exit – how the infectious agent leaves the reservoir

Mode of transmission – how the infection enters the body

Portal of entry – locations where the infectious agent could enter the body (e.g., eyes, mouth, nose) Susceptible host – any person receiving healthcare

• follow recommended standard precautions • vaccination against the infectious agent.

Figure 2: Chain of Infection Transmission Sourced from NHMRC Guidelines 6

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3.0 Origins of the Guideline

Infection prevention and control measures are central to speech pathologists providing high quality service provision to all clients, as well as facilitating a safe working environment for all practitioners. The development of the profession-relevant guideline arose from the need for Speech Pathology Australia members to have access to appropriate and profession-specific infection prevention and control information. The Speech Pathology Australia Infection Prevention and Control Guideline for Speech Pathologists aligns with ‘ Aspiration 8 - Quality services: Innovation and continual pursuit of knowledge’ of the Speech Pathology 2030 – Making Futures Happen 7 report and broadly links to pillar three, ‘ Our workforce: Speech pathologists are equipped for quality practice that meets community need’ of the Speech Pathology Australia Strategic Plan 2020-2022 . 8 The practice settings considered in compiling this guideline include acute and rehabilitation hospital settings, aged care, community, early childhood education, schools, disability, justice, home setting and private practice. 3.1 Rationale Infection prevention and control is each individual’s responsibility. Healthcare providers have a legal obligation to eliminate risks and provide a healthy and safe work environment for individuals, clients and others as reasonably feasible. 9-12 Appropriate systems and reporting structures (governance) need to be in place to minimise risks to clients and health practitioners, monitor service provision and improve the quality of clinical care. Health practitioners need to be accountable for their professional practice in the implementation of an infection prevention and control guideline. 9,10,12 The guideline has been designed to support individual speech pathologists implement infection prevention and control measures within their professional practice. Speech pathology specific examples have been included throughout the guideline. These examples should be used to form the basis of considering what infection prevention and control measures are required for individual clinical tasks, settings and scenarios.

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4.0 Infection Prevention and Control Framework: Overview

The evidence and frameworks contained in The Australian Guidelines for the Prevention and Control of Infection in Healthcare (referred to as NHMRC Guidelines in the current guideline) 9 provide the foundation for the speech pathology infection prevention and control guideline. The Speech Pathology Australia guideline does not exhaustively detail all aspects of infection prevention and control. For more information, access the NHMRC Guidelines (https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control- infection-healthcare-2019), 9 Safe Work Australia Guidelines (e.g., biohazards) (https://www. safeworkaustralia.gov.au/) 13 and relevant Australia and New Zealand Standards (e.g., AS/NZ Standards) (https://www.standards.org.au/). 14 Speech Pathology Australia does not legally mandate adherence to the guideline. Speech pathologists must use their judgement to inform the appropriate implementation and management of infection prevention and control principles, in accordance with any workplace, regulatory or governing body requirements including Speech Pathology Australia Clinical Guidelines , Speech Pathology Australia Code of Ethics and the Speech Pathology Australia National Code of Conduct. The guideline should be used to inform planning, practice and service delivery within the context of infection prevention and control whilst referring to the best available evidence from Speech Pathology Australia, workplace organisations and services, governing bodies and government information. During unprecedented events, information and recommendations may vary in response to factors such as geographical location, rates of community transmission, vulnerability of the community, sector and client considerations. Speech pathologists should also consider a risk assessment framework to support their decision making regarding the provision of services, particularly at the time of an outbreak, epidemic or pandemic. Examples of such risk assessment tools developed for speech pathology practice during the COVID-19 pandemic include the Speech Pathology Australia Risk Assessment Tool (COVID-19) [SPA- RAT (COVID-19)], 15 The Royal College of Speech and Language Therapists (RCSLT) Restoring service: Framework to support decision making , 16 and RCSLT guidance on reducing the risk of transmission and use of PPE. 17 Conducting an infection prevention and control risk review can assist in applying suitable modifications to each practice setting (see Appendix A). It is important to note that the guideline does not include information or replace legislation, requirements and standards related to: • Australian Register for Therapeutic Goods manufacturers recommendations for reporcessing of equipment and reusabele medical devinces ( Therapeutic Goods Act 1989 ) • Food safety and services ( Food Standards Australia New Zealand Act 1991 ) • Laundry services ( AS/NZS: 4146: 2000 Laundry Practice ) • Practice design ( Australasian Health Facility Guidelines (AusHFG) • Waste management and disposal ( AS3816:2018 Management of clinical and related waste ) • Workplace Health and Safety ( Work Health and Safety Act 2011 ) • Reprocessing of reusable medical equipment ( AS/NZS4187:2014 Reprocessing of reusable medical devices in health service organisations ). Early recognition of infectious agents and prompt implementation of appropriate infection prevention and control precautions is critical for minimising and preventing the transmission of infection.

