This action states

Clinicians assess infection risks and use transmission-based precautions based on the risk of transmission of infectious agents, and consider:

  1. Patients’ risks, which are evaluated at referral, on admission or on presentation for care, and reevaluated when clinically required during care
  2. Whether a patient has a communicable disease, or an existing or a pre-existing colonisation or infection with organisms of local or national significance
  3. Accommodation needs to manage infection risks
  4. The need to control the environment
  5. Precautions required when the patient is moved within the facility or to external services
  6. The need for additional environmental cleaning or disinfection
  7. Equipment requirements

Intent

Exposure of other patients or the workforce to infectious agents that cannot be contained by standard precautions alone is minimised. Risk is assessed at all access opportunities to the health service organisation, and necessary precautions are implemented and maintained for as long as necessary.

Reflective questions

How do clinicians decide on the need to apply transmission-based precautions?

How do clinicians assess and manage infection risks when a patient presents for care?

Key tasks

  • Use the results of the organisational risk assessment and gap analysis to identify priority areas for review, action or monitoring.
  • Review and use surveillance data to identify which communicable diseases, emerging risks or infectious agents of local, national or international significance affect the health service organisation, patients and the workforce.
  • If available, use national systems and definitions to collect surveillance data on infectious agents.
  • Identify the systems that are already in place to manage the risk of transmission of these infectious agents.
  • Set up or review the processes for communicating risks and risk management strategies to clinical areas or units, services or facilities (internal and external) that may be involved in the care of the patient.

Strategies for improvement

Hospitals

Review and assess the organisation’s processes that will inform risk management strategies to minimise exposure of patients, the workforce and the organisation to infectious agents. These include:

  • How the risk of infection or communicable disease is assessed on admission, on referral or on presentation for care in the organisation
  • What processes are in place to reassess the risks when clinically indicated during care
  • How infection risks are acted on, if identified
  • What processes are in place to inform the workforce or external services of a risk of an infectious agent or communicable disease
  • How contracts and service performance of any external providers of goods and services are reviewed.

Information sources to help with this assessment may include:

  • Data on waiting times for admission, movement through the emergency department and delays in patient placement because of a lack of appropriate accommodation, resources and equipment
  • Pathology reports on infectious agents of local, national or international significance that require transmission-based precautions
  • Surveillance data and reports from the organisation and other sources (for example, national, or state or territory surveillance reports) that have been gathered using national systems and definitions (if available)
  • Incident reports relating to possible transmission of infectious agents
  • Consumer feedback reports
  • Maintenance or service history and pathology reports to identify appropriate monitoring of air-handling systems, water supply systems and other relevant equipment
  • Data on cleaning and disinfection regimes.

Develop strategies to respond to any risks identified as part of the review, or any risks identified as part of a public health response or pandemic planning.

Include identified risks in the organisation’s quality improvement program so that actions and outcomes are monitored, measured, assessed and reported to leadership, the workforce and consumers. If appropriate, report recommendations to external departments, facilities or services that may be involved in the care of the patient.

If the health service organisation is part of a larger organisation or corporate group, refer to their policies, procedures and protocols for managing and communicating risk of infectious agents of local, national and international significance.

The Australian Guidelines for the Prevention and Control of Infection in Healthcare provide detailed information about risk assessment processes for infection prevention and control.

Day Procedure Services

Review and assess the organisation’s processes that will inform risk management strategies to minimise exposure of patients, the workforce and the organisation to infectious agents. These include:

  • How the risk of infection or communicable disease is assessed on admission, on referral or on presentation for care in the organisation
  • What processes are in place to reassess the risks when clinically indicated during care
  • How infection risks are acted on, if identified
  • What processes are in place to inform the workforce or external services of a risk of an infectious agent or communicable disease
  • How contracts and service performance of any external providers of goods and services are reviewed.

Information sources to help with this assessment may include:

  • Data on waiting times for admission, rescheduling of procedures and delays in patient placement because of a lack of appropriate accommodation, resources and equipment
  • Pathology reports on infectious agents of local, national or international significance that require transmission-based precautions
  • Surveillance data and reports from the organisation and other sources (for example, corporate, national, or state and territory surveillance reports) that have been gathered using national systems and definitions (if available)
  • Incident reports relating to possible transmission of infectious agents
  • Consumer feedback reports
  • Maintenance or service history and pathology reports to identify appropriate monitoring of air-handling systems, water supply systems and other relevant equipment
  • Data on cleaning and disinfection regimes.

Develop strategies to respond to any risks identified as part of the review, or any risks identified as part of a public health response or pandemic planning.

Include identified risks in the organisation’s quality improvement program so that actions and outcomes are monitored, measured, assessed and reported to leadership, the workforce and consumers. If appropriate, report recommendations to other services and clinicians that may be involved in the care of the patient.

