14.1 Infection Control, Standard & Transmission-Based Precautions

Infection Control, Standard & Transmission-Based Precautions

Infection prevention and control form the ethical and operational bedrock of safe occupational therapy delivery across the care continuum—from intensive care units (ICUs) and acute inpatient rehabilitation to subacute skilled nursing facilities (SNFs), outpatient clinics, schools, and home health settings. Certified Occupational Therapy Assistants (COTAs) frequently engage in high-contact, hands-on therapeutic activities, including Activities of Daily Living (ADLs) such as bathing, toileting, and feeding; functional mobility; splint fabrication; physical agent modalities (PAMs); and handling shared therapeutic equipment.

Failure to adhere to rigorous infection control standards exposes medically vulnerable clients, healthcare personnel, and the community to life-threatening healthcare-associated infections (HAIs), including multidrug-resistant organisms (MDROs), spore-forming bacteria, and airborne pathogens.

1. Standard Precautions & OSHA Bloodborne Pathogens Standard

Standard Precautions represent the primary tier of infection prevention and are designed for the care of all clients, in all settings, at all times, regardless of their confirmed or suspected infection status. The underlying clinical premise is that every client encounter, piece of bodily fluid, broken skin surface, and mucous membrane is potentially infectious.

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|                   THE DUAL-TIER INFECTION CONTROL FRAMEWORK                 |
|                                                                             |
|   [TIER 1: STANDARD PRECAUTIONS] (Universal baseline for ALL clients)      |
|   • Hand hygiene before & after every client contact.                       |
|   • PPE use based on anticipated risk of bodily fluid exposure / splashes.  |
|   • Respiratory hygiene & cough etiquette.                                  |
|   • Safe injection practices & sharps safety disposal.                      |
|   • Environmental cleaning & disinfection of reusable therapy items.        |
|                                                                             |
|   [TIER 2: TRANSMISSION-BASED PRECAUTIONS] (Pathogen-specific add-on)       |
|   • Contact Precautions (Direct/indirect contact with surfaces/skin).       |
|   • Droplet Precautions (Large respiratory droplets within 3–6 feet).       |
|   • Airborne Precautions (Small droplet nuclei suspended in air currents).  |
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Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard

The OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030) protects healthcare personnel from occupational exposure to bloodborne viruses, most notably Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and Human Immunodeficiency Virus (HIV).

Key Mandates for Occupational Therapy Practitioners:

1. Universal Exposure Control: Assume all human blood and specified body fluids (semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, and any body fluid visibly contaminated with blood) are infectious.
2. Engineering & Work Practice Controls:
   • Sharps Disposal: Scalpels and blades used in custom thermoplastic splint fabrication must be immediately disposed of in rigid, puncture-resistant, leak-proof, red Biohazard Sharps Containers located at the point of use. Never recap, bend, or shear needles/blades by hand.
   • Prohibited Activities: Eating, drinking, applying cosmetics/lip balm, or handling contact lenses in therapy clinic areas where blood or infectious materials are present is strictly forbidden.
3. Hepatitis B Vaccination: Employers must offer the Hepatitis B vaccination series free of charge to all personnel with potential occupational exposure within 10 working days of initial assignment.
4. Post-Exposure Prophylaxis (PEP) Protocol:
   • Immediate Action: Wash the needlestick or puncture wound immediately with soap and water for several minutes. Flush exposed mucous membranes (eyes, nose, mouth) with copious amounts of saline or clean running water.
   • Reporting & Evaluation: Report the incident immediately to the clinical supervisor/occupational health department.
   • Medical Follow-Up: Prompt baseline testing of source individual (with consent) and exposed clinician, followed by initiation of post-exposure prophylaxis (e.g., antiretroviral therapy within 2 hours for HIV, Hepatitis B immune globulin/vaccine booster if indicated) and follow-up serological surveillance.

2. Hand Hygiene Protocols: Alcohol-Based Rub vs. Soap & Water

Hand hygiene is universally recognized as the single most effective clinical intervention for preventing healthcare-associated infections and halting the transmission of antimicrobial-resistant pathogens.

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|                     HAND HYGIENE DECISION MATRIX                            |
|                                                                             |
|   WHEN TO USE SOAP & WATER ONLY:             WHEN TO USE ALCOHOL-BASED RUB: |
|   1. Hands are VISIBLY SOILED or dirty.     1. Before direct client contact.|
|   2. Exposure to SPORE-FORMING bacteria     2. After direct client contact. |
|      (Clostridioides difficile).             3. After contact with body     |
|   3. Outbreaks of Norovirus (non-enveloped).   fluids / non-intact skin.    |
|   4. Before eating / preparing food.        4. Moving from contaminated     |
|   5. After using the restroom.                 body site to clean site.     |
|   * Requires MINIMUM 20 SECONDS friction!   5. After removing gloves/PPE.   |
|                                              * Rub 15-20 sec UNTIL DRY!     |
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Detailed Hand Hygiene Modality Comparison