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Standard and Transmission-Based Precautions The NHMRC Guidelines outline a two-tiered approach to infection prevention and control, which provides high-level protection to speech pathologists, clients and others when effectively implemented. 6,9 This two-tiered approach and the principles within it generally apply regardless of the service location and includes: Standard and Transmission-Based Precautions The NHMRC Guidelines outline a two-tiered approach to infection prevention and control, which provide high-level protection to speech pathologists, clients and others when effectiv ly implemented. 6,9 This two-tiered approach and the principles within it generally apply regardless of the service location and inclu es: Early recognition of infectious agents and prompt implementation of appropriate infection prevention and control precautions is critical for minimising and preventing the spread of infection.

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Routinely applied standard precautions for infection prevention as a minimum level of control.

[04] Infection Prevention and Control Framework: Over

Effective management of infectious agents where standard precautions may not be sufficient on their own by applying additional transmission-based. precautions

Standard precautions must be in place at all times.

Standard precautions Apply to everyone, all the time, regardless of their perceived or confirmed infectious status to minimise the risk of transmitting infectious agents. Standard precautions are the primary strategy for the prevention of infectious agent transmission. 18-19 Transmission-based precautions Apply when standard precautions alone are insufficient to prevent the transmission of infectious agents. The method of transmission of the infectious agent determines the precaution type. The three categories (see Figure 3) include contact, droplet and airborne. 9,20,21 There is robust discussion and emerging research concerning the specific details of droplet and airborne transmission (e.g., particle size and distance). Currently, these transmission-based precautions are defined as: Contact (including bloodborne) o The most common mode of transmission and usually involves transmission by direct touch (person-to-person) or indirectly by touching, contaminated environmental surfaces, shared aids/devices/equipment/toys), clothing or via contact with blood or body substances (e.g., vomit, saliva) 10 Standard precautions Apply to everyon , all the time, re ardles of their perceived or confirmed infectious status to minimise the risk of spreading infectious agents. Standard precautions are the primary strategy for the prevention of infectious agent tr nsmission . 18-19 •

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• Droplet o Expelled infectious respiratory droplets which may lead to infection of others directly through susceptible mucosal surfaces (e.g., eyes, nose, mouth). • Airborne o Inhalation of small particles or evaporation of larger particles (in conditions of low humidity) that contain infectious agents o Aerosols containing infectious agents can be dispersed by air currents (e.g., ventilation or air conditioning systems) and inhaled o Exposure may occur from behaviours that generate aerosolised particles (e.g., coughing) or from performing an aerosol generating procedure (AGP). 22-25 • Combination o Combination of airborne, contact and droplet. Depending on the communicable disease, MRO or transmissible infection, it will require a combination of precautions to prevent their transmission.