If the day procedure service is part of a larger organisation or corporate group, refer to its policies, procedures and protocols for managing and communicating risk of infectious agents of local, national and international significance.

The Australian Guidelines for the Prevention and Control of Infection in Healthcare provide detailed information about risk assessment processes for infection prevention and control.

Examples of evidence

Select only examples currently in use:

  • Policy documents about the assessment of infection risks and implementation of transmission-based precautions to manage the risks
  • Patient referral or admission documentation that demonstrates assessment of infection risks and precautions to manage risks
  • Committee and meeting records in which infection risks and precautions to manage them were discussed
  • Audit results of the use of precautions for infection risks
  • Training documents about assessing infection risks and precautions to manage the risks
  • Examples of activities that have been implemented and evaluated to improve assessment and management of infection risks
  • Observation that relevant equipment, including personal protective equipment, is available to the workforce
  • Observation of physical and environmental controls for managing the risk of transmission of infectious agents
  • Cleaning schedules that outline further requirements associated with infection risk
  • List of communicable diseases or infectious agents of local or national significance that affect the health service organisation, patients and the workforce
  • Examples of communication with the workforce and patients about the risk of infectious agents and communicable diseases, and measures that can be used to reduce the risks.

MPS & Small Hospitals

MPSs and small hospitals should:

  • Use the results of the organisational risk assessment and gap analysis to identify priority areas for review, action or monitoring
  • Review and use surveillance data to identify which communicable diseases, emerging risks, or infectious agents of local, national or international significance affect the health service organisation, patients and the workforce
  • If available, use national systems and definitions to collect surveillance data on infectious agents
  • Identify the systems that are already in place to manage the risk of transmission of these infectious agents
  • Set up or review the processes for communicating risks and risk management strategies to clinical areas or units, services or facilities (internal and external) that may be involved in the care of the patient.

Review and assess the organisation’s processes that will inform risk management strategies to minimise exposure of patients, the workforce and the organisation to infectious agents. These include:

  • How the risk of infection or communicable disease is assessed on admission, on referral or on presentation for care in the organisation
  • What processes are in place to reassess the risks when clinically indicated during care
  • How infection risks are acted on, if identified
  • What processes are in place to inform the workforce or external services of the risk of an infectious agent or communicable disease
  • How contracts and service performance of any external providers of goods and services are reviewed.

Information sources to help with this assessment may include:

  • Data on waiting times for admission, movement through clinics or the emergency department, and delays in patient placement because of a lack of appropriate accommodation, resources and equipment
  • Pathology reports on infectious agents of local, national or international significance that require transmission-based precautions
  • Surveillance data and reports from the organisation and other sources (for example, national, state or territory surveillance reports) that have been gathered using national systems and definitions (if available)
  • Incident reports relating to possible transmission of infectious agents
  • Consumer feedback reports
  • Maintenance or service history and pathology reports to identify appropriate monitoring of air-handling systems, water supply systems and other relevant equipment
  • Data on cleaning and disinfection regimes.

The Australian Guidelines for the Prevention and Control of Infection in Healthcare provide detailed information about risk assessment processes for infection prevention and control.

Hospitals

Review and assess the organisation’s processes that will inform risk management strategies to minimise exposure of patients, the workforce and the organisation to infectious agents. These include:

  • How the risk of infection or communicable disease is assessed on admission, on referral or on presentation for care in the organisation
  • What processes are in place to reassess the risks when clinically indicated during care
  • How infection risks are acted on, if identified
  • What processes are in place to inform the workforce or external services of a risk of an infectious agent or communicable disease
  • How contracts and service performance of any external providers of goods and services are reviewed.

Information sources to help with this assessment may include:

  • Data on waiting times for admission, movement through the emergency department and delays in patient placement because of a lack of appropriate accommodation, resources and equipment
  • Pathology reports on infectious agents of local, national or international significance that require transmission-based precautions
  • Surveillance data and reports from the organisation and other sources (for example, national, or state or territory surveillance reports) that have been gathered using national systems and definitions (if available)
  • Incident reports relating to possible transmission of infectious agents
  • Consumer feedback reports
  • Maintenance or service history and pathology reports to identify appropriate monitoring of air-handling systems, water supply systems and other relevant equipment
  • Data on cleaning and disinfection regimes.

Develop strategies to respond to any risks identified as part of the review, or any risks identified as part of a public health response or pandemic planning.

Include identified risks in the organisation’s quality improvement program so that actions and outcomes are monitored, measured, assessed and reported to leadership, the workforce and consumers. If appropriate, report recommendations to external departments, facilities or services that may be involved in the care of the patient.

If the health service organisation is part of a larger organisation or corporate group, refer to their policies, procedures and protocols for managing and communicating risk of infectious agents of local, national and international significance.