[!IMPORTANT] The "Five Moments for Hand Hygiene" (World Health Organization):

1. Before touching a client (e.g., prior to taking vitals, assisting with transfers, or range of motion).
2. Before clean / aseptic procedures (e.g., prior to dressing changes, catheter management, or splint fabrication on open wounds).
3. After body fluid exposure risk (e.g., after assisting with toileting, perineal hygiene, wound care, or emptying urinary drainage bags).
4. After touching a client (e.g., upon concluding an ADL session or gait training).
5. After touching client surroundings (e.g., after touching bedrails, wheelchair armrests, nightstands, or IV poles, even if the client was not directly touched).

3. Transmission-Based Precautions: Contact, Droplet & Airborne

When standard precautions alone are insufficient to prevent the spread of highly transmissible or epidemiologically significant pathogens, Transmission-Based Precautions are implemented as a secondary tier of defense.

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|                  TRANSMISSION-BASED PRECAUTIONS SUMMARY                     |
|                                                                             |
|   [CONTACT ISOLATION]        [DROPLET ISOLATION]        [AIRBORNE ISOLATION]|
|   • Gown + Gloves upon entry • Surgical Mask upon entry • N95 Respirator or |
|   • Dedicated equipment      • Eye protection if splash   PAPR before entry |
|   • Bleach wipes for C. diff • 3 to 6-foot perimeter    • Negative pressure |
|   • Pathogens: MRSA, VRE,    • Pathogens: Flu, Mumps,     AIIR room (closed)|
|     C. diff, Scabies, CRE      Pertussis, Meningitis    • TB, Measles, Varic|
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Comprehensive Isolation Categories Matrix

[!WARNING] Critical COTA Isolation Rule: Clostridioides difficile (C. diff) Protocol:

1. Alcohol-based hand sanitizers DO NOT KILL C. diff SPORES. The COTA must wash hands with soap and warm water for at least 20 seconds after treating any client on Contact Enteric Precautions.
2. Standard quaternary ammonium hospital disinfectant wipes do not destroy spores. The COTA must use EPA-registered sodium hypochlorite (bleach-based) sporicidal wipes to decontaminate all rehabilitation equipment used during the session.

4. Personal Protective Equipment (PPE) Donning & Doffing Sequences

Adhering to the exact sequence of putting on (donning) and removing (doffing) PPE is critical. The highest rate of clinician self-contamination occurs during improper PPE doffing, when contaminated outer surfaces contact the healthcare worker's skin, mucous membranes, or scrubs.

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|                     CDC PPE DONNING & DOFFING SEQUENCES                     |
|                                                                             |
|   [DONNING SEQUENCE] (Putting On)            [DOFFING SEQUENCE] (Taking Off)|
|                                                                             |
|   1. GOWN                                    1. GLOVES                      |
|      (Fully cover torso, fasten neck/waist)     (Glove-in-glove technique)  |
|        |                                          |                         |
|        v                                          v                         |
|   2. MASK OR RESPIRATOR                      2. GOGGLES / FACE SHIELD       |
|      (Fit flexible band to nose bridge,         (Handle by headband/arms)   |
|       perform user seal check)                    |                         |
|        |                                          v                         |
|        v                                     3. ISOLATION GOWN              |
|   3. GOGGLES OR FACE SHIELD                     (Unfasten ties, peel from   |
|      (Place over face/eyes & adjust fit)         shoulders inside-out)      |
|        |                                          |                         |
|        v                                          v                         |
|   4. GLOVES                                  4. MASK OR RESPIRATOR          |
|      (Extend cuffs OVER wrists of gown)         (Grasp bottom then top ties;|
|                                                  remove OUTSIDE room for TB)|
|                                                   |                         |
|                                                   v                         |
|                                              5. PERFORM IMMEDIATE           |
|                                                 HAND HYGIENE!               |
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Step-by-Step Doffing Protocol (Preventing Self-Contamination)

1. Gloves (Most Contaminated Surface):
   • Outside-to-Outside, Inside-to-Inside: Grasp the outside edge of the contralateral glove near the wrist with the gloved hand. Peel downward, turning the glove inside-out into a ball held in the remaining gloved hand.
   • Slide ungloved fingers under the wrist of the remaining glove without touching the exterior surface. Peel the second glove off inside-out over the first glove, forming a contained bundle. Discard into biohazard/trash receptacle.
2. Goggles / Face Shield:
   • The front of the eye protection is contaminated. Do not touch the front!
   • Grasp the ear pieces or headband from the back of the head and lift upward and away from the face. Discard or place in designated decontamination bin.
3. Isolation Gown:
   • The gown front and sleeves are contaminated. Unfasten neck and waist ties.
   • Grasp the gown at the shoulders/neck and peel it downward and away from the body, rolling the contaminated exterior inward into a neat bundle. Discard.
4. Mask or N95 Respirator:
   • The front of the mask/respirator is contaminated. Do not touch the front!
   • Grasp the bottom elastic band/ties first, lift over the back of the head, then grasp the top band/ties and pull forward away from the face. For Airborne isolation, exit the AIIR room and close the door before removing the N95 respirator.
5. Hand Hygiene:
   • Immediately wash hands with soap and water or perform alcohol-based hand rub upon completion of PPE removal.