Figure 3: Transmission of Infectious Agents

Figure 3: Transmission of Infectious Agents Adapted from NHMRC Guidelines 6

[[04] Infection Prevention and Control Framework: Overview

Adapted from NHMRC Guidelines 6

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Hierarchy of Control The hierarchy of control is a hazard identification approach used to control or eliminate risks in a work setting or environment. Risk is ranked according to five levels from the most effective to the least effective controls (see Figure 4). These include elimination (and substitution), engineering controls, administrative controls, and PPE. 11,26 Control measures that provide the greatest impact should always be selected. Focus on the highest level of control in the first instance, before progressing to the next level. Eliminate hazards and as many associated risks as possible, before considering other types of control. Notably, administrative controls and PPE are the least effective controls as they do not control the hazard at the source and rely on human behaviour and supervision to be implemented. Select one or a combination of risk controls to respond to any given scenario, IN ADDITION to standard precautions and mandated protocols.1 1,13,27 See Table 1 for workplace examples applied to biohazards (i.e. any biological or chemical substance that is dangerous to humans, animals, or the environment). 27 Figure 4: Applying the Hierarchy of Controls, adapted from National Institute of Occupational Health and Safety 28

There are a number of infection prevention and control strategies that disrupt or stop the chain of infection and transmission of infectious agents that cause illness or infection. These are often implemented using the hierarchy of controls. The hierarchy of controls is a pyramid of strategies that uses the most effective to the least effective strategy.

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Table 1: Examples of the Hierarchy of Controls Applied to Biohazards in Practice

Level of Control

Workplace Example

• Assess the need to conduct work in-person (e.g., therapy, assessment, administration) and work remotely where possible. • Use technology to facilitate remote working practices (e.g., telepractice to delivery therapy, virtual meetings with colleagues). • Perform procedures that present a higher infection risk with the appropriate standard and transmission based precuations. • The positioning of the speech pathologist, client and any individuals during the session (e.g., • Identify physical barriers (e.g., acrylic screen) • The location of sessions (e.g., inside or outside) • Air-handling (e.g., ventilation) • Sensor controls to minimise high touch items (e.g., water taps, doors, bins) • Vaccinations • Standard precautions (e.g., hand hygiene, cough etiquette, clean frequently). • Communicate risks, rules and expectations (e.g., posters, education session, emails, text messages) • Limit number of individuals in an area (e.g., scheduling clients, staggering staff) • Length of sessions • Combining telepractice and face-to-face sessions to reduce length of sessions • Wear the most appropriate PPE for the task as determined by standard and transmission-based precautions (e.g., gloves, mask) • Policies and procedures face on or side-by-side, limiting time spent within the physical distance range between individuals).

Elimination Do not introduce the hazard or remove the hazard completely

Substitution Use a safer method of service delivery, product or approach

Engineering Controls A mechanical device or physical process

Administrative Controls Work methods or procedures that minimise exposure to a hazard

PPE Used or worn minimise risks to their health and safety

Adapted from multiple sources 11,27,29,30

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A Combination of Controls Applied to Workplace Health and Safety Infection protection for staff should be an integral part of the infection prevention and control and occupational health and safety programs of every healthcare practice. Suggested elimination, engineering and administrative controls to support staff include: • Elimination controls o Speech pathologists need to consider their health or vulnerability status and that of close contacts before interacting with clients or colleagues. o Speech pathologists should not go to work if they feel unwell or have any signs or symptoms of a potentially infectious agent. o Early recognition of infection status and identifying at-risk clients and staff is important for risk minimisation. • Administrative controls o If a speech pathologist has a confirmed or suspected infectious agent, it is essential for the individual to:  consult a medical practitioner as soon as possible to determine safe work practices to minimise putting clients and other workers at risk  undergo regular medical follow-up and comply with the informed clinical management of the presenting condition  Inform their employer as appropriate. Engineering controls o The Australian Immunisation Handbook recommends that all health practitioners are vaccinated and remain up-to-date with the vaccinations required for their workplace or practice setting (See Table 2) 31 o Mandatory health practitioner vaccination and screening programs are outlined by state or territory health authorities and/or Commonwealth legislation. •