The Australian Guidelines for the Prevention and Control of Infection in Healthcare provide detailed information about risk assessment processes for infection prevention and control.

Day Procedure Services

Review and assess the organisation’s processes that will inform risk management strategies to minimise exposure of patients, the workforce and the organisation to infectious agents. These include:

  • How the risk of infection or communicable disease is assessed on admission, on referral or on presentation for care in the organisation
  • What processes are in place to reassess the risks when clinically indicated during care
  • How infection risks are acted on, if identified
  • What processes are in place to inform the workforce or external services of a risk of an infectious agent or communicable disease
  • How contracts and service performance of any external providers of goods and services are reviewed.

Information sources to help with this assessment may include:

  • Data on waiting times for admission, rescheduling of procedures and delays in patient placement because of a lack of appropriate accommodation, resources and equipment
  • Pathology reports on infectious agents of local, national or international significance that require transmission-based precautions
  • Surveillance data and reports from the organisation and other sources (for example, corporate, national, or state and territory surveillance reports) that have been gathered using national systems and definitions (if available)
  • Incident reports relating to possible transmission of infectious agents
  • Consumer feedback reports
  • Maintenance or service history and pathology reports to identify appropriate monitoring of air-handling systems, water supply systems and other relevant equipment
  • Data on cleaning and disinfection regimes.

Develop strategies to respond to any risks identified as part of the review, or any risks identified as part of a public health response or pandemic planning.

Include identified risks in the organisation’s quality improvement program so that actions and outcomes are monitored, measured, assessed and reported to leadership, the workforce and consumers. If appropriate, report recommendations to other services and clinicians that may be involved in the care of the patient.

If the day procedure service is part of a larger organisation or corporate group, refer to its policies, procedures and protocols for managing and communicating risk of infectious agents of local, national and international significance.

The Australian Guidelines for the Prevention and Control of Infection in Healthcare provide detailed information about risk assessment processes for infection prevention and control.

Examples of evidence

Select only examples currently in use:

  • Policy documents about the assessment of infection risks and implementation of transmission-based precautions to manage the risks
  • Patient referral or admission documentation that demonstrates assessment of infection risks and precautions to manage risks
  • Committee and meeting records in which infection risks and precautions to manage them were discussed
  • Audit results of the use of precautions for infection risks
  • Training documents about assessing infection risks and precautions to manage the risks
  • Examples of activities that have been implemented and evaluated to improve assessment and management of infection risks
  • Observation that relevant equipment, including personal protective equipment, is available to the workforce
  • Observation of physical and environmental controls for managing the risk of transmission of infectious agents
  • Cleaning schedules that outline further requirements associated with infection risk
  • List of communicable diseases or infectious agents of local or national significance that affect the health service organisation, patients and the workforce
  • Examples of communication with the workforce and patients about the risk of infectious agents and communicable diseases, and measures that can be used to reduce the risks.

MPS & Small Hospitals

MPSs and small hospitals should:

  • Use the results of the organisational risk assessment and gap analysis to identify priority areas for review, action or monitoring
  • Review and use surveillance data to identify which communicable diseases, emerging risks, or infectious agents of local, national or international significance affect the health service organisation, patients and the workforce
  • If available, use national systems and definitions to collect surveillance data on infectious agents
  • Identify the systems that are already in place to manage the risk of transmission of these infectious agents
  • Set up or review the processes for communicating risks and risk management strategies to clinical areas or units, services or facilities (internal and external) that may be involved in the care of the patient.

Review and assess the organisation’s processes that will inform risk management strategies to minimise exposure of patients, the workforce and the organisation to infectious agents. These include:

  • How the risk of infection or communicable disease is assessed on admission, on referral or on presentation for care in the organisation
  • What processes are in place to reassess the risks when clinically indicated during care
  • How infection risks are acted on, if identified
  • What processes are in place to inform the workforce or external services of the risk of an infectious agent or communicable disease
  • How contracts and service performance of any external providers of goods and services are reviewed.

Information sources to help with this assessment may include:

  • Data on waiting times for admission, movement through clinics or the emergency department, and delays in patient placement because of a lack of appropriate accommodation, resources and equipment
  • Pathology reports on infectious agents of local, national or international significance that require transmission-based precautions
  • Surveillance data and reports from the organisation and other sources (for example, national, state or territory surveillance reports) that have been gathered using national systems and definitions (if available)
  • Incident reports relating to possible transmission of infectious agents
  • Consumer feedback reports
  • Maintenance or service history and pathology reports to identify appropriate monitoring of air-handling systems, water supply systems and other relevant equipment
  • Data on cleaning and disinfection regimes.

The Australian Guidelines for the Prevention and Control of Infection in Healthcare provide detailed information about risk assessment processes for infection prevention and control.