5. Decontamination, Disinfection & Therapeutic Equipment Care

In occupational therapy, equipment is shared among multiple clients across therapy sessions. Contaminated therapy tools (e.g., adaptive feeding utensils, button hooks, reachers, splinting materials, dynamometers, therapy mats, exercise weights, and pediatric toys) can serve as vectors for microbial cross-transmission.

Spaulding Classification System in Occupational Therapy

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|                 SPAULDING CLASSIFICATION FOR MEDICAL DEVICES                |
|                                                                             |
|   [1. CRITICAL ITEMS]       ---> Enters sterile tissue or vascular system   |
|                                  (e.g., surgical scalpels, needles).        |
|                                  REQ: STERILIZATION (Autoclave, gas).       |
|                                                                             |
|   [2. SEMI-CRITICAL ITEMS]  ---> Contacts mucous membranes / non-intact skin|
|                                  (e.g., oral motor tools, dynamic splints   |
|                                   over open graft sites).                   |
|                                  REQ: HIGH-LEVEL DISINFECTION.              |
|                                                                             |
|   [3. NON-CRITICAL ITEMS]   ---> Contacts only INTACT skin                  |
|                                  (e.g., reachers, BP cuffs, therapy mats,   |
|                                   weights, sensory toys, ADL boards).       |
|                                  REQ: INTERMEDIATE / LOW-LEVEL DISINFECTION.|
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Practical Decontamination Protocols for OT Practitioners:

• Contact Time (Wet Dwell Time): Disinfectant wipes (e.g., quaternary ammonium, hydrogen peroxide, sodium hypochlorite) require a specific wet dwell time—typically 1 to 4 minutes—to achieve microbial kill. The COTA must ensure the treated surface remains visibly wet for the entire duration specified by the manufacturer.
• Pediatric Clinic Guidelines: All shared toys mouthed by children or handled in pediatric sessions must be placed into a dedicated "Dirty Toy Bin" immediately following the session and washed with warm soapy water followed by EPA-registered non-toxic sanitizing rinse before returning to circulation.
• Adaptive Feeding Utensils: Utensils used in feeding retraining must be washed in a commercial high-temperature sanitizing dishwasher (≥160°F–180°F) or dedicated single-patient use.
• Fabric & Porous Straps: Hook-and-loop (Velcro) straps on splints and positioning belts harbor bacteria; use non-porous wipeable strapping (e.g., polyurethane-coated straps) for isolation clients or provide single-patient replacement straps.

6. Clinical Case Vignette: Infection Control in Rehabilitation

Clinical Case Vignette: A 68-year-old client admitted to the subacute rehabilitation unit following total knee arthroplasty develops severe hospital-acquired diarrhea and tests positive for Clostridioides difficile (C. diff). The occupational therapy plan of care targets lower-body dressing, toilet transfers, and adaptive grooming. The COTA arrives at the client's room to conduct an ADL session.

Step-by-Step Infection Control Protocol:

1. Signage & PPE Donning: The COTA observes the "Contact Enteric Isolation" sign on the door. Prior to entering the room, the COTA dons a clean isolation gown, ties it securely at the neck and waist, and dons disposable examination gloves, extending the glove cuffs over the gown wrists.
2. Session Execution: The COTA brings dedicated single-patient equipment (a dedicated reacher, sock aid, and dressing stick stored in the client's room). Transfer and dressing training are completed within the client's private room.
3. Equipment Decontamination: At the conclusion of the session, the COTA uses EPA-registered sodium hypochlorite (bleach-based) wipes to thoroughly wipe down the commode seat and therapy equipment, ensuring a full 4-minute wet contact time.
4. PPE Doffing: Inside the client's room near the doorway exit, the COTA removes gloves using the glove-in-glove technique, unfastens the gown, peels it away from the body inside-out, rolls it into a bundle, and discards it into the biohazard trash receptacle.
5. Hand Hygiene Execution: The COTA proceeds directly to the in-room sink, applies soap and warm running water, and vigorously scrubs all hand surfaces for 25 seconds before rinsing, drying with paper towels, and using a clean paper towel to turn off the faucet. The COTA avoids using the hallway alcohol rub dispenser, recognizing that alcohol is ineffective against C. diff spores.