Table 2: Recommended Vaccinations for all Health Practitioners

Health practitioners

Disease/Vaccine

All health practitioners (includes all practitioners and students directly in- volved in client care or the handling of human tissues, blood or body fluids) • • • • Health practitioners who work with remote Indigenous communities in Northern Territory, Queensland, South Australia and Western Australia; and other specified health practitioners in some jurisdictions • • Health practitioners who may be at a high risk of ex- posure to drug-resistant cases of tuberculosis (depen- dent on state or territory guidelines) • • •

Hepatitis B Influenza

Pertussis (dTpa)

MMR (if non-immune) Varicella (if non-immune) Vaccines listed for ‘All health practitioners’

Hepatitis A

Vaccines listed for ‘All health practitioners’ Bacillus Calmette-Guérin (BCG) vaccine

Adapted from NHMRC Guidelines 9

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Checklist B: Vaccination and screening

Yes No N/A Action Required/ Evidence

Do you have an appropriate staff immunisation policy based on state or territory health authority and/or Commonwealth legislation, specifying a framework for the assessment, screening and vaccination of health practitioners? Do your secure staff immunisation records include screening results, vaccination history, serology, immunisations with batch details and a record of staff who choose not to vaccinate? Do you have processes in place to manage vaccination refusal, contraindication to vaccination or vaccine non-response of your staff? Do you have a method for immediately determining risk to your practitioners and workers when a client presents with an infectious disease? Does your practice have comprehensive written policies regarding disease-specific work restriction and exclusion? Does your practice have a comprehensive occupational health program to manage health practitioners in specific circumstances that put them at greater risk of infection? Do you have health care associated infection and/or adverse event surveillance policies and procedures?

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Administrative Controls Applied to Client Education Educating and engaging clients, significant others, teachers, support workers and carers is a sustainable way to improve the risk of infectious agent transmission in a clinical setting. 9 Administrative controls include: • Support the client to understand and adhere to any current infection prevention and control requirements (e.g., hand hygiene, mask requirements) • Discuss the specific risks (e.g., infection, MRO colonisation) associated with planned procedures or tasks • Assist clients in feeling comfortable disclosing their health or risk status • Encourage clients to identify and communicate risks via feedback channels (e.g., real- time, survey, email or feedback forms) • Provide appropriate education materials (including literacy level, ‘easy English’ and aphasia-friendly considerations) through a variety of written, verbal and visual media • Educate clients in the appropriate use, storage, disposal and/or cleaning of any assistive technology or adaptive equipment provided for personal use.

Checklist C: Administrative controls

Yes No N/A Action Required/ Evidence

Does your practice or workplace have (or have access to) client education materials on infection prevention and control, using a variety of media, literacy levels & languages? Do individuals know how to provide feedback if they want to? Do clients know how to use what you provide them in-line with infection prevention and control over time? Do clients have access to hand hygiene practices on entry?

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5.0 Standard Precautions

Standard precautions are work practices that are required to achieve a basic level of infection control in all workplace environments. 32 It is vital to establish clear standard precautions and ensure these precautions are implemented in all clinical areas and practice settings. 3 There are key actions required by speech pathologists to ensure adherence to infection prevention and control measures when undertaking day-to-day practice tasks. The most significant considerations for potential transmission of an infectious agent are: • Clothing • Environmental surfaces • Healthcare worker hands • Shared items or devices (e.g., electronic tablet, waiting room toys, stethoscope). An overall summary of standard precautions is listed below. To provide further detail and information for clinical and practice settings, a more in-depth discussion of each standard precaution is provided in the proceeding sections . Standard precautions consist of: • Hand hygiene (i.e. ‘5 Moments of Hand Hygiene) 33 o Wash hands with soap and water and use alcohol-based hand rubs for all clinical activity (see Section 5.1) • Respiratory hygiene and cough etiquette o Minimise the transmission of droplet and airborne routes of infectious agent transmission (e.g., respiratory illness) using a series of actions (see Section 5.2) Appropriate use of PPE o Access and wear appropriate equipment depending on the setting and the type of precautions required (see Section 5.3) • Routine management of the physical environment o Maximise environmental hygiene and minimise or prevent the transmission of infectious agents from the environment to individuals through adequate cleaning (see Sections 5.4 and 7.0) • Appropriate reprocessing of reusable medical equipment and instruments o Undertake the required steps to sufficiently clean equipment and instruments used during procedures or in clinical practice (see Section 5.5) Aseptic non-touch technique o Protect clients from infection during procedures by minimising contamination (see Section 5.6) • Safe use and disposal of sharps o Minimise or prevent the risk of injury or potential exposure to bloodborne infectious agents • Waste management o Adhere to local, state and territory legislation and regulations to safely handle general and clinical waste (see Section 5.7) • Appropriate handling of clothing and linen o Minimise or prevent the potential risk of infectious agent transmission via fabrics or textiles (see Section 5.8). Standard precautions should also be followed in the handling of the following items, regardless of whether they contain visual blood; non-intact skin; and mucous membranes: • Blood (including dried blood) • •

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• Bodily fluids (e.g., vomit, saliva) excluding sweat. It is also essential to consider how standard precautions can be implemented and maintained across all environments. For example: • Ensure ready access to handwashing or hand sanitiser (pending available amenities in the environment) for the speech pathologist and the client • Ensure routine environmental and equipment (including assessment and intervention materials) cleaning between consultations, clinical procedures and sessions. Common tasks that may result in some form of exposure to infectious agents include: • Assessment and intervention with clients who may vomit, have an episode of incontinence and/or cry. • Assessment and treatment of clients who present with conditions that can be transmitted by contact, droplet and aerosol routes. • Assessment and treatment of clients with wounds. • Close assessment and treatment of clients with chronic respiratory conditions, excessive phonation and/or saliva control difficulties (including self-soothing behaviours, (e.g., ‘blowing raspberries’) and mouthing/sucking on the body (e.g., thumb) then touching objects). • Direct client contact and handling during assessment and therapy (e.g., helping to adjust the back support on a wheelchair to improve the position for speech, helping position a client in the bed for a swallow assessment, or holding an infant for a feeding trial). • Handling and use of medical devices including shared client care equipment (e.g., stethoscopes, wheelchairs). • Handling of client’s assistive technology such as communication technology, glasses, hearing aids and wheelchairs. • Handling of shared (between practitioners and clients) assessment and therapy objects (e.g., pen, prompt cards.) • Mealtime management and mealtime equipment. • Shared or communal clinic and practice environments (including multi-room or multi- site visits). 5.1 Hand Hygiene Effective hand hygiene is the most important strategy to prevent and reduce the risk of infectious agent transmission in healthcare activities that result in healthcare associated infections. Hands can become contaminated through contact with all individuals and environmental surrounds (i.e. clients, health practitioners and workplace environments). Hand hygiene involves washing hands with soap and water or using an alcohol-based rub (waterless antimicrobial agent). The most appropriate agent to complete hand hygiene depends on whether hands are visibly soiled, the type of activity undertaken and any exposure to certain potential pathogens. Practice regular hand hygiene as part of a multi-factorial approach to effectively minimise or prevent the transmission of infectious agents. It is also essential to educate and encourage clients to conduct hand hygiene. Ensure that clients have access to amenities to clean their hands when needed. 5 Moments of Hand Hygiene All speech pathologists must perform the relevant ‘5 Moments of Hand Hygiene’ 33 before and after every episode of client contact. The ‘5 Moments’ (see Figure 5) apply to all healthcare and

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practice settings. Undertake the steps required for the task. For example, ‘Step 2’ may not be required if not performing an aseptic task such as tracheal suctioning for a tracheostomy client in an acute hospital setting. Suggested tasks and occasions that require appropriate hand hygiene are listed in Table 3 to help guide practice behaviours. It is important to note that this is not a definitive list, and clinical decision making is required for individual contexts or scenarios. apply to all healthcare and practice settings. Undertake the steps required for the task. For example, ‘Step 2’ may not be required if not performing an aseptic task such as tracheal suctioning for a tracheostomy client in an acute hospital setting. Suggested tasks and occasions that require appropriate hand hygiene are listed in Table 3 to help guide practice behaviours. It is important to note that this is not a definitive list, and clinical decision making is required for individual contexts or scenarios. 5.0

Figure 5: The 5 Moments of Hand Hygiene Figure 5: The 5 Moments of Hand Hygiene Adapted from World Health Organization Guidelines 34

Adapted from World Health Organization Guidelines 34

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Demonstrate proper infection prevention management by performing routine hand hygiene before and after any client contact and after the removal of gloves.

[05] Standard Precautions

Table 3: Examples of Hand Hygiene Situations for Speech Pathologists and Clients

Before

After

• Eating/handling of food and drinks • Entering a client’s home • Entering clinical or practice areas (including schools and client’s home) • Handling invasive medical devices • Immediately before conducting a clean/aseptic procedure • Moving from a contaminated to a clean body site of a client • Touching the client’s assistive technology • Putting on gloves • Starting/leaving work • Touching or contacting a client, particularly immuno- compromised clients • Using a computer keyboard, laptop, tablet or mobile device in a clinical or practice area

• Contact with communal surfaces, being in client care areas and using shared client care equipment • Blowing/wiping/touching nose and mouth • Eating/handling of food and drinks • Hands becoming visibly soiled • Handling laundry/equipment/waste • Leaving clinical or practice areas (including schools and client’s home) • Remove gloves • Smoking • Touching a client and/or their item or items within their immediate vicinity – this includes any assistive technology the speech pathologist and client are touching • Touching blood, body fluids, secretions, excretions, non-intact skin and contaminated items, even if gloves are worn • Touching own items such as a phone, identity tag, keys, torch, pen • Using a computer keyboard, tablet or mobile device in a clinical or practice area • Using the bathroom

Adapted from NHMRC Guidelines 9 Adapted from NHMRC Guidelines 9

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Other Aspects of Hand Hygiene • Ensure appropriate hand care is undertaken as intact skin provides a natural barrier to infectious agents • Cover any cuts and abrasions on the hands with a waterproof dressing • Use moisturising hand cream to maintain good skin condition • Seek medical advice if any skin problems are present that impact on effective hand hygiene and hand care (e.g., lesions, irritation or dermatitis) • Keep fingernails short and clean • Do not wear artificial nails, nail adornments and/or nail polish • Avoid long sleeves, and if worn, sleeves should be rolled or pushed up above the elbow • Keep forearms and hands-free from jewellery–bare below the elbow–(e.g., wrist watches, bracelets, rings with stones or ridges) during clinical tasks - exception a plain ring/band that can easily move around the finger while performing hand hygiene • Do not wash or apply alcohol-based rub to gloves • Gloves are not considered a substitute for hand hygiene practice • Perform hand hygiene before handling clean linen, and after handling clothing and linen for laundering. Soap and Water • Most effective method of hand hygiene. • Follow the handwashing technique as outlined by the World HealthOrganisation (WHO) (see Figure 6) 34. • Water temperature is not as important as running water. • Soap (plain or antimicrobial) and running water (warm or cold) loosens, dilutes, and flushes dirt and infectious agents. • Dry hands thoroughly after washing with a clean towel. • Damp hands transfer up to 1000 times more infectious agents than dry hands. • Perform any time hands are visibly soiled. • Before handing food and/or eating. • After using the bathroom. • After exposure to potential spore-forming pathogens. Note: Spore-forming pathogens are a dormant  f orm of vegetative bacteria and are highly resistant to physical and chemical influences. Various diseases are linked to spore-forming pathogens, including food poisoning, food spoilage, antibiotic-associated diarrhoea and gas gangrene. 35-37 Alcohol-Based Rub • Fast and effective way to remove infectious agents contracted from touching contaminated surfaces • Fast and effective on visibly clean hands • Follow the hand rubbing technique as outlined by WHO (see Figure 6) 34 • Ensure alcohol-based hand rub meets hospital-grade requirements and contains between 60% and 80% v/v ethanol or equivalent